For the nursing student and new grad, time management can be one of the trickiest skills to learn. When I first started in the ICU, my preceptor kept having to refocus me as I felt like I was being pulled in two directions at once (two patients, two directions…on the floor I’m sure the tug-of-war is even more intense!). When you’re new, it can be difficult to manage your time effectively simply because you’re still learning what needs to be done and you lack a routine, which takes time to develop.

One of the first things I did which really helped was to keep a piece of paper with my bedside chart (yes, our unit utilized paper charting at that time). On this paper I would jot down quick lists of how I was going to cluster my interventions the NEXT time I went into the room. This kept me from going in every five minutes, but instead I got it down to every 30 minutes, sometimes every hour if the patient was stable enough. Of course, some patients require almost constant observation and intervention, but for those patients for whom you can cluster care, this strategy was incredibly helpful. Over time it became part of my routine and now I find that I automatically think ahead in this way so that I can maximize each time I enter the patient’s room.

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For example, my list might look something like this:

  • Turn
  • Oral Care
  • Print CVP waveform
  • Label IV lines
  • Hang new bag NS
  • Switch BP to other arm
  • Measure urine output
  • Take a temp
  • Measure NGT residual

I found that if I could do at least five things on each trip into the room, it drastically cut down on the “oh, one more thing” little trips that ate up so much of my time. Now, this may seem like “duh,” because it looks so obvious, but trust me…as a newbie this was something I had to actually make into a habit. Otherwise, I’d think of something that needed to be done and go do it right then, rather than thinking ahead about what ELSE I could do while I was in there. Once I got this habit down my workday flowed much more smoothly and I had time to actually start thinking about my patients in a more global sense.

As far as developing routines go, my workday typically flows the same each day, but unexpected situations will always throw a wrench into things. In general, the mornings are much more predictable. As the day progresses, new variables coming into play – rounds, new orders, and new problems the patient develops.

Let’s go through an example

In this scenario, you’ve got two patients. Patient A (Alice) is critically ill, on a ventilator and receiving titratable medication to keep her blood pressure normalized. Patient B (Bob) is doing much better and will probably transfer out in the next day or so. With this patient load, the day pretty much looks like this:

0645-0715: Get report, greet both patients/families, perform a quick focused assessment pertaining to the patient’s main problem. For example, a quick neuro check should be conducted on stroke patients, a quick respiratory assessment should be conducted for patients with respiratory dysfunction, etc. This focused assessment should also include looking at vital signs and assessing for pain. In addition, if the patient is post-surgical, look at the dressing for signs of bleeding. At this time ask each patient what I can bring them when I come back for their full assessment. By asking what you can bring the patient THE NEXT TIME you come in, I find it cuts down on call-lights and it helps the patient feel more secure and confident their needs will be met.

0715-0730: Fill pockets with frequently used items (blunts to cap off unused IV lines, alcohol swabs, and tape.) Ensure I have three pens, a hemostat, scissors and my stethoscope. Print EKG strips for both patients, take a quick look at labs, check to see if I need to replace K or Mg, write out my schedule of meds, lab draws, and to-do items. Bob asked for a warm blanket, so I’ll grab that along with the glucometer and his breakfast tray. Unless my other patient needs me right now, I can take three extra minutes with Bob to check his blood glucose and set up his breakfast tray.

0730-0800: Perform a full head-to-toe on Alice first and make every effort to chart it on the flowsheet before moving on. Sometimes this is possible and sometimes there will be a more pressing need. If Alice is a typical ICU patient, then she has hemodynamic monitoring to evaluate, arterial-lines to level, waveforms to print, medications to titrate, and may need a turn and oral care if on the ventilator (which she is). The goal is to cluster care and get as much done as possible with this first assessment. While I’m in the room, I’ll do a quick survey of what supplies are already in there and what supplies I need to bring THE NEXT TIME I go in. I’ll also update the patient/family on the general plan and goals for the day, and find out if there is anything important they would like to accomplish that day. Maybe the patient wants to nap later because they were up all night, or want to go to the atrium for some fresh air, or get their hair washed. Whatever it is, find out what their goals are and work them into your plan of care for the day. Once I’ve completed my assessment, I’ll start making a list of the patients problems and things to bring up during rounds. This problem list will essentially become my care plan for the day.

0800-0830: Assess Bob and do the same things for him that I did for Alice. Depending on how sick your patients are, this may go a lot more quickly or it may take a while. I generally try not to stress if it takes me until 0830 to fully assess and document the assessment on both patients. Depending on what 0900 meds Bob has, I will aim to administer them now since I’m already in the room (clustering for the win!).

0830-0930: If Alice has urgent needs that the physician needs to address, I’ll call him/her as soon as I have all the data I need (lab values, vital signs, urine output, etc.) Otherwise, it’s time for morning meds for Alice then meds for Bob if I didn’t give them already.

As far as meds go, you have to use your judgment. Let’s say Alice is in for septic shock and has scheduled antibiotics at 0900. Her antibiotics are obviously going to take precedence over Bob’s daily famotidine tablet. Also, you’ll want to be sure to look at what antibiotics you have that are all due at the same time (yes, this happens frequently). If you happen to have an antibiotic that infuses over 60 to 120 minutes, this can be problematic if you don’t have multiple IV lines.

Be sure to check IV compatibility and see what you can Y-site in together so that you can get them in on time. If necessary, you simply may need to start another peripheral IV. Speaking of IV compatibility, if I have a patient on a lot of IV meds, I will print out an “IV compatibility” report to see in advance what I can Y-site together. I put a copy by the bedside and a copy with my report sheet so it’s always easily accessible.

One more thing I try to do early in the day is to label all my IV lines and pumps. Though the pump shows the name of the drug on the display it can be difficult to see quickly and easily. Having your IV lines labeled is a very important component of patient safety. To do this, trace each bag to its pump then to the patient. You want to make sure everything is as it should be and that nothing incompatible is running together. If the line isn’t labeled, then clearly label each line directly above the y-site closest to the patient. If there’s an emergency situation, you want to know ASAP which line can be used to push life-saving medications (and it’s not the line infusing insulin, so label, label, label!).

0930-1000: Get ready for rounds! We have a list of items that we address in the same format each time, so I just go through the list and write out my notes. This takes a few minutes prep, but makes rounds go much more smoothly. This is also where my problem list comes in to play. If my patient is in dire need of something, I obviously won’t wait until rounds to bring it up to the physician. But for less urgent things, I can get a handful of issues all handled at once. If I have time here, I’ll catch up on charting, review the H&P if I haven’t already and maybe (just maybe), reheat my morning coffee.

1000-1400: Rounds occur on my unit anytime between 1000 and 1200 (give or take). At this point in the day I’m basically going through my scheduled interventions, assessments, meds, and tasks. If I need to take my patient off the unit, I will try to do that during this time frame as it can seriously throw off your schedule and you don’t want to save the for the end of the day if possible. STAT orders may get entered during rounds, so I will address those as quickly as possible as well.

1400-1700: By now the team has finished rounds and the physicians have seen your patients. This means you have new orders, so this is a perfect time to review my plan for the day and make adjustments. I’ll update my to-do list and see what will have to be passed along to my friends on the next shift. This is also the time when I catch up on charting things like the patient’s care plan, education, and other required documentation beyond the patient’s physical assessments and my nursing interventions. If I have sent any labs I’m checking for those results throughout the day. This is also typically when I’ll have time to organize and tidy my patient’s rooms if necessary.

1700-1845: My end-of-shift routine includes calculating I/Os, clearing the pumps, emptying Foley bags, emptying all other collection devices, writing end-of-shift summaries, checking for any outstanding labs, and buttoning up my shift.

1845-1915: It’s time to give report, clock out, go home, shower, eat, and RELAX!

Of course, this is an example of a predictable day with patients who aren’t doing anything unexpected. In reality, you can pretty much count on changing your plan multiple times. Whether it’s a transfer, an admit from the ED, hemodynamic instability, a code blue or even multiple code browns, you will always be reevaluating and reprioritizing your workflow. In general, though, this is how I try to organize my day in the ICU. The key is to leave enough wiggle room to account for the unexpected happening – because it will!

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