Skillful ICU practitioners not only integrate a vast array of data pertaining to the individual under treatment but also bring to bear the most appropriate therapy. Many decisions need to be made very quickly, and securing the needed information has the potential to consume enormous time. Faced with uncertainty and many competing priorities, the temptation is strong to forgo making a decision, to rely on memory, or to trust the verbal counsel of readily available colleagues. Potential for error and, consequently, the opportunity to improve care are high. The dramatic development of computer and communications technology has enabled partial closure of the information gap. Over a few short years, most physicians have been made aware of or now make active use of computerized medical records, remote digital access to laboratory data, and imaging studies from unit-based workstations or personal computers. Impressive displays of trended information as well as raw and processed data can be configured to the user’s specific needs. A somewhat smaller but growing proportion of physicians now use the powerful search engines of public or private electronic libraries to rapidly identify and retrieve relevant articles from the medical literature. The first steps toward this goal of timely information access have already been taken—not only by bedside computers, but also by hand-carried computers and PDAs of ever-increasing power. These
units not only package vital references, drug information, and periodically updated digests of evidence-based practice (e.g., Up-to-Date) but also allow wireless access to the Internet and to the hospital’s own local network (intranet) for timely retrieval of patient-specific data. Without question, the potential benefits and consequences of this extraordinary leap into the information age have only begun to develop.

As most experienced practitioners realize, the ICU tends to function best with a team approach in which caregivers of varied descriptions (physicians, nurses, therapists, etc.) are professionally acquainted, mutually respected, and equally committed. All must be apprised of the current therapeutic objectives. The day-to-day routines and the expectations for the unit must be well understood, ideally with an awareness of the work schedules and priorities of all involved. Despite the unquestioned value of “hard data,” overreliance on “the numbers” to guide decision making fosters an immature and dangerous style of practice. Drawing from momentby-moment observations made over extended periods, a well-trained nurse or therapist is often the caregiver with the best insight regarding the relation of events and medications to evolving problems, tolerance of current therapy, and the probable effects of intended interventions (weaning from mechanical ventilation, mobilization, transport, reaction to medication, mental status, airway secretions, etc.). The clinician must seek their active involvement and advice in the planning process. For the team to operate with maximum effectiveness, the nurse, respiratory therapist, and unit pharmacologist (if available) should make formal rounds with the physician to share observations and advice as well as to be kept abreast of the doctor’s current thinking and care plan. The specific objectives of therapy and conditions or developments for which the doctor desires to be contacted should be communicated explicitly. Enormous benefit accrues from well-thought-out protocols and goal-directed orders that account for patient response. Uncertainty regarding the appropriateness and dosage of certain medications often can be addressed, valuable time can be saved, and prescription errors can be avoided by communicating the intent of treatment. The latter strategy lends flexibility and allows timely dosage adjustment (e.g., for fluids and/or diuretics). A very common error is to write an order, to assume that it was carried out, and then to fail to follow up on the result of its execution. Setting clear goals for the nurse or the therapist, allowing for “online” modification of dosing in accordance with those goals, and automatic notification when the goals cannot be met tighten the linkage between patient and caregivers. (“Adjust the furosemide drip to maintain output > input by at least 1 L per shift” is more likely to succeed than “Give 40 mg furosemide IV TID.”) Goal-directed order writing extends many of the same advantages offered by formalized care protocols (e.g., for heparin adjustment or insulin delivery) to a much broader and less-constrained therapeutic context.

In addition to discussions with other caregivers, the physician must review the chart record, nursing notes, orders, medication and therapy lists, bedside data board, ventilator sheet, and laboratory record. Increasingly, all such information is incorporated into an electronic medical record (EMR) and the caregivers are given direct responsibility for detailed documentation and for entering orders that are not transcribed but are immediately entered. This new emphasis on electronic documentation—in many cases designed as much as a billing instrument than a communication tool—has given rise to templated notes laden with “cut and paste” entries and unnecessary replication of laboratory data. The need to communicate and document through the computer has taken its toll on effective communication among caregivers and discourages the physician from returning to the bedside. Just how the benefits and detriments of the electronic medical record (EMR) play out in the ICU has yet to be fully experienced.

The need to carefully review the current listing of medications with the patient’s ongoing and resolved problems clearly in mind cannot be overemphasized. To prevent delays and errors, it is a good idea to enter intended orders at the time of the bedside visit. The nursing record often provides an overlooked and valuable source of information. Puzzling entries with the potential to influence decision making should be clarified by direct verbal communication. Calculations required to synthesize the clinical picture and formulate revisions to the care plan (e.g., anion gap, systemic vascular resistance, respiratory compliance, airway resistance) should be automated or made quickly available at the bedside. Specific attention should be directed to the patient’s weight, net fluid balance, intake, urinary and fecal output (Ins and Outs), diet, and drugs (those scheduled and those given as needed). Sedatives, antibiotics, vasoactive agents, and diuretics tend to be of special interest. The volume and description of expectorated or suctioned airway secretions and gastric aspirates should be noted.

The contribution of the physical examination has become devalued as our technical abilities to image noninvasively, to monitor cardiorespiratory function, and to use laboratory data have improved. However, certain key bits of information that are impossible to gather quickly by other means should be assessed by physical examination one or more times daily in virtually every patient with cardiorespiratory instability or compromise.
Although the directed physical examination is the practical standard, outstanding clinicians are sufficiently disciplined to quickly but systematically assess certain aspects of the physical examination each day, not only to detect areas of concern but also to develop the background against which to gauge any future changes.

Certain consequences of protracted bed rest are well known to most practitioners, whereas other, subtler repercussions are either unknown or ignored. Physiologic adaptations to gravity affect nearly all organ systems, and release from gravitational stress may set in motion changes that impede recovery.