Off the Charts

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

My hospital uses dry-erase whiteboards as a tool to communicate with patients and family members. Mounted to the walls in the patients’ rooms, the boards are prominent and concise.  Aside from a lot of basic information, notes get added to the board when diagnostic tests are completed, when complementary therapies have been implemented, and when housekeeping staff visit. The “meat” of the board, however, is the section that addresses plans and goals for the day. The plans and goals are updated and modified continuously by nursing staff. They’re specific to each patient, yet, despite their personalization, the goals for ICU patients tend to fall into distinct categories.

The first category includes goals which are often set by the patients themselves. They tend to require a certain amount of collaboration and active participation. These types of goals, which include things like “maximize incentive spirometer use,” “ambulate,” and “advance diet,” imply a relatively healthy state and tend to predict transfer orders.

The next type of goal is aimed at restoring health and stability. These goals don’t necessarily require patient participation and often focus on pathophysiologic processes. On the whiteboards of these rooms, the listed goals are likely to include things like “wean ventilator,” “control agitation,” “control fever,” or “increase level of consciousness.” In these cases, the goals are often of more interest to the family members than the patients.

The most critically ill and unstable patients are the hardest people for whom to establish goals, and sometimes the immediacy and focus required to support these patients preclude the time required to formulate and write goals on a dry-erase board. The more pressing the needs of the patient, the briefer the goals tend to be, and the brevity often portends the gravity of the situation: “oxygenate,” “ventilate,” “perfuse.” The goal “live” also belongs to this category, although decorum discourages writing “live” as the plan for the day.

Overall, the whiteboards are excellent communication tools. Although they’re not always utilized or appreciated by the ICU patients themselves, they often serve as touchstones for family members, who take comfort in written updates and established goals. They provide a different kind of communication to the nurses, though. In a unit where stability can be as fleeting as a dry-erase marker, the whiteboards sometimes provide a snapshot of general direction—especially for those reading between the lines.