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Departments: Spotlight on Clinical Care

Standardizing Multidisciplinary Rounds

Creation of an Efficient and Effective Process to Care for the Critically Ill

Brown, Lauren MSN, RN; Saini, Virender MD; Carter, Chris PharmD

Author Information
JONA: The Journal of Nursing Administration: January 2020 - Volume 50 - Issue 1 - p 5-8
doi: 10.1097/NNA.0000000000000830
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Abstract

Multidisciplinary rounding is a useful tool to help ensure effective and comprehensive care of critically ill patients within the ICU.1,2 However, rounding efficiency and effectiveness are often compromised by lack of standardization of elements including start time and location, multidisciplinary representatives required to attend, patient presentation highlights, and physician workflow.3,4 Failure of any or all of these elements may lead to poor multidisciplinary attendance, inefficient or ineffective patient presentation, and process dissatisfaction among team members. These outcomes may, in turn, adversely affect patient care.

In 2017, the study authors noted inefficiencies and process failures in multidisciplinary rounds within our ICU. Specifically, rounds did not start on time, frequently ran longer than necessary, and often did not include essential members including respiratory therapists (RTs), clinical dietitians, and case managers (CMs). We sought to remedy our situation by implementing a standardized rounding process implemented in April 2018. This article describes the impact of this standardized process on rounding time and multidisciplinary member attendance.

Methods

We conducted a retrospective review of rounding data from January 22, 2018, to June 8, 2018, in our ICU. The study site is a 28-bed mixed ICU serving patients in the following service lines: neurosurgery, neurology, cardiothoracic surgery, colorectal surgery, general surgery, and medicine. Of note, the hospital is a nonteaching center, and ICU nurses present patient information during multidisciplinary rounds. The rounding team in the ICU is ideally comprised of a critical care physician, a charge nurse, the bedside nurse, a critical care pharmacist, a RT, a physical or occupational therapist, a clinical dietitian, and a CM. The study was approved by the SSM Health St. Louis institutional review board.

In order to standardize multidisciplinary rounds, the study authors created a simplified and streamlined rounding template for ICU nurses to follow during patient presentation (Figure 1). This template emphasized presentation of history of present illness, events over the last 24 hours, abnormal laboratory values within the last 24 hours, a discussion of pertinent problems and their treatments organized by organ system, a review of a “FASTCHUGSBID” mnemonic to efficiently review all critical aspects of ICU patient care, and statement of the patient's code status, daily goals, and plan for the day.5,6 In addition, study authors standardized start time and location of rounds, encouraged critical care physicians to examine patients before rounds began, reestablished communication and expectations with multidisciplinary team members and their departments regarding attendance on rounds, and worked with the case management department and the hospital's executive team to add a dedicated CM to the ICU.

Figure 1
Figure 1:
SSM Health St Clare Hospital ICU rounding checklist.

Rounding data were collected on consecutive days by the critical care pharmacist on days he attended rounds on Mondays through Fridays. The “preimplementation” phase included data collected over 33 rounding days from January 22, 2018, to March 23, 2018. A 3-week rollout period was provided from March 26, 2018, to April 13, 2018, in order to allow ICU nurses to practice the use of the new rounding template. No data were collected during this rollout period. The “postimplementation” phase included data collected over 30 rounding days from April 16, 2018, to June 8, 2018. Data collected included the number of patients discussed during rounds, rounding time in hours, and attendance of a RT, clinical dietitian, and CM. Rounding time was defined as the time elapsed between the convening of rounds by the critical care physician and completion of the last patient discussion. Attendance on rounds was defined as being present for half or more of all patient discussions during rounds. All decisions regarding data collected were adjudicated by the critical care pharmacist.

Continuous, nonparametric data were summarized as medians (interquartile ranges) and compared via a Mann-Whitney U test. Categorical data were compared using the Fisher exact test. All statistical testing was completed using Minitab 17 software (Minitab Inc, State College, Pennsylvania).

Results

Study results are summarized in Table 1. The median number of ICU patients discussed on rounds was similar during the preimplementation and postimplementation phases (8 vs 7 patients, P = .115). Rounding time was decreased by 20 minutes in the postimplementation phase (80 vs 60 minutes, P = .007), which represented a 25% reduction. Additionally, attendance of RTs (15% vs 66%, P < .001), clinical dietitians (33% vs 100%, P < .001), and CMs (0% vs 97%, P < .001) significantly improved in the postimplementation period.

Table 1
Table 1:
Results

Discussion

In an effort to remedy the barriers to efficiency and effectiveness of the multidisciplinary rounding process within our ICU, we created a rounding template, standardized rounding operations, and took measures to better ensure multidisciplinary team member attendance. After implementation of a standardized rounding template, we found that rounding time was decreased by 25%. This improvement in efficiency was satisfying to many team members at our institution (many covering multiple patient areas) as time was freed up for other direct and nondirect patient care activities. The magnitude of time savings may increase in larger units with higher patient censuses. Additionally, shortening rounds may improve team member attention span and focus.4

We discovered that team members from disciplines that had either inconsistent or rare attendance on rounds prior to our standardization process attended rounds on a more consistent basis after that process was initiated. This improvement was likely a result of reinforcement of how the rounding process should optimally operate, reinforcement of the expectation that vital team members should attend and share their expertise on rounds, and the addition of a dedicated CM in the ICU.

Several studies have suggested an association between multidisciplinary rounds and improved quality in patient care, including clinical benefits for patients such as decreased length of stay and decreased mortality.1,2 These benefits have been attributed to an improvement in the comprehensiveness/effectiveness of the rounding process through addition of key attendees as well as an improvement of its efficiency and focus. We did not assess such outcomes in our study but do postulate that they would likely have improved as the result of our interventions as we were able to show improvement in both comprehensiveness (addition of personnel) and efficiency (rounding time reduction). However, confirmation of this hypothesis would require further study and methodology similar to the aforementioned studies.

The results of this study must be interpreted in the context of its limitations. First, our study is limited to proving a cause and effect relationship by its retrospective design and inability to account for all confounding variables and is therefore hypothesis generating. Also, as the data were collected only by the critical care pharmacist, the potential for recording bias cannot be ignored.

Conclusion

We report a 25% reduction in rounding time and improved multidisciplinary attendance after the introduction of a rounding template, standardized rounding operations, and measures to better ensure multidisciplinary team member attendance. We postulate that patient outcomes would have likely improved because of our efforts based on the results of past studies, but additional study is needed to confirm this hypothesis. We suggest the implementation of these strategies in other ICUs that experience similar inefficiencies and process failures during multidisciplinary or traditional rounds.

References

1. Ganesan R, Rajakumar P, Fogg L, Silvestri J, Kane JM. WE CARE 4 KIDS: use of a rounding tool in the pediatric intensive care unit. Pediatr Qual Saf. 2017;2(6):e044.
2. Fanari Z, Barekatain A, Kerzner R, Hammami S, Weintraub WS, Maheshwari V. Impact of a multidisciplinary team approach including an intensivist on the outcomes of critically ill patients in the cardiac care unit. Mayo Clin Proc. 2016;91(12):1727–1734.
3. Reimer N, Herbener L. Round and round we go: rounding strategies to impact exemplary professional practice. Clin J Oncol Nurs. 2014;18(6):654–660.
4. Dittman K, Hughes S. Increased nursing participation in multidisciplinary rounds to enhance communication, patient safety, and parent satisfaction. Crit Care Nurs Clin N Am. 2018;30:445–455.
5. Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005;33(6):1225–1229.
6. Vincent WR, Hatton KW. Critically ill patients need “FASTHUGS BID” (an updated mnemonic). Crit Care Med. 2009;37(7):2326–2327.
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