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J Nurs Care Qual Vol. 30, No. 2, pp. 160–166 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Implementation of Patient-Centered Bedside Rounds in the Pediatric Intensive Care Unit Sandeep Tripathi, MD; Grace Arteaga, MD; Gina Rohlik, RN, CNS; Bradley Boynton, RRT; Kevin Graner, RPh; Yves Ouellette, MD, PhD Implementation of effective family-centered rounds in an intensive care unit environment is fraught with challenges. We describe the application of PDSA (Plan, Do, Study, Act) cycles in a quality improvement project to improve the process of rounds and increase family participation and provider satisfaction. We conducted pre-/postintervention surveys and used 5 process measures for a total of 1296 daily patient rounds over 7 months. We were successful in conducting familycentered rounds for 90% of patients, with 40% family participation and a 64.6% satisfactory rating by pediatric intensive care unit providers. Key words: interdisciplinary communication, familycentered rounds, patient-centered care, quality improvement, rounds
R
OUNDS and bedside reporting can be key communication strategies to engage patient involvement in care and exchange information among providers and patients. Patient engagement and communication with providers can mitigate safety errors and risks. The format of this practice may vary depending on the setting (academic or private), and the structure may vary depending on personal preference of providers. Regardless, rounds
Author Affiliation: Pediatric Intensive Care Unit, Department of Pediatrics, Mayo Clinic, Rochester, Minnesota. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). The authors declare no conflict of interest. Correspondence: Sandeep Tripathi, MD, Department of Pediatrics, Mayo Clinic, 200 1st St SW, Rochester, MN 55904 ([email protected]) Accepted for publication: September 20, 2014. Published ahead of print: December 10, 2014 DOI: 10.1097/NCQ.0000000000000107
and bedside reporting take place every morning in most of the critical care units across the country.1 Little work has been done to enhance the effectiveness or efficiency of such an important part of patient care. To our knowledge, the only randomized controlled trial regarding daily intensive care unit (ICU) rounds was conducted by Landry and colleagues2 in Quebec, Canada. The investigators in this study randomized 22 patients in the pediatric intensive care unit (PICU) to bedside and conference room rounds and analyzed family and resident satisfaction. The results showed no difference in resident satisfaction. However, family satisfaction was noted to be significantly higher with bedside presentations. In addition to being 1 of the 6 aims of health care quality described by the Institute of Medicine,3 the patient-centered model of care has been shown to improve patient as well as provider satisfaction, with a decrease in medical errors.4,5 Family-centered care encompasses the understanding that patients and their families need open, honest, and unbiased communication with all health
160
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Implementation of Patient-Centered Bedside Rounds in PICU care providers.6 In a 2003 policy statement, the American Academy of Pediatrics7 recommended physician rounding in patient rooms along with family members. Having family involvement in the decision making is the main goal of such a practice. The PICU at the Mayo Clinic is a combined medical and surgical (noncardiac) 16-bed unit, with approximately 1200 admissions per year. The daily morning rounds in the unit, although multidisciplinary, had no family (or patient) involvement, as providers preferred rounding in conference rooms, away from the bedside. The limited parent involvement in rounding practice and consequently decision making severely limited our ability to provide patient-centered care. With an overarching objective to enhance patient-centered care in the PICU, we initiated a quality improvement (QI) project to implement patient-centered rounds. In addition, we attempted to improve our multidisciplinary communication approach to rounding, decision making, and problem solving. Our approach centered on consecutive Plan, Do, Study, Act (PDSA) cycles, incorporating available peer-reviewed evidence into each cycle. The specific aims of this project included improvement in patient centeredness (to enhance patient centeredness in rounding practices in the PICU by removal of barriers): teamwork (to improve the multidisciplinary approach to rounding, decision making, and problem solving by involving bedside nurses, pharmacists, respiratory therapists, and clinical dietitians in daily patient rounds); communication (to standardize resident daily presentation); and safety (to implement nurse driven daily checklist). METHODS In this project, we used 4 PDSA cycles (see Supplemental Digital Content Table 1, available at: http://links.lww.com/JNCQ/ A150) to conduct disciplined, sequential tests of change for the purpose of making measurable improvements in PICU rounds that could be sustained. As per institutional policy, QI
161
projects are exempted from our institutional review board’s review. The QI project was initiated by the PICU leadership with the formation of a team comprising physicians, a clinical nurse specialist, pharmacists, and respiratory therapists. The team developed and conducted a preintervention survey of the multidisciplinary PICU patient care team, had a series of meetings to understand the barriers and strengths of the current system, and brainstormed ways to promote better communication among team members. A simultaneous review of literature was conducted to identify and incorporate previously described rounding strategies and best practices, including a thorough investigation of the outlines of rounding practice as described by Lane and colleagues.1 The literature review revealed 2 necessary interventions: rounds should be moved from conference rooms to a more patient-centered approach at the bedside and a nurse-driven rounding checklist would be helpful. A checklist was designed to standardize the script of rounds, involve the patient and family, establish daily patient goals, and aid in further process improvement (see Supplemental Digital Content, Figure 1, available at: http:// links.lww.com/JNCQ/A148). A standardized resident reporting script was also created (see Supplemental Digital Content, Figure 2, available at: http://links.lww.com/JNCQ/A149). Several educational sessions were conducted for all members of the multidisciplinary PICU patient care team to educate them on the format and the checklist. The content and structure of the rounding checklist and resident reporting script evolved through the PDSA cycles. Throughout the study, the completed rounding checklists were analyzed by the investigators and modifications to the checklist were made. The study also underwent monthly review by a PICU QI team. In addition, a PICU certified nursing specialist led informal focus groups throughout the study to support nurses, pharmacists, and respiratory therapists with the new process and address accomplishments, concerns, and perceived barriers. Once the rounding checklist was
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fully implemented, a postintervention survey was distributed to the multidisciplinary PICU team to determine the success of the intervention. For the purpose of this project, patientcentered rounds were defined as follows: interdisciplinary work rounds at the bedside in which the patient or family are encouraged to contribute to discussion and share in the control of the management. To determine the impact of this QI process, the following performance measures were accessed throughout the PDSA cycles: patient-centered rounds percentage, rounding checklist completion, participation of family member in rounds, daily goal completion, compliance with other patient care bundles (central line-associated blood stream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection). To ensure that our interventions did not cause unanticipated harm, we used countermeasures, which we expected would be affected adversely with this change in practice. In our study, the time it took to complete rounds and the amount of distraction during rounds would have been ideal countermeasures. However, rounds rarely progress uninterrupted and nursing interactions are necessary for duties outside of the scope of the rounding procedure, making the ideal countermeasures difficult to measure. With this change in practice, pharmacists had a more active role with patient interaction, which limited their ability to review medications in real time. Thus, the countermeasures used in this study were the multidisciplinary PICU patient care team members’ perceived length of rounds and the number of pharmaceutical interventions per patient. RESULTS PDSA cycles We used 4 distinct PDSA cycles to accomplish our objective of changing the process of PICU rounds to make them more patient-centered. In the first cycle (assessment and planning), we identified the barriers in
patient-centered rounding in the PICU by conducting a presurvey. As a result of this PDSA cycle, we created a rounding policy with standardization of the resident presentations and checklist. The second PDSA cycle focused on the execution of the bedside rounds. In this cycle, we collected predefined process measures and countermeasures and made modifications based on continuous feedback. On the basis of the feedback from stakeholders, mobile workstations with electronic medical record access were procured and provided to the staff. We implemented the third PDSA cycle to incorporate care process bundles into the nursing presentation. Daily compliance of this process was monitored, and training and education of the staff were accomplished. The last PDSA cycle was conducted to effectively implement the assessment of daily goals during bedside rounds (see Supplemental Digital Content, Table 1, available at: http://links.lww.com/JNCQ/A150). Process and countermeasures A total of 1296 multidisciplinary rounds were conducted during the various phases of the project. Of these, 300 were during the preintervention phase (rounds in the conference room), 747 during the 3 PDSA cycles, and 249 in the postimplementation phase. Using the Nursing Rounding Checklist utilization as a surrogate of the bedside rounds, we were able to consistently achieve close to 90% success in conducting rounds at the bedside. Family participation in the rounds increased from 0% to 43% with the institution of bedside rounds; however, this percentage decreased to 28% in the next phase, before rebounding back to 40%. Family participation remained stable at 38% in the postintervention stage. To increase awareness of the families regarding PICU rounding, a brochure was created with pictorial depiction of the family-centered rounding process. The Nursing Rounding Checklist completion also remained steady at 80% in various phases (Table 1). Care bundles were incorporated in the checklist in the third PDSA cycle. The
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Table 1. Results of 5 Process Measures Used to Evaluate Effectiveness of Change in Rounding Practice Intervention
1 2 3 4 5 6 7 8
Sample sizea Checklist used Family participation in rounds Checklist completion Daily goal completion CLABSI bundle compliance VAP bundle compliance CAUTI bundle compliance
Postintervention
Jul
Aug
Sep
Oct
162 91% 43% 81% NA 50% 67% 88%
335 89% 28.3% 81.9% NA 43% 71% 63%
250 87% 42% 84% 52% 57% 33% 100%
249 91.9% 38% 80% 47% 57% 62% 67%
Abbreviations: CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated blood stream infection; NA, not applicable; VAP, ventilator-associated pneumonia. a Preintervention April-June 2013; sample size = 300.
compliance with the bundles varied widely in the different phases of the study but, on average, remained around 60%. Monitoring of the daily goals started in the fourth PDSA cycle and remained close to 50% (Table 1). Total pharmacy interventions used as a countermeasure remained unchanged from a mean of 0.93 (SD = 0.14) before institution of bedside rounds to a mean of 0.925 (SD = 0.01) after the patient-centered rounds. Pre- and postintervention survey The study began with a preintervention survey of the multidisciplinary PICU team (N = 72: nurses, n = 30; respiratory therapists, n = 13; residents, n = 16; consultants, n = 6; pharmacists, n = 7; 55% response rate), which aided in the creation of the interventions. A postintervention survey (N = 63: nurses, n = 24; respiratory therapists, n = 12; residents, n = 13; consultants, n = 7; pharmacists, n = 6; dietitian, n = 1; 47% response rate) determined the impact of the interventions on the team satisfaction. When comparing the pre- and postintervention survey data, 64.6% of the PICU rounding team members were very satisfied or satisfied with the changes in the rounding practice, and only 17.7% wanted to return to the confer-
ence room. Among the team members, nurses were most satisfied with the bedside rounds practice (83.3% satisfied or very satisfied, and no one was very dissatisfied) whereas pharmacists were the least satisfied with the practice (33.3% satisfied and 50% very dissatisfied). The percentage of team members who preferred patient-centered rounds increased from 32% to 55.5% after the intervention (Table 2). Difficulty to coordinate with the subspecialist on the rounding team was the major concern in the presurvey (23.1%); this decreased to 13.7% after implementation of the bedside rounds. Interestingly, in the presurvey, 21.7% of the respondents had no concerns, whereas in the postintervention survey, only 5.8% had no concerns. This may be related to the fact that prior to implementation, providers had no experience with the practice, so they could not identify any concerns. Less teaching and rounds time were concerns that were expressed more in the postintervention survey, whereas difficulty in writing orders during rounds and coordination with subspecialist were less in the postintervention survey (see Supplemental Digital Content, Table 2, available at: http://links. lww.com/JNCQ/A151). The perceived length of patient-centered rounds showed that 35%
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Table 2. Preference of Rounding Format Among PICU Staff Before and After Implementation of Practice Change Round Format Preference
Preintervention survey Postintervention survey
Brief in the Conference Room, Followed by Bedside Reporting
Conference Room With Family Present
n
Bedside
Conference Room
72
32%
38%
26%
4%
63
55.5%
15.8%
22.2%
6.3%
Abbreviation: PICU, pediatric intensive care unit.
of the team members believed that there was not a significant increase in rounding time. Furthermore, 19.2% of the team members indicated that patient-centered rounds actually reduced rounding time and only 14% reported that they increased rounding time by more than 25%. DISCUSSION With this QI project, we demonstrated a successful change in our rounding practice in the PICU to a bedside patient-centered multidisciplinary model. We also have shown that by using the PDSA cycle, a structured, gradual change can be made and sustained. Individual PDSA cycles were guided by the stakeholders input through formal surveys and informal feedback sessions as well as the best practice recommendations by the review of literature. Lane and colleagues1 described 9 themes for patient care rounds in the ICU, and our study enhanced our practice of each of these themes and added another theme of patient centeredness. There was increased provider satisfaction with the bedside patient-centered rounding environment. These results agree with prior studies.8 Although we did not directly measure the rounding time, the subjective assessment of PICU health care providers was that
the rounding time did not increase substantially. This is in contrast to the findings of a prior study demonstrating an increase in the rounding time.9 Our results also mimic the findings of a prior study stating that distraction due to high background noise in the ICU along with round interruption is the largest impediment to bedside rounds and can decrease the quality of communication.10 Inability to effectively use electronic medical records and placement of orders was a concern among 16% of the PICU staff. We attempted to overcome this barrier by incorporating mobile workstations, which led to a decrease in this concern to 5.8% in the postintervention survey. Provision of computers to pharmacists has been shown to increase their information retrieval and increase their availability on rounds.11 In our study, the pharmacists were not satisfied with bedside rounds despite the availability of portable computers; this may also be due to short duration of the implementation, and we expect this to evolve as the process becomes more established. We incorporated a standardized rounding process involving structured presentation and explicit definition of each health care provider’s role during rounds. This approach has been shown in a prior study to significantly increase both health care provider’s satisfaction12 and quality of the discussion.
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Implementation of Patient-Centered Bedside Rounds in PICU The results from the postintervention survey demonstrated that 64.6% of the providers were either very satisfied or satisfied with the rounding process. Since communication failures are responsible for up to 70% of the sentinel events in hospitals,13,14 any intervention leading to improvement in communication has potential to improve safety and patient outcomes. Utilization of a structured checklist during rounds has been well documented. Rounding checklists have been found to increase provider satisfaction, understanding of care, communication, adherence to practice guidelines, and clinical outcomes.15 We incorporated a checklist into our rounding process to ensure adherence to practice guidelines. Completion of the checklist was monitored for compliance, and our results showed a 91.9% compliance rate at the end of the intervention. Daily goal-oriented discussion has been associated with improved patient outcomes.15 After the third PDSA cycle, we implemented policy of establishing daily goals as part of morning rounds. Multidisciplinary rounds have been associated with improved patient outcomes.16 By using the multidisciplinary approach, the discussion during rounds became more concrete and goal-oriented. Prior studies have shown that lack of accountability, role confusion among providers, and illdefined ownership and responsibility for tasks by team members are associated with significant dissatisfaction in a team involving members of different disciplines.14 Although our practice model has always been multidisciplinary in nature, the new format specified roles and allotted time for each team member to communicate. A non–team-based (hierarchical) structure of health care provider relationships leads to poor documentation and access to patient information that restrict information exchange.17 Team building and the creation of a congenial nonthreatening discussion environment were used to enhance the representation of patient’s information during rounds.
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The traditional approach to ICU rounding involves the resident or fellow presenting data, followed by discussion among health care team members, with or without the presence of nursing staff. The absence of collaborative decision making leads to decreased nurse satisfaction.18 A significant effort was made in the implementation of our model to encourage nurse participation in the decision making. We used the bedside rounding checklist to increase nurse participation, and our results demonstrated this approach to be a successful technique. Greater health care provider autonomy has been described as facilitator for the collegial workplace environment.18 The project empowered nurses, pharmacists, and respiratory therapists to express concerns and provide suggestions for patient care. The results demonstrated staff satisfaction, with nurse satisfaction to be the highest at 83.3%. While patient- and family-centered care is widely advertised by the majority of health care organizations, it is difficult to quantify the degree of family centeredness. We used family involvement in morning rounds as a surrogate marker for family-centered care. While this may be the minimal requirement, further research needs to be done to identify ideal objective and subjective markers for familycentered care. Daily morning rounds are essential for collaborative decision making for inpatient care. A patient-centered bedside rounding model allows for nursing and other health care providers to contribute meaningfully to the patient care plan. In our project, the implementation of PDSA techniques into a complex environment such as the PICU encountered several obstacles, mainly distraction and noise environment. These obstacles are not unique to our practice, but they interfere with further spread of patient-centered rounds and its application to other centers. Daily patient-centered rounds in a complex environment should be considered under the realm of health care delivery, and as such more work needs to be done to increase its efficiency.
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CONCLUSIONS Despite a growing body of literature documenting the value of evidence-based practices, effective implementation of such practices is limited. There are multiple issues in translating such complex interventions into clinical nursing practice. A well-intentioned
but poorly designed practice change can result in unintended results.19 Our current project describes an effective utilization of an evidence-based approach to implement a multidisciplinary family-centered patient care rounds in the PICU. This successful project can serve as an example for implementation of other ideas and practice changes.
REFERENCES 1. Lane D, Ferri M, Lemaire J, McLaughlin K, Stelfox H. A systematic review of evidence- informed practices for patient care rounds in the ICU. Crit Care Med. 2013;41(8):2015-2029. 2. Landry MA, Lafrenaye S, Roy MC, Lyr C. A randomized controlled trial of bedside rounds vs. conference room care presentation in a pediatric intensive care unit. Pediatrics. 2007;120(2):275-280. 3. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001. 4. Huffines M, Johnson K, Naranjo LS, Smith R. Improving family satisfaction and participation in decision making in an ICU. Crit Care Nurse. 2013;33(5):5668. 5. Taylor B, Marcantonio ER, Pagovich O, Carbo A. Do medical inpatients who report poor service quality experience more adverse events and medical errors. Med Care. 2008;46(2):224-228. 6. Sisterhen LL, Blaszak RT, Woods MB, Smith CE. Defining family-centered rounds. Teach Learn Med. 2007;19(3):319-322. 7. American Academy of Pediatrics. Committee on hospital care: family-centered care and the pediatrician role. Pediatrics. 2003;112(3):691-696. 8. Rehder KJ, Uhl TL, Meliones JN. Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit. Pediatr Crit Care Med. 2012;13:6-10. 9. Alvarez G, Coiera E. Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform. 2005;74:791-796. 10. Lyons MN, Standley TD, Gupta AK. Quality improvement of doctors’ shift-change handover in neurocritical care. Qual Saf Health Care. 2010;19:e62.
11. Cummings A, Parker CD, Kwapniowski LA, Reynolds G. Using mobility technology to improve pharmacist workflow in the PICU rounding process. J Health Inf Manag. 2008;22:39-43. 12. Dodek PM, Raboud J. Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 2003;29: 1584-1588. 13. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl):i85-i90. doi:10.1136/qshc.2004.010033 14. Blough CA, Walrath JM. Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. J Nurs Care Qual. 2007;22(2):159-163. 15. Pronovost P, Berenholtz S, Dorman T. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-75. 16. Kim MM, Barnato AE, Angus DC. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170:369376. 17. Collins SA, Bakken S, Vawdrey DK. Model development for EHR interdisciplinary information exchange of ICU common goals. Int J Med Inform. 2011;80:e141-e149. 18. Hill K. The sound of silence—nurses’ non-verbal interaction within the ward round. Nurs Crit Care. 2003;8:231-239. 19. Deitrick LM, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual. 2012;27(1):13-19.
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J Nurs Care Qual Vol. 30, No. 2, pp. 160–166 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Implementation of Patient-Centered Bedside Rounds in the Pediatric Intensive Care Unit Sandeep Tripathi, MD; Grace Arteaga, MD; Gina Rohlik, RN, CNS; Bradley Boynton, RRT; Kevin Graner, RPh; Yves Ouellette, MD, PhD Implementation of effective family-centered rounds in an intensive care unit environment is fraught with challenges. We describe the application of PDSA (Plan, Do, Study, Act) cycles in a quality improvement project to improve the process of rounds and increase family participation and provider satisfaction. We conducted pre-/postintervention surveys and used 5 process measures for a total of 1296 daily patient rounds over 7 months. We were successful in conducting familycentered rounds for 90% of patients, with 40% family participation and a 64.6% satisfactory rating by pediatric intensive care unit providers. Key words: interdisciplinary communication, familycentered rounds, patient-centered care, quality improvement, rounds
R
OUNDS and bedside reporting can be key communication strategies to engage patient involvement in care and exchange information among providers and patients. Patient engagement and communication with providers can mitigate safety errors and risks. The format of this practice may vary depending on the setting (academic or private), and the structure may vary depending on personal preference of providers. Regardless, rounds
Author Affiliation: Pediatric Intensive Care Unit, Department of Pediatrics, Mayo Clinic, Rochester, Minnesota. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). The authors declare no conflict of interest. Correspondence: Sandeep Tripathi, MD, Department of Pediatrics, Mayo Clinic, 200 1st St SW, Rochester, MN 55904 ([email protected]) Accepted for publication: September 20, 2014. Published ahead of print: December 10, 2014 DOI: 10.1097/NCQ.0000000000000107
and bedside reporting take place every morning in most of the critical care units across the country.1 Little work has been done to enhance the effectiveness or efficiency of such an important part of patient care. To our knowledge, the only randomized controlled trial regarding daily intensive care unit (ICU) rounds was conducted by Landry and colleagues2 in Quebec, Canada. The investigators in this study randomized 22 patients in the pediatric intensive care unit (PICU) to bedside and conference room rounds and analyzed family and resident satisfaction. The results showed no difference in resident satisfaction. However, family satisfaction was noted to be significantly higher with bedside presentations. In addition to being 1 of the 6 aims of health care quality described by the Institute of Medicine,3 the patient-centered model of care has been shown to improve patient as well as provider satisfaction, with a decrease in medical errors.4,5 Family-centered care encompasses the understanding that patients and their families need open, honest, and unbiased communication with all health
160
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Implementation of Patient-Centered Bedside Rounds in PICU care providers.6 In a 2003 policy statement, the American Academy of Pediatrics7 recommended physician rounding in patient rooms along with family members. Having family involvement in the decision making is the main goal of such a practice. The PICU at the Mayo Clinic is a combined medical and surgical (noncardiac) 16-bed unit, with approximately 1200 admissions per year. The daily morning rounds in the unit, although multidisciplinary, had no family (or patient) involvement, as providers preferred rounding in conference rooms, away from the bedside. The limited parent involvement in rounding practice and consequently decision making severely limited our ability to provide patient-centered care. With an overarching objective to enhance patient-centered care in the PICU, we initiated a quality improvement (QI) project to implement patient-centered rounds. In addition, we attempted to improve our multidisciplinary communication approach to rounding, decision making, and problem solving. Our approach centered on consecutive Plan, Do, Study, Act (PDSA) cycles, incorporating available peer-reviewed evidence into each cycle. The specific aims of this project included improvement in patient centeredness (to enhance patient centeredness in rounding practices in the PICU by removal of barriers): teamwork (to improve the multidisciplinary approach to rounding, decision making, and problem solving by involving bedside nurses, pharmacists, respiratory therapists, and clinical dietitians in daily patient rounds); communication (to standardize resident daily presentation); and safety (to implement nurse driven daily checklist). METHODS In this project, we used 4 PDSA cycles (see Supplemental Digital Content Table 1, available at: http://links.lww.com/JNCQ/ A150) to conduct disciplined, sequential tests of change for the purpose of making measurable improvements in PICU rounds that could be sustained. As per institutional policy, QI
161
projects are exempted from our institutional review board’s review. The QI project was initiated by the PICU leadership with the formation of a team comprising physicians, a clinical nurse specialist, pharmacists, and respiratory therapists. The team developed and conducted a preintervention survey of the multidisciplinary PICU patient care team, had a series of meetings to understand the barriers and strengths of the current system, and brainstormed ways to promote better communication among team members. A simultaneous review of literature was conducted to identify and incorporate previously described rounding strategies and best practices, including a thorough investigation of the outlines of rounding practice as described by Lane and colleagues.1 The literature review revealed 2 necessary interventions: rounds should be moved from conference rooms to a more patient-centered approach at the bedside and a nurse-driven rounding checklist would be helpful. A checklist was designed to standardize the script of rounds, involve the patient and family, establish daily patient goals, and aid in further process improvement (see Supplemental Digital Content, Figure 1, available at: http:// links.lww.com/JNCQ/A148). A standardized resident reporting script was also created (see Supplemental Digital Content, Figure 2, available at: http://links.lww.com/JNCQ/A149). Several educational sessions were conducted for all members of the multidisciplinary PICU patient care team to educate them on the format and the checklist. The content and structure of the rounding checklist and resident reporting script evolved through the PDSA cycles. Throughout the study, the completed rounding checklists were analyzed by the investigators and modifications to the checklist were made. The study also underwent monthly review by a PICU QI team. In addition, a PICU certified nursing specialist led informal focus groups throughout the study to support nurses, pharmacists, and respiratory therapists with the new process and address accomplishments, concerns, and perceived barriers. Once the rounding checklist was
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fully implemented, a postintervention survey was distributed to the multidisciplinary PICU team to determine the success of the intervention. For the purpose of this project, patientcentered rounds were defined as follows: interdisciplinary work rounds at the bedside in which the patient or family are encouraged to contribute to discussion and share in the control of the management. To determine the impact of this QI process, the following performance measures were accessed throughout the PDSA cycles: patient-centered rounds percentage, rounding checklist completion, participation of family member in rounds, daily goal completion, compliance with other patient care bundles (central line-associated blood stream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection). To ensure that our interventions did not cause unanticipated harm, we used countermeasures, which we expected would be affected adversely with this change in practice. In our study, the time it took to complete rounds and the amount of distraction during rounds would have been ideal countermeasures. However, rounds rarely progress uninterrupted and nursing interactions are necessary for duties outside of the scope of the rounding procedure, making the ideal countermeasures difficult to measure. With this change in practice, pharmacists had a more active role with patient interaction, which limited their ability to review medications in real time. Thus, the countermeasures used in this study were the multidisciplinary PICU patient care team members’ perceived length of rounds and the number of pharmaceutical interventions per patient. RESULTS PDSA cycles We used 4 distinct PDSA cycles to accomplish our objective of changing the process of PICU rounds to make them more patient-centered. In the first cycle (assessment and planning), we identified the barriers in
patient-centered rounding in the PICU by conducting a presurvey. As a result of this PDSA cycle, we created a rounding policy with standardization of the resident presentations and checklist. The second PDSA cycle focused on the execution of the bedside rounds. In this cycle, we collected predefined process measures and countermeasures and made modifications based on continuous feedback. On the basis of the feedback from stakeholders, mobile workstations with electronic medical record access were procured and provided to the staff. We implemented the third PDSA cycle to incorporate care process bundles into the nursing presentation. Daily compliance of this process was monitored, and training and education of the staff were accomplished. The last PDSA cycle was conducted to effectively implement the assessment of daily goals during bedside rounds (see Supplemental Digital Content, Table 1, available at: http://links.lww.com/JNCQ/A150). Process and countermeasures A total of 1296 multidisciplinary rounds were conducted during the various phases of the project. Of these, 300 were during the preintervention phase (rounds in the conference room), 747 during the 3 PDSA cycles, and 249 in the postimplementation phase. Using the Nursing Rounding Checklist utilization as a surrogate of the bedside rounds, we were able to consistently achieve close to 90% success in conducting rounds at the bedside. Family participation in the rounds increased from 0% to 43% with the institution of bedside rounds; however, this percentage decreased to 28% in the next phase, before rebounding back to 40%. Family participation remained stable at 38% in the postintervention stage. To increase awareness of the families regarding PICU rounding, a brochure was created with pictorial depiction of the family-centered rounding process. The Nursing Rounding Checklist completion also remained steady at 80% in various phases (Table 1). Care bundles were incorporated in the checklist in the third PDSA cycle. The
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Implementation of Patient-Centered Bedside Rounds in PICU
163
Table 1. Results of 5 Process Measures Used to Evaluate Effectiveness of Change in Rounding Practice Intervention
1 2 3 4 5 6 7 8
Sample sizea Checklist used Family participation in rounds Checklist completion Daily goal completion CLABSI bundle compliance VAP bundle compliance CAUTI bundle compliance
Postintervention
Jul
Aug
Sep
Oct
162 91% 43% 81% NA 50% 67% 88%
335 89% 28.3% 81.9% NA 43% 71% 63%
250 87% 42% 84% 52% 57% 33% 100%
249 91.9% 38% 80% 47% 57% 62% 67%
Abbreviations: CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated blood stream infection; NA, not applicable; VAP, ventilator-associated pneumonia. a Preintervention April-June 2013; sample size = 300.
compliance with the bundles varied widely in the different phases of the study but, on average, remained around 60%. Monitoring of the daily goals started in the fourth PDSA cycle and remained close to 50% (Table 1). Total pharmacy interventions used as a countermeasure remained unchanged from a mean of 0.93 (SD = 0.14) before institution of bedside rounds to a mean of 0.925 (SD = 0.01) after the patient-centered rounds. Pre- and postintervention survey The study began with a preintervention survey of the multidisciplinary PICU team (N = 72: nurses, n = 30; respiratory therapists, n = 13; residents, n = 16; consultants, n = 6; pharmacists, n = 7; 55% response rate), which aided in the creation of the interventions. A postintervention survey (N = 63: nurses, n = 24; respiratory therapists, n = 12; residents, n = 13; consultants, n = 7; pharmacists, n = 6; dietitian, n = 1; 47% response rate) determined the impact of the interventions on the team satisfaction. When comparing the pre- and postintervention survey data, 64.6% of the PICU rounding team members were very satisfied or satisfied with the changes in the rounding practice, and only 17.7% wanted to return to the confer-
ence room. Among the team members, nurses were most satisfied with the bedside rounds practice (83.3% satisfied or very satisfied, and no one was very dissatisfied) whereas pharmacists were the least satisfied with the practice (33.3% satisfied and 50% very dissatisfied). The percentage of team members who preferred patient-centered rounds increased from 32% to 55.5% after the intervention (Table 2). Difficulty to coordinate with the subspecialist on the rounding team was the major concern in the presurvey (23.1%); this decreased to 13.7% after implementation of the bedside rounds. Interestingly, in the presurvey, 21.7% of the respondents had no concerns, whereas in the postintervention survey, only 5.8% had no concerns. This may be related to the fact that prior to implementation, providers had no experience with the practice, so they could not identify any concerns. Less teaching and rounds time were concerns that were expressed more in the postintervention survey, whereas difficulty in writing orders during rounds and coordination with subspecialist were less in the postintervention survey (see Supplemental Digital Content, Table 2, available at: http://links. lww.com/JNCQ/A151). The perceived length of patient-centered rounds showed that 35%
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Table 2. Preference of Rounding Format Among PICU Staff Before and After Implementation of Practice Change Round Format Preference
Preintervention survey Postintervention survey
Brief in the Conference Room, Followed by Bedside Reporting
Conference Room With Family Present
n
Bedside
Conference Room
72
32%
38%
26%
4%
63
55.5%
15.8%
22.2%
6.3%
Abbreviation: PICU, pediatric intensive care unit.
of the team members believed that there was not a significant increase in rounding time. Furthermore, 19.2% of the team members indicated that patient-centered rounds actually reduced rounding time and only 14% reported that they increased rounding time by more than 25%. DISCUSSION With this QI project, we demonstrated a successful change in our rounding practice in the PICU to a bedside patient-centered multidisciplinary model. We also have shown that by using the PDSA cycle, a structured, gradual change can be made and sustained. Individual PDSA cycles were guided by the stakeholders input through formal surveys and informal feedback sessions as well as the best practice recommendations by the review of literature. Lane and colleagues1 described 9 themes for patient care rounds in the ICU, and our study enhanced our practice of each of these themes and added another theme of patient centeredness. There was increased provider satisfaction with the bedside patient-centered rounding environment. These results agree with prior studies.8 Although we did not directly measure the rounding time, the subjective assessment of PICU health care providers was that
the rounding time did not increase substantially. This is in contrast to the findings of a prior study demonstrating an increase in the rounding time.9 Our results also mimic the findings of a prior study stating that distraction due to high background noise in the ICU along with round interruption is the largest impediment to bedside rounds and can decrease the quality of communication.10 Inability to effectively use electronic medical records and placement of orders was a concern among 16% of the PICU staff. We attempted to overcome this barrier by incorporating mobile workstations, which led to a decrease in this concern to 5.8% in the postintervention survey. Provision of computers to pharmacists has been shown to increase their information retrieval and increase their availability on rounds.11 In our study, the pharmacists were not satisfied with bedside rounds despite the availability of portable computers; this may also be due to short duration of the implementation, and we expect this to evolve as the process becomes more established. We incorporated a standardized rounding process involving structured presentation and explicit definition of each health care provider’s role during rounds. This approach has been shown in a prior study to significantly increase both health care provider’s satisfaction12 and quality of the discussion.
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Implementation of Patient-Centered Bedside Rounds in PICU The results from the postintervention survey demonstrated that 64.6% of the providers were either very satisfied or satisfied with the rounding process. Since communication failures are responsible for up to 70% of the sentinel events in hospitals,13,14 any intervention leading to improvement in communication has potential to improve safety and patient outcomes. Utilization of a structured checklist during rounds has been well documented. Rounding checklists have been found to increase provider satisfaction, understanding of care, communication, adherence to practice guidelines, and clinical outcomes.15 We incorporated a checklist into our rounding process to ensure adherence to practice guidelines. Completion of the checklist was monitored for compliance, and our results showed a 91.9% compliance rate at the end of the intervention. Daily goal-oriented discussion has been associated with improved patient outcomes.15 After the third PDSA cycle, we implemented policy of establishing daily goals as part of morning rounds. Multidisciplinary rounds have been associated with improved patient outcomes.16 By using the multidisciplinary approach, the discussion during rounds became more concrete and goal-oriented. Prior studies have shown that lack of accountability, role confusion among providers, and illdefined ownership and responsibility for tasks by team members are associated with significant dissatisfaction in a team involving members of different disciplines.14 Although our practice model has always been multidisciplinary in nature, the new format specified roles and allotted time for each team member to communicate. A non–team-based (hierarchical) structure of health care provider relationships leads to poor documentation and access to patient information that restrict information exchange.17 Team building and the creation of a congenial nonthreatening discussion environment were used to enhance the representation of patient’s information during rounds.
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The traditional approach to ICU rounding involves the resident or fellow presenting data, followed by discussion among health care team members, with or without the presence of nursing staff. The absence of collaborative decision making leads to decreased nurse satisfaction.18 A significant effort was made in the implementation of our model to encourage nurse participation in the decision making. We used the bedside rounding checklist to increase nurse participation, and our results demonstrated this approach to be a successful technique. Greater health care provider autonomy has been described as facilitator for the collegial workplace environment.18 The project empowered nurses, pharmacists, and respiratory therapists to express concerns and provide suggestions for patient care. The results demonstrated staff satisfaction, with nurse satisfaction to be the highest at 83.3%. While patient- and family-centered care is widely advertised by the majority of health care organizations, it is difficult to quantify the degree of family centeredness. We used family involvement in morning rounds as a surrogate marker for family-centered care. While this may be the minimal requirement, further research needs to be done to identify ideal objective and subjective markers for familycentered care. Daily morning rounds are essential for collaborative decision making for inpatient care. A patient-centered bedside rounding model allows for nursing and other health care providers to contribute meaningfully to the patient care plan. In our project, the implementation of PDSA techniques into a complex environment such as the PICU encountered several obstacles, mainly distraction and noise environment. These obstacles are not unique to our practice, but they interfere with further spread of patient-centered rounds and its application to other centers. Daily patient-centered rounds in a complex environment should be considered under the realm of health care delivery, and as such more work needs to be done to increase its efficiency.
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CONCLUSIONS Despite a growing body of literature documenting the value of evidence-based practices, effective implementation of such practices is limited. There are multiple issues in translating such complex interventions into clinical nursing practice. A well-intentioned
but poorly designed practice change can result in unintended results.19 Our current project describes an effective utilization of an evidence-based approach to implement a multidisciplinary family-centered patient care rounds in the PICU. This successful project can serve as an example for implementation of other ideas and practice changes.
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