Critical Path Network

Multidisciplinary rounds at bedside involve patients, families

Win-win situation lowers LOS, improves satisfaction

After Concord (NH) Hospital's multidisciplinary cardiac care team began holding daily collaborative rounds with patients and family members on the cardiac patient care unit, length of stay decreased and patient satisfaction scores rose.

The entire cardiac surgery team holds 10-minute briefings at every bedside each weekday, to review the patient's care plan and progress, determine his or her needs, and clarify each team member's responsibility for the patient's care that day.

The patient always is the center of the team and is encouraged to make comments and ask questions and family members are invited to participate, says Addie Camelio, BSW, social worker on the cardiac care team.

Improving care coordination

The hospital initiated the rounds as a pilot project in 2000 as a way to improve care coordination for cardiac surgery patients.

"We started looking at how we could better coordinate care for our cardiac population. All of the disciplines that provide care for cardiac patients are very busy. We decided that rounds at the bedside, with the whole team and the patient and family participating, would help us all communicate with each other as well as with the patient and family members," Camelio says.

The 230-bed community hospital treats about 250 patients a year in its cardiac surgery program. The Center for Cardiac Care includes a dedicated cardiac operating suite, two cardiac catheterization labs, a telemetry and cardiac intensive care unit, comprehensive cardiac rehabilitation facilities, and a heart failure program.

The rounds, led by a nurse practitioner, begin while the patient still is in the intensive care unit following cardiac surgery and continue when the patient moves to the progressive care unit and until discharge. The same team follows the patient throughout the stay.

The multidisciplinary team includes the surgeon, bedside nurse, nurse practitioner, social worker, care coordinator, pharmacist, physical therapists, and occupational therapists. At Concord Hospital, care coordinators and social workers are assigned by unit and work together as a team. The same team coordinates care for cardiac patients in the intensive care unit and the progressive care unit.

The team asks patients for permission to come to their bedside and talk about their care and invites family members to be involved as well. In eight years, only two patients have refused to allow the rounds. The vast majority of family members welcome the opportunity to attend and participate, Camelio adds.

"We were very pleased with the reception of the patients and family members who participate. It is an opportunity for the team to get to know them and for the family to get to know everyone who was treating their loved one," she says.

Holding rounds at the bedside with the entire team is a departure from the normal rounds and is a win-win situation for the treatment team as well as the patients and family members, Camelio says.

Since the average length of stay for cardiac surgery patients is only four days, timely communication between team members is extremely important, she adds.

"Instead of going back and reading notes, we have the entire team together, and we can work together to help the patient progress. We're not making phone calls or paging each other to find out what is going on with the patient. We are able to catch up with each other and compare notes. The therapist is with the surgeon and they both know what is happening," she says.

The arrangement benefits the team members because each discipline knows what the others are planning for that day.

For instance, cardiac patients must be able to walk for six minutes before they can be discharged. If the physical therapist is doing a six-minute walk that day, Camelio knows to complete everything that is needed for discharge.

"There are certain things that cardiac patients have to do before discharge. Now there is no delay in these things happening because the team is all on the same page. There's no delay in the physicians' orders," she explains.

Rather than being physician-driven, the rounds are team-driven.

"The physician still has the last word, but the team is very savvy about what should be happening with the patient, and in many cases, we don't have to wait for the physician to write an order to act," Camelio says.

For instance, if a patient isn't progressing during therapy and the physical therapist feels he or she needs a rehabilitation consultation, the therapist can ask for the order during the rounds and set up the consultation, rather than trying to track down the physician and possibly delaying the discharge.

"We are more proactive than reactive. The result is a smoother hospital stay, a shorter length of stay, and happier patients," Camelio says.

The rounds allow the treatment team to get to know the patient and the family and to learn more about family dynamics and the situation at home, she notes.

"I know who will be at home with the patients and whether or not they will be able to provide care after discharge or if the patient will need some kind of assistance. This knowledge helps as we start planning the discharge right away," Camelio adds.

Most family members show up for the rounds and welcome the interaction with the team.

"Everybody wants the team to come in. Patients on other units ask what they have to do to get that kind of attention," she says.

Families appreciate having the entire team present, rather than having to talk to each one individually to find out about the patient's condition and progress, Camelio reports.

"We no longer have a lot of calls from patients and family members who have questions or concerns. I never anticipated the gratefulness that patients and family members express. It's very rewarding," she says.

The multidisciplinary rounds help educate the family on what the patient needs to be able to accomplish before being discharged and helps eliminate their fears of caring for someone who has had open heart surgery, Camelio says.

Even if the patient is extremely ill or on a ventilator, the family still wants to meet to learn what's happening with the patient, to go over the plan for the day and the long-term outlook.

When the team started the multidisciplinary rounds, they kept a "glitch book" in which they wrote down anything the patient and family members said had gone wrong during the stay.

Glitches ranged from the paper towel dispenser being jammed to medication errors.

The team tracked the glitches, looked for causes, and came up with solutions.

For instance, when the physicians couldn't get X-rays when they needed them, the team invited the radiology department to a meeting and discussed how the schedules of the cardiac team and the radiology schedule could better mesh.

The team no longer tracks the glitches but when a glitch occurs, someone on the team takes the initiative to take care of it and reports back the next day.

"It's a matter of teamwork. Everybody works together to make sure that that patients get everything they need and that the process goes smoothly," Camelio says.