This month we are going to focus on interdisciplinary rounds — more specifically, walking or bedside rounds. Bedside rounds have fallen in and out of favor over the years, but more recently have become increasingly popular. Recognized as a tool for improving efficiency and communication, they have been endorsed by the Institute for Healthcare Improvement (www.ihi.org) and The Joint Commission (www.jointcommission.org). They are also an effective and efficient tool for hospital case managers to use to gather information on their patients and to hear the plans of the other members of the interdisciplinary care team.
Teams and Communication
In order for teams to be the most effective, they must have hard-wired communication processes in place. These formal processes for communication are enhanced with informal means of communication that happen throughout the day between and among caregivers. Additionally, case managers must consider all the methods by which they communicate. For example, case managers conduct elements of vertical communication which might include communication with the case management department leader, the physician advisor, or case management extender.
Case managers also participate in horizontal communication on a routine basis, including communication with nurses, physicians, hospitalists, radiologists, lab technicians, and pharmacists. There are a lot of individuals and departments that require constant input and information-sharing with case managers. So, how do case managers keep all these communication channels synchronized and organized?
Part of the solution includes handoff communication. Handoffs occur when a patient is transferred from one caregiver to another for a day or for the remainder of an episode of care. Case managers hand off their patients to social workers, other case managers, next level of care providers, nursing unit managers, and others. The Joint Commission’s Patient Safety Goal Number 2 emphasizes the need to improve effective communication among caregivers. It speaks to the need for effective communication to be in the form of written as well as verbal communication and recommends five expectations for effective handoffs:
1. Interactive communication allowing for the opportunity for questioning between the givers and receivers of patient information.
2. Up-to-date information regarding the patient’s care, treatment and services, condition, and any recent or anticipated changes.
3. A process for verification of the received information, including repeat-back or read-back, as appropriate.
4. An opportunity for the receiver of the handoff information to review relevant patient historical data, which may include previous care, treatment, and services.
5. Interruptions during handoffs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten.
How do these five strategies apply to case management? They tell us that as case managers we must be sure to have interactions that are communicative as we hand off patients, not just written notes or reminders. These interactions should be comprehensive and include details as outlined in numbers 2 and 4 above. We should have a process to ensure that the person receiving our information understands it, and finally, we should be sure to conduct the handoff in a location where we can be sure to have minimal interruptions.
There are a variety of tools for effective handoffs. Below is a list that includes the department primarily responsible for the process.
• Change of shift rounds: Dept. of Nursing
• Teaching rounds: Dept. of Medicine
• Patient care conferences: Interdisciplinary
• Huddles: Interdisciplinary
• Internal patient transfers: Interdisciplinary
• Walking rounds: Interdisciplinary
Patient Care Conferences
Patient care conferences are used as an adjunct to walking rounds and are planned when more detailed information needs to be conveyed than can be done in the walking rounds format. These rounds may also include family members. Consider patient care conferences when the specific patient case is complex or involves legal, ethical, or other similar issues.
Huddles are a shortened version of patient care rounds. They are typically conducted in the afternoon as a follow-up to the rounds done in the morning. Huddles can be scheduled or impromptu, but are typically scheduled. If the huddle is a routine meeting that is a follow-up to morning walking rounds, then it is usually attended by a staff RN, case manager, and physician.
Internal Patient Transfers
When patients move from one unit to the other or from the emergency department to an inpatient unit, there should be written summaries and verbal exchanges of information between case managers and/or social workers. This is one area in which case managers often fall short.
Why Walking Rounds
Walking rounds, or bedside rounds, enable all members of the healthcare team who are caring for a specific patient to offer their individual expertise and make informed contributions to the care of that patient. During walking rounds, all the various disciplines are able to come together to better coordinate the patient’s care. Walking rounds also improve communication among and between the team members. The IHI and The Joint Commission both consider walking rounds as best practice. According to the Center for Patient Safety, standardizing work is one of the best ways to reduce errors (www.centerforpatientsafety.org).
In addition, walking rounds are a critical element of patient flow. They are a tool for identifying delays in patient care processes as they are happening and take action to correct them using the resources of the entire care team. Walking rounds are not change of shift report. They are an interdisciplinary care planning tool where expected outcomes of care, barriers to care, care transitions, and discharge information can be shared among the team members.
The Focus for Rounds
There are a number of elements to focus on for walking rounds. During rounds, each of these elements should be focused on as part of the “talking points.” We will discuss more on the talking points later. The elements listed below can be used to support your hospital’s rounds talking points.
• Coordination of care: This component is key to the walking rounds process. Coordination of care should begin with a review of the patient’s current status with input from each team member. This should be followed by a discussion and clarification of the patient’s goals and expected outcomes of care. Finally, a comprehensive plan of care should be developed or modified as appropriate.
• Communication: Rounds is the best time to discuss any issues associated with patient safety, patient education, and daily goals. By communicating together as a team, the group can be better assured that a consistent approach will be used by all the team members.
Key Components to Consider When Developing Rounds
The following steps, while not necessarily linear, are essential elements for the development of the rounding process.
1. Identify and refine your goals for rounds. The rounds development team should determine what the purpose is for rounding in your organization and reach consensus from the group as to what the goals of rounding will be. The goals should be consistent throughout the organization regardless of the unit or specialty service.
2. Create a structure and stick to it. The rounds development team should define the structure for rounds prior to implementation. This structure should be consistent throughout the organization so that whatever unit is rounding should have a similar process.
3. Identify the leader of rounds. The leader should be identified by discipline or job title. This might be a physician, hospitalist, nurse manager or case manager, for example. Whenever possible, the leader should be consistent regardless of unit or specialty. A back-up to the leader should also be identified.
4. Pick a standard time for rounds each day. A time should be selected that is mandatory and applied consistently on every unit. The only exception to this might be the critical care units.
5. Engage with the patient and the family. A mechanism for including the patient and family in rounds should also be established. This might include discussions with them at the bedside, and additional patient care conferences as needed.
6. Measure success. Before beginning your organization-wide rounds, have the rounds development team identify the ways in which you might measure the success of your rounding process. Collect pre-implementation data before you begin.
Who Should Attend Rounds?
There is a minimum list of disciplines that should be attending rounds, and others can be added as needed. With the patient at the center, recommended team members should include the staff nurse caring for the patient, the hospitalist or physician of record, and the case manager. Additional disciplines can be added as needed. Additional team members will be dependent on the specialty of the nursing unit. For example, if the unit specializes in orthopedics, then it would be recommended that a physical therapist be included in rounds. On a geriatric unit, a nutritionist might be a good addition. At a minimum, be sure that the team members selected represent all relevant disciplines. Some may need to be added on an ad hoc basis as well.
Strategies for Getting Started
A good first step is to leverage your existing rounds processes. It is possible that some of your nursing units already conduct some form of a rounding process. This may be in a conference room or bedside. Conduct an assessment of the current rounds on the units that have them and compile a spreadsheet outlining the similarities and differences between them. Some of the existing rounds may already be in the format that the rounds planning committee has established and will need little to no revision or change. Others may be totally off the mark and need complete revision to their existing processes.
The next step would be to seek out one or two nursing units that are willing to participate. Willing participants increase the likelihood that you will be successful with the first units that are implemented. Start small by implementing on one or two units first. In this way, you can identify any issues that may need to be adjusted or corrected and make those corrections before you go any further.
Start by educating the team members as to the goals of the rounds and the processes. Segment the processes so that team members can gradually embrace the elements of the rounding process.
The rounds planning team should develop a daily documentation tool that can be placed in the electronic medical record and be used to document the attendees of rounds and the outcomes. Each patient should have a daily goal documented and agreed on by the interdisciplinary team. Track interventions and patient outcomes against these goals on rounds each day and get feedback from each team member caring for the patient.
Scheduling the rounds by nursing beds is a good way to frame the structure. Identify the beds assigned to each staff nurse and cohort the beds accordingly. If you need to round with a specialty physician, then focus on those patients with that physician.
Scripting, or developing “talking points” for the team, can increase the likelihood that the rounds will be kept to the key elements and not take too long. Standardize the key questions that the team wants to answer as well as the questions that the team wants to address with the patient and family. Write them on the goal sheet or some other tool. Use the scripting as a means of keeping the discussion of each patient to sixty seconds on the average. Remind the team to keep academic discussion related to anatomy and pathophysiology, medications, or similar issues out of the patient’s room unless the patient specifically asks to be included in these discussions.
Part of the scripting should include what will be said to the patient as well as how to manage the patient and family’s expectations. Be sure to include something about addressing patient questions that may require more time. Let the patient know that someone will come back after the rounds are completed to address their questions. Also plan to have support staff trained to bring the patients water, tissues, or other such items if they ask for them during rounds.
Format for Scripting
Item #1: Diagnostic one-liner. A diagnostic one-liner should include the age, sex, relevant history related to the current problem, and the current chief complaint or reason for hospitalization. This is a good way to begin the rounding discussion.
Item #2: Demographics. The patient’s demographics should be included in the scripting. Demographics should include the following:
• Admission date
• Expected length of stay
• Primary physician
• Insurance information
• Relevant family information or other support systems
Item #3: Problem list. The problem list should cover any pertinent medical history. Pertinent medical history refers to medical or surgical problems or events that may have relevance to the current hospitalization. You may want to use a systems-based list of current medical problems. Include a discussion of any invasive tubes or devices currently in use. Included in this should be Foley catheters, drains, or other such similar devices.
Item #4: Expected tasks to be completed or ordered. Expected tasks to be completed might include laboratory or radiology tests that have yet to be done or other diagnostics not yet completed. Delays such as these can have a negative impact on cost, quality of care, and length of stay and should always be included in a rounds discussion.
Additionally, any tests needed to be ordered should also be discussed. This is the time to identify any gaps in care and address them with the team. The physician can then follow up with an order if that is what is lacking.
Item #5: If/Then. Frequent issues to be expected that will need a plan to resolve can be discussed in an if/then format. For example, “If patient is hypertensive, then give hydralazine”. This format can be used to reinforce any practice guidelines that you may have by standardizing the intervention associated with a specific diagnostic finding or physical assessment.
Item #6: Therapeutics. The discussion should also include a review of therapeutics or treatments the patient is currently receiving, such as the following:
• IV meds — focus on when they can be switched to oral
• Diet with any weaning orders
• Oxygen with any weaning instructions
• Progressive ambulation
Item #7: Results and other important facts related to:
• Radiology test results
Item #8: Care coordination. The case manager should interject with the patient’s expected length of stay, plus any patient care barriers of a social or insurance nature that might impede the patient’s ability to be discharged.
This month, we began our discussion of walking rounds with an overview of why rounds are important and how you might begin to structure rounds in your organization. Because IHI and TJC both identify walking rounds as best practice, we have focused our discussion on the elements needed for a successful walking rounds process.
Next month, we will continue our discussion of walking rounds with strategies for preparing for rounds, as well as how to engage the patient and family in the rounding process.