Making Patients Part of the Team Helps Hospital Cut LOS, Boost HCAHPS Scores
Interdisciplinary rounds bring care planning to the bedside
Length of stay dropped and patient satisfaction rose when Emory Saint Joseph’s Hospital in Atlanta began holding Structured Interdisciplinary Bedside Rounds (SIBR).
- The rounds are held daily, last about an hour, and are attended by physicians, nurses, case managers, pharmacists, and other disciplines providing care for the patients.
- As team members discuss the patient’s condition, the care plan, and discharge needs, they encourage the patient and family to give their input.
- Initially, the team members were concerned about finding the time for the rounds, but they report the rounds save time by bringing the team together and eliminating phone calls and trying to track other clinicians down.
After Emory Saint Joseph’s Hospital in Atlanta began holding interdisciplinary rounds at the bedside and encouraging patients and family members to participate, length of stay dropped, patient satisfaction increased, and patient safety issues decreased on the units where the pilot was implemented.
Emory Saint Joseph’s piloted the Structured Interdisciplinary Bedside Rounds (SIBR) process on two units in 2014 and added two additional units last year.
SIBR process was developed by a team of clinicians and lay advisors at Emory Healthcare in 2010 as part of the health system’s Care Transformation initiative aimed at providing patient-and-family-centered care.
“SIBR moves the plan of care to the bedside and involves the patient and family members. We don’t talk about the patient with each other — we talk to the patients and family members and make them part of the team,” says Ginger Parks, MSN, RN, NEA-BC, unit director of Pulmonary and Internal Medicine at the 410-bed acute care hospital.
The bedside rounds are part of Emory Saint Joseph’s Accountable Care Unit model, Parks says. “It’s one component of the total package of relationships between providers and patients. Our goal is to make sure that the patient becomes a central part of the care and that all providers are on the same page,” Parks adds.
The rounds are held at the same time every day, and typically last about an hour, or three-to-five minutes per patient, Parks says. They are strictly structured and follow a specific script. The unit charge nurse is the rounds manager and keeps a list of issues that need follow-up, and makes sure the follow-up is completed.
Participants include the physician, the nurse, the case manager, a pharmacist, and any other discipline providing care for the patient. For instance, a respiratory therapist attends rounds on the pulmonary unit. Family members are encouraged to participate in the rounds and are present about 75% of the time, Parks says. “If the family isn’t there, the physician calls them after rounds and gives them an update,” she says.
“SIBR puts the patient at the center of the plan and enables them to see their care process in a different way. Having the entire team together in the same room minimizes miscommunication, identifies gaps in care, and helps us avoid errors,” she says.
The physician opens the conversation by introducing the team and giving an update on the patient’s condition and treatment plan. Each team member also provides the patient and family an update, and asks for their input. The team develops a plan for the day and talks about details of the discharge plan.
The pharmacist brings a workstation on wheels so that medication orders can be entered into the medical record at the moment they are issued. “The nurse is aware that medication has been ordered and can make sure it arrives on the unit and that the patient gets it in a timely manner,” Parks says.
The team goes over a checklist for safety issues filled out by the night shift nurses as they evaluate the patients. The list notes if patients have a Foley catheter, a central line, venous thromboembolism prevention, skin integrity issues, hypo- and/or hyperglycemia, and that applicable core measures have been completed. The night nurse also notes the insertion date of any device, vital signs, intake and output, mental status, and any concerns.
“The best way to prevent a device-related infection is to remove the device as quickly as possible. The safety checklist ensures that we have a conversation every day about whether the device is still needed,” she says.
After the rounds, the case manager, the physician, and the nurse review all of the discharges anticipated for the day to make sure everything is in place.
Case managers find the rounds particularly beneficial, Parks says. “The case manager gets a good idea of the physician’s plan for the patient, the family’s perception of the patient’s needs, any roadblocks to discharge, and other information needed to facilitate a smooth transition,” she says.
Since the rounds began, the length-of-stay index (the ratio of actual to expected length of stay) on the two units in the pilot dropped to 0.92 and 0.86, Parks reports. The two units, which treat mostly geriatric and complex patients with multiple comorbidities, have had only one patient who developed a central line infection and one patient with a catheter-associated urinary tract infection over a two-year period.
The average score on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) increased 16 points from fiscal 2015 to fiscal 2016 on the units, Parks adds.
Parks attributes the drop in length of stay to eliminating gaps in care. “In the past, we would think we were ready to discharge a patient, but would find out on the last day that something was preventing discharge. Now the team share information and we identify any roadblocks earlier,” she says.
When the SIBR was rolled out, the biggest concern among participants was how to carve out time for the rounds, but now the team members see the rounds as a way to share information more efficiently, Parks says.
“Before these rounds, the team had multiple, duplicative conversations and phone calls throughout the day to get the same information they gathered during the rounds. By rounding at the bedside, we’ve increased efficiency, and the time we’ve gained on the back end is greater than the time we spend on rounds,” she says.
Team members go through formal and internal education about the rounds and can become SIBR certified by completing a course of study. Certified staff train new employees and observe them to ensure that they are following the process.
Before implementing SIBR, the team at Emory Saint Joseph’s held tabletop rounds in a room.
“We’re still refining the process. As healthcare changes, we have to be adaptable and move people through the system faster than in the past. Patients have more complex needs than ever before, which means that preparing people to transition to the next level of care is increasingly important,” Parks says.
Length of stay dropped and patient satisfaction rose when Emory Saint Joseph’s Hospital in Atlanta began holding Structured Interdisciplinary Bedside Rounds.
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