By Toni Cesta, PhD, RN, FAAN

Introduction

In the last two editions of Case Management Insider, we discussed the notion of interdisciplinary walking/bedside rounds and strategies for developing and implementing these rounds in your organization. This month, we will continue our discussion with a review of how to script rounds and what role each team member plays.

Rounding With Hospitalists

The hospitalist plays a key role in the rounding process. Hospitalists have become an increasingly visible part of the majority of hospitals and health systems today. They should play an equally integral part in the rounding process. Without hospitalists, it is very difficult to ensure that a physician is present at rounds at the same time every day unless it is a resident or an intern.

Unfortunately, some hospitals do not employ house staff or hospitalists. While their numbers are few, this can create a true dilemma for them when implementing rounds. For the majority, either a hospitalist or a house staff member can fill in the role of physician on the interdisciplinary rounding team.

The greatest barrier to ensuring that the hospitalist is in attendance or leading rounds every day is the fact that many hospitals are not assigning hospitalists to designated geographic areas — specifically, nursing units. Attendance is particularly difficult if hospitalists are scattered throughout the hospital. It becomes an impossible task for them to be at all rounds every day. It also is a scheduling nightmare for the nursing units trying to arrange these rounds.

For our discussion, we will consider the hospitalist and case manager as unit-based. This is considered best practice and should be the template for implementing effective and efficient rounds.

Scripting

Scripting is a way of organizing what each team member will be expected to say during rounds. It provides a structure for the dialogue so that team members do not spend too much time on one patient, do not veer off topic, and come prepared to present their clinical perspectives during rounds.

It also can ensure that key questions are standardized. They can be written on a goal sheet or other tool. Academic questions or discussions can be conducted in the hallway before the team enters the patient’s room. If the discussion will be longer than anticipated, that deeper conversation can be held until rounds are completed. In this way, other team members are not held up, and rounds can continue in a timely manner.

The average amount of time per patient should be 60 seconds. There will be occasions when this time may be a bit longer or shorter depending on the situation. If the patient has a lot of questions that may require additional time, the appropriate team member can return once rounds have been completed. Finally, should patients ask for non-emergent items such as tissues or water, a support staff member can bring those without disrupting the rounding process. By standardizing all of these elements, time is much more easily managed.

Scripting should include specific areas of discussion, including the following:

• Demographics

a. Name/medical record number;

b. Room number;

c. Admission date;

d. Primary team members;

e. Code status;

f. Family information;

g. Insurance information.

• Problem List

a. Pertinent medical history;

b. List of current problems;

c. Invasive tubes/devices, if any.

• Expected Tasks to be Completed

a. Labs/radiology results;

b. Order or follow up on tests.

• Diagnostic One-Liner

a. Includes age, sex, relevant medical history, and current chief reason for hospitalization.

• If/Then

a. Frequent issues to be expected with a plan to resolve in if/then format. Example: “If hypertensive, then please give hydralazine.”

• Therapeutics

a. Medications;

b. Focus on when IV meds can be switched to oral;

c. Diet with any weaning orders;

d. Oxygen with weaning instructions;

e. Progressive ambulation.

• Results and Other Important Facts

a. Labs;

b. Cultures;

c. Radiology test results;

d. Consults.

• Care Coordination

a. Expected length of stay;

b. Day of stay. Example, day three of an expected five-day stay;

c. Any patient care barriers:

i. Social;

ii. Insurance;

iii. Adherence.

The development of daily goals is a critical tool for managing length of stay and patient care progression. It provides the team with a structured, interdisciplinary approach to patient management. The development of goals is part of the scripting process, and the team should understand how to develop daily goals and see this as a mandatory part of the rounding infrastructure.

The process should be as follows:

The team should determine the key goals for that day, providing feedback and reflection on the progress toward the goals every day. Reset the goals as needed. If goals have been met, then new, forward-moving goals may need to be written. If the patient is progressing toward discharge, this may not be necessary.

Once identified, the goals should be documented so that they are readily accessible to the entire care team, as well as the patient and family. They can be documented on the patient’s white board in his or her room so that the patient and family are included in the process. By being aware of the goals, the patient and family are much more likely to be active participants in the care recovery process, rather than passive receivers of care.

The involvement of the patient and family in the rounding process is what differentiates walking rounds from other types of rounds. Including them in the discussion of daily goals will increase the likelihood of participation as active members in their care recovery. This process can be a very powerful tool in managing length of stay, reducing readmissions, and improving patient satisfaction.

It is important to orient the patient and family to rounds before inviting them to participate. A designated team member, either the staff nurse or case manager, should discuss the focus of rounds, the rounding routine, and what expectations the patient and family should have from the rounding process.

Other strategies for engaging the patient and family include posting the day and time of rounds both inside the patient’s room and in the hallways and nursing station, if appropriate.

A team member should begin bedside rounds with a brief introduction to the patient and family. This should be repeated each time rounds are conducted. Include the purpose of rounds and the time the team will spend with the patient and family. Finally, the team member should encourage the patient and family members to participate.

Physician/Hospitalist

The process for each discipline should include three phases. These are the pre-rounds, rounds, and post-rounds phases. Each phase is unique to the professional and should be included as part of the scripting process.

We will begin with the physician provider who is attending rounds.

Pre-Rounds Phase

• Listen to last 24-hour patient update;

• Discuss diagnosis;

• Enter patient orders;

• Review preliminary plan for discharge, medications, and tests.

Rounds Phase

• Sit next to patient;

• Introduce team;

• Interview patient;

• Discuss plan of care, test results, next steps, other recommendations;

• Answer any questions.

Post-Rounds Phase

• Enter orders and clarify issues;

• Enter progress notes;

• Call consulting physicians and family regarding test results;

• Summarize expectations to team members.

Resident/Intern

House staff also must be prepared to attend rounds as they often are a support to the attending of record. Below are the phases that a house officer should include when preparing and attending rounds.

Pre-Rounds Phase

• Present patient’s case to attending physician/hospitalist/team;

• Update team on patient’s condition;

• Give recommendation for the plan of care;

• Enter any orders, including medications.

Rounds Phase

• Support attending physician/hospitalist during discussion;

• Help answer any questions.

Post-Rounds Phase

• Enter patient orders as needed;

• Enter progress notes;

• Call consulting physicians as directed by attending;

• Discuss any medication reconciliation issues with clinical pharmacist.

Staff RN

The staff RN is a key player in the rounding process. During rounds, the bedside nurse can provide the interdisciplinary team with clinical updates and the patient’s progress for the past 24 hours. Conversely, he or she can ask the attending or hospitalist what the next steps and goals of care are so that he or she does not have to seek the physician out later.

This real-time communication speeds up the process of care and reduces the opportunity for things to fall through the cracks. The staff nurse should consider the following as it relates to rounding:

Pre-Rounds Phase

• Review patient progress over past 24 hours;

• Focus on any abnormal findings;

• Review any patient/family concerns;

• Identify barriers to patient discharge or throughput;

• Review any issues such as activity, Foley catheter, IV, wound vac.

Rounds Phase

• Bring laptop or other device to room;

• Discuss any gaps or delays in care;

• Listen to conversation with patient/family;

• Ask/answer questions from patient/family/team as necessary;

• Take note of orders to be written later.

Post-Rounds Phase

• Verify orders;

• Discuss and implement medication monitoring;

• Identify who will correct any gaps or delays in care;

• Make decisions about any remaining concerns;

• Document outcomes of rounds.

Case Manager

Case managers are one of the three mandatory disciplines to attend rounds. The others are the physician and the staff nurse. Case managers are key players in the exchange of information. Through their role in care coordination, they also need to understand the plan for the day as well as the stay.

Through the rounds communication process, the case manager can better understand what services are needed as well as what services may have been delayed. This is a much more efficient method for managing patient flow and can result in shortened lengths of stay and lower cost of care.

Pre-Rounds Phase

• Review admission status;

• Review case management admission assessment;

• Review initial discharge plan and patient insurance;

• Review expected length of stay and discharge date.

Rounds Phase

• Discuss expected length of stay and discharge date;

• Discuss any barriers or delays in care;

• Discuss discharge plan with team;

• Discuss the discharge plan with patient and family;

• Identify any additional patient education needs;

• Identify any triggers for referral to social work;

• Answer any questions.

Post-Rounds Phase

• Clarify next steps based on patient’s goals and progress toward expected outcomes;

• Correct any barriers or delays in care as needed;

• Document any changes to the discharge plan;

• Refer to social work as needed.

Social Worker

Depending on the case management model, the social worker may not be able to attend all rounds every day. If the social worker is covering more than one unit, he or she may have to provide patient information and updates to the RN case manager prior to rounds and be represented by the case manager on rounds.

If the social worker needs to speak with the entire team about a particular patient, then he or she must plan to attend rounds on that unit on that day.

The social worker has unique information to share related to the patient’s psychosocial, financial, and discharge planning issues that may be relevant to the entire team, and should attend accordingly.

The following action steps should be considered as the social worker prepares for rounds and/or attends rounds:

Pre-Rounds Phase

• Review case management admission assessment;

• Review reasons for referral;

• Determine patient’s psychosocial needs;

• Review the discharge plan;

• Review expected length of stay and discharge date.

Rounds Phase

• Begin psychosocial assessment;

• Address any psychosocial barriers or issues;

• Discuss anticipated date of discharge and discharge destination;

• Offer assistance and support to patient and family.

Post-Rounds Phase

• Discuss next steps based on goals achieved by patient;

• Document any updates to the discharge plan;

• Complete in-depth psychosocial assessment.

Clinical Pharmacist

The clinical pharmacist can play a key role on the interdisciplinary care team, where pharmaceutical issues can create vulnerabilities for specific patients. Examples of patients who may experience these issues might include cancer, geriatrics, or hospice.

Patients also may experience polypharmacy issues combined with a change in mental status, such as delirium. These issues can affect the patient’s outcomes, length of stay, and cost. Engaging the pharmacist as needed is a valuable aid in addressing any medication-related issues.

The rounding process for the pharmacist is as follows:

Pre-Rounds Phase

• Review daily documentation;

• Review medication profile, history, and medication reconciliation;

• Review PRN (“as needed”) medication use;

• Discuss medication concerns and abnormal lab/culture findings;

• Discuss any patients experiencing a change in mental status.

Rounds Phase

• Listen to conversation;

• Ask/answer any patient questions;

• Note orders to be placed later.

Post-Rounds Phase

• Verify orders;

• Discuss and implement medication monitoring;

• Make decisions about any medication concerns;

• Document progress notes;

• Provide medication education to patient/family as needed.

Clinical Documentation Improvement Specialist

The clinical documentation specialist (CDS) is not often included in rounds. The CDS can perform his or her role more effectively if he or she is able to attend rounds and listen to the physician’s plan of care and the patient’s progress toward outcomes, then compare this information to the actual documentation in the medical record.

Here are the process steps for the CDS:

Pre-Rounds Phase

• Review patient information in medical record;

• Listen to overview of patient.

Rounds Phase

• Listen to patient status from each member of the clinical team;

• Consider any questions to ask the physician.

Post-Rounds Phase

• Identify and/or clarify any additional diagnoses/conditions and query if necessary;

• Review physician documentation for accuracy;

• Provide any needed physician education.

Summary

In Part Three of our series on interdisciplinary walking rounds, we reviewed the role of each team member. We also discussed the importance of scripting as a tool to keep each team member’s communication timely, on-track, and relevant.

As you consider who to include on the walking rounds team, bear in mind the unique role each member can play, particularly as it relates to their contribution to the patient’s care plan and care progression.

In the next edition of Case Management Insider, we will continue our discussion with a checklist for rounds and ways to measure the outcomes of interdisciplinary walking rounds