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By Toni Cesta, PhD, RN, FAAN
This month, we conclude our four-part series on the topic of interdisciplinary care rounds. We have focused on why interdisciplinary walking rounds are so important for care coordination, patient throughput, patient satisfaction, and many other outcomes. We discussed the roles of each team member when conducting interdisciplinary rounds, particularly walking bedside rounds. We also reviewed how team members can prepare for rounds, how they should conduct themselves during rounds, and what tasks may need to be completed following rounds.
In this issue, we will focus on talking points for rounds, documentation related to rounds, measuring the success of rounds, and how to manage your rounding process in the future.
Bedside rounds must be carefully managed and choreographed. The management of rounds is critical to success. Rounds that are too long or do not stay on topic will result in poorer outcomes and may ultimately fail as members stop attending. To ensure a greater measure of success, the team planning for implementation of new rounds or revision of existing rounds must spend time developing talking points for each team member.
First, there should be general rules of the road for team members. These rules should be hardwired and adhered to at all times. These rules should include the following:
• Rounds must take place at a consistent time daily;
• All key members of the interdisciplinary team are expected to attend and to be on time;
• Rounds begin when the facilitator or team lead is in attendance;
• Each team member must come prepared to present at rounds and stay true to his or her talking points;
• Each team member should spend no more than two minutes on any one patient. If additional time is needed, that patient should be discussed after rounds.
The physician attending rounds often is the leader of rounds. The physician leader sets the tone and the timing for rounds. He or she should discuss the following talking points:
• The reason for hospitalization;
• The plan of care;
• Expected length of stay;
• Expected outcomes for the day and for the hospital stay;
• The discharge plan;
• Any delays or barriers.
The staff nurse is expected to present his or her assignment of patients, and leave the rounds to return to direct patient care.
The nurse brings a different perspective from that of the physician. The staff nurse should discuss the following topics related to his or her role as the direct care provider:
• The patient’s progress as it relates to the plan of care;
• Any barriers to the patient’s progression, such as pain or inability to walk or eat;
• Any issues related to the family;
• Any transition points, such as discontinuing IV meds, removing drains or other devices, or diet progression.
Case managers play an important role in walking rounds. They bring knowledge about the patient’s discharge planning progress, any insurance issues that may impede that discharge plan, any family issues, and any barriers to care or throughput.As a case manager, you also should discuss the patient’s actual against expected length of stay and ensure that the white board in the patient’s room reflects this information.
As you prepare to speak on rounds, consider organizing your talking points in categories that relate to your roles and functions. Examples of these include:
Category: Coordination of Care
• The actual against expected length of stay;
• Any care progression delays;
• Any barriers to care;
• Achievement of any outcomes of care.
Category: Discharge Planning
• Status of the discharge plan;
• Any insurance barriers related to the plan for discharge;
• Any family and/or patient dynamics affecting the discharge plan.
Category: Utilization Management
• Any insurance issues that may affect the discharge plan in a negative way (uninsured or underinsured);
• Status of any pending insurance approvals.
By organizing your talking points in this way, you will be more organized in your thinking and less likely to leave out any important information.
Depending on your hospital’s case management model, the social worker may or may not be available to attend rounds. If the social worker is the sole discharge planner, then he or she may be able to attend rounds. If the social worker is following cases on a referral basis from the case manager or other members of the team, he or she will not be able to attend rounds. In the second example, the social worker is likely to be covering more than one unit, but only a handful of patients on each of these units. In this case, the social worker should provide any pertinent psychosocial or discharge planning information to the case manager who will present it in rounds.
The talking points listed below should be presented by either the social worker or the case manager:
• Psychosocial issues affecting the hospital stay and/or discharge plan;
• Concerns that may warrant a behavioral health intervention;
• Any necessary community referrals;
• The status of the discharge plan.
The social worker brings unique information to the interdisciplinary team as to the patient’s family dynamics, living situation, financial situation, and other psychosocial issues.
It is important that the social worker have a voice in the walking rounds process.
Ancillary providers should participate in rounds on the units where their specialty is of importance.
As previously discussed, each specialty should be included on units where their discipline’s care plan and discharge plan are most relevant. For example, physical therapy should be present on orthopedic unit rounds and where their knowledge is critical to the patient. The nutritionist might attend rounds on a geriatric or oncology unit. Below are the specific talking points for one of these specialties.
• Goals of care;
• Status of interventions;
• Barriers to care;
• Any barriers affecting the discharge plan.
Another useful tool for conducting rounds is a checklist. The list can be used as a way to remind each team of their talking points. It also can be used as a tool to streamline each interdisciplinary team member’s documentation. Some electronic medical records have similar tools readily available.
The advantage of using an electronic tool is that it is easier to edit the content and not have to start from the beginning each day. If this is not the case in your hospital, you can have such a tool added to the system or use a paper tool.
When developing your own version of the checklist, consider which team members are participating in the walking rounds process and be sure each of these members is represented. Discuss their talking points with them to ensure that all relevant information is included on the checklist. You may also consider creating a separate list for each team member that they can carry and use. Think creatively as you implement your own checklist.
Below are sample elements of a checklist/documentation tool:
• Patient name;
• Date and day of week;
• Attending in charge and team;
• Identified surrogate/caregiver (if needed);
• Goals of care (aggressive/palliative/unknown/other);
• Expected discharge destination;
• Has the patient been out of bed in prior 24 hours?
• Walking? If not, why?
• Injuries/Nutritional status;
• Presumptive diagnosis;
• Expected length of stay;
• Day of hospitalization;
• Expected discharge date;
• What happened in last 24 hours;
• What can be expedited?
• What can be done as outpatient?
• Pending results of tests and consults;
• How will test results affect the care plan?
• Medication review:
- All current meds;
- Convert to oral medication?
- Home infusion?
• Barriers to next level of care/discharge:
The Institute for Healthcare Improvement has identified some standard outcomes that you should be able to achieve with an effective walking rounds process:
• Improved teamwork and communication between providers;
• Reduced duplication and redundancy;
• Reduced length of stay;
• Improved patient flow;
• Reduced errors;
• Expedited discharge planning;
• Increased collaboration and satisfaction among the team.
During the implementation and testing phase of your rounding process, ensure that you are holding the gains that you are making. It is very important that you measure these process steps regularly as you roll out the nursing units to the new way of conducting rounds.
It is important that you keep track of how the rounds are performing as you move through the implementation process. Rather than looking at the outcomes achieved through the rounding, these measures are focused on the rounding process itself. It is easy for the team to fall back into bad habits if the rounds are not monitored and measured. The following are examples of how you can best keep track of the progress of your walking rounds process.
1. Measure the numbers of days a week that the rounds occur.
If rounds are frequently canceled, you will need to find out the cause or causes of the cancellations. It may be that the leader is absent or specific team members are not participating. Patterns like this can lead to a failure of the rounding process.
2. Keep track of how often rounds begin on time.
If rounds frequently start late, a root cause analysis may be needed to determine why.
3. Track the number of disciplines represented on rounds and, specifically, that the core members are present.
You may find that rounds occur as scheduled but that certain members often are absent. This may require a corrective action to get absent members back on board or it may only require speaking to the individuals.
4. Measure the percentage of patients with a documented daily goal in their record.
Since one of the core elements of effective rounds is that each patient has at least one documented daily goal, this measure should be conducted routinely on an adequate sample size of charts. A typical sample size is approximately 30 medical records.
5. Observe how well the team adheres to scripting and talking points.
Someone will need to objectively observe the rounds and take notice of each discipline’s talking points to ensure that they are being followed. If not, the rounds can lose focus and take more time than allotted. If this happens with your team members, re-education of the scripts may be needed.
6. Observe the time spent on each patient during the rounds, including at the bedside.
The rounds should be designed to allow for an average of 60 seconds per patient. New admissions may need more time, and longer-stay patients less time. You should observe rounds and measure the time spent with each patient to ensure that the time intervals are not too long.
In addition to measuring the processes of rounds, you will also want to measure the outcomes achieved. The following represent those that you may consider including in your outcomes measures.
• Reduction in length of stay. The team discusses the care plan and any changes that can be made in a timely manner. Barriers also can be identified and addressed in real time.
• Reduction in ICU patient days. Review clinical picture, treatment goals, and test results of ICU patients. Patients ready for transfer can be identified in a timely manner and expedited quickly.
• Reduction in morbidity and mortality. Team member collaboration and use of best-practice care bundles can have a positive effect on these measures.
• Quick assessments. The team can get a sense of patients’ progress by observing and communicating with the patients.
• Environmental check. Reinforce the importance of a clean patient environment and removing unnecessary supplies and linens to the nurses and patient assistants.
• Safety check. Rounds present an opportunity to check the safety of patients at high risk for falls or who may pull their lifesaving devices or lines.
• Regulatory check. For this step, make note of any regulatory compliance check issues in the patient’s room; for example, the number of side rails on the bed.
• Patient satisfaction. Patients and families are happy to see members of the care team and appreciate being included in the care processes. Be sure to include the day and date of discharge on the white board in the patient’s room.
• Staff satisfaction and education. Staff members note and report any instances where education may be lacking and improvements can be made. They also promote a culture of safety and quality.
• Ventilator days. Team members identify stable patients who can wean off ventilator or be removed from ventilator by reviewing their clinical picture, vital signs, treatment goals, and diagnostic test results. The staff nurse collaborates with the respiratory specialist to ensure patients are ready for ventilator changes.
• Number of pharmacy changes such as discontinuing antibiotics. Measure whether changes occurred in a timely manner and when clinically appropriate.
• Number of discharge delays. Measure delays associated with communication, physician practice, or care coordination.
• Number of discharges before noon. Better coordination among the team members will improve discharge times.
• Number of patients with a discharge plan within 24 hours of admission. Through improved coordination, communication, and a timely assessment by the case manager and social worker, an initial discharge plan can be identified early in the stay.
Walking bedside rounds can make a difference as you place the patient and family in the center of all patient care activities. In 30 minutes, the team can achieve a patient interaction, focused quick assessment, plan of care discussion, safety check, environmental check, regulatory check, and patient and staff education. Within the current demands of healthcare, this culture of safety, transparency, efficiency, collaboration, and autonomy makes a big difference in the quality of care patients receive.
Financial Disclosure: Author Melinda Young, Author Jeanie Davis, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Leslie Coplin, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.