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Round Up Staff for Better Rounds


 

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become.


—Ethan Cumbler, MD, director of the acute care for the elderly service, University of Colorado Hospital

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Tips for Effective Multidisciplinary Rounds

  • Make sure you know your reasons for doing them;
  • Start small and then expand to other areas;
  • Make sure the right people attend;
  • Meet at a set time and location so participants can plan their day;
  • Start and end on time;
  • Define roles and expectations for everyone doing the rounds;
  • Stay focused. Don’t spend longer than you need on any one patient;
  • Practice with a script;
  • Look for trends and identify opportunities to improve processes; and
  • Measure the outcomes.—BD

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

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