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Dissecting Multidisciplinary Cardiac Surgery Rounds
Abstract
Multidisciplinary rounds in the critical care environment have demonstrated increased communication, a reduction in medical errors, a shorter hospital stay, and consequently, economic savings. We attempt to assess the cost of this intervention, and to review the time utilization of professionals participating in the process.
We analyzed video-recorded weekly multidisciplinary teaching rounds on cardiac patients in a pediatric intensive care unit (n = 22). Rounding time was categorized as presentation or discussion and was measured in minutes. The cost of a round was calculated by multiplying the hourly salary of all healthcare professionals present by the time spent rounding and measured in US dollars.
Median rounding time per patient was 15 minutes (range, 5 to 29). Patient presentation took between 2 and 8 minutes (median 4), or 26% of the rounding time. Time needed for discussion, including teaching and planning, varied between 2 and 25 minutes (median 10.5). Median number of participants was 13.5 (range, 11 and 16). Mean cost in salaries per patient rounded was $140.87 (95% confidence interval: $106.80 to $174.90).
Multidisciplinary rounds are a low-cost medical intervention with proven benefits. Available tools and rounding cultural changes should be adopted to shorten data retrieval and presentation time to the benefit of discussion and teaching. Current billing requirements for rounding multidisciplinary teams do not reflect the realities of their time use.
... Performing IBR reduces adverse events, 25,31,32,35 it has been shown to reduce LOS in some, 13,29,32,33,36 but not all studies. 21,22,35,37 Regarding 28-day readmission rate, no effects were found. ...
... The highest ratings for benefits are those related to interprofessional communication 13,26,28,31,36,38,[40][41][42][43][44] and coordination. 10,17,18,[23][24][25]28,36,41 Interdisciplinary bedside rounds improve communication and therefore teambuilding between nurses and physicians and other professionals included in the rounds. ...
Background:
Research indicates that having multiple healthcare professions and disciplines simultaneously at the patient's bedside improves interprofessional communication and collaboration, coordination of care, and patient-centered shared decision-making. So far, no review has been conducted, which included qualitative studies, explores the feasibility of the method, and looks at differences in definitions.
Objectives:
The aim of the study was to explore available evidence on the effects of interdisciplinary bedside rounds (IBRs) on patient centeredness, quality of care and team collaboration; the feasibility of IBRs; and the differences in definitions.
Data sources:
PubMed, Web of Science, and Cochrane databases were systematically searched. The reference lists of included articles and gray literature were also screened. Articles in English, Dutch, and French were included. There were no exclusion criteria for publication age or study design.
Study appraisal and synthesis methods:
The included (N = 33) articles were critically reviewed and assessed with the Downs and Black checklist. The selection and summarizing of the articles were performed in a 3-step procedure, in which each step was performed by 2 researchers separately with researcher triangulation afterward.
Conclusions and implications of key findings:
Interdisciplinary bedside round has potentially a positive influence on patient centeredness, quality of care, and team collaboration, but because of a substantial variability in definitions, design, outcomes, reporting, and a low quality of evidence, definitive results stay uncertain. Perceived barriers to use IBR are time constraints, lack of shared goals, varied responsibilities of different providers, hierarchy, and coordination challenges. Future research should primarily focus on conceptualizing IBRs, in specific the involvement of patients, before more empiric, multicentered, and longitudinal research is conducted.
... Moving forward, institutions may find that exploring the dynamics of interprofessional care and coordination is an effective means of improving bundle adherence. Table 1 highlights other notable ICU initiatives, including ICU rounding practices (87,(128)(129)(130)(131)(132)(133)(134)(135)(136), the Comprehensive Unitbased Safety Program (137)(138)(139)(140)(141)(142)(143)(144)161), Patient and Family Advisory Councils (PFACs) (145)(146)(147)(148), end-of-life care (104-107, 149, 150), coordinated sedation awakening trial (SAT) and SBT (46, 151), intrahospital transport (152,153), and transitions of care in and out of the ICU (154-160), as important initiatives that require an interprofessional approach for success. ...
... Rounds are a critical forum for exchange of information and decision making in the ICU. Because rounds are time and resource intensive (128,129) and there is a risk for misreporting and misinterpreting data (130), emphasis has been placed on improving rounding structure and process. ...
... Additional medical specialists that are involved closely include neonatologists, paediatric general surgeons, paediatric pulmonologists and paediatric neurologists. Recent studies have demonstrated that multidisciplinary rounds in the critical care environment increase communication, reduce medical errors, shorten hospital stay and consequently produce economic savings [7,8]. In-house, 24-hour, attending-level coverage is recommended for any general PICU as well as for PCICUs [3,9], although this ideal is rarely achieved and may not be affordable in many health economies. ...
... In addition to paediatric cardiology, PCIC, anaesthesia and cardiac surgery, a PCICU incorporates many other subspecialties , such as neonatology, paediatric pulmonology and adult cardiology [3,7]. ...
Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least '150 major procedures per year in children' and must provide a 'specialized paediatric intensive care unit'.
... The session's beginning was indicated by the HCT's arrival at the patient's room, while the end was indicated by the HCT physically moving to the next patient. 19,20 An observation form 15 was used to collect (1) observation day, (2) number and roles of HCT members, (3) patient and/or family presence, (4) rounding location (eg, bedside or hallway), (5) rounding beginning and ending time, and (6) performance of each checklist item (yes/no). To capture the full scope of checklist compliance, we intentionally included in our data rounding observations with and without patients and/or families. ...
Introduction:
Checklists are used to operationalize care processes and enhance patient safety; however, checklist implementation is difficult within complex health systems. A family-centered rounds (FCR) checklist increased physician performance of key rounding activities, which were associated with improved parent engagement, safety perceptions, and behaviors. To inform FCR checklist implementation and dissemination, we assessed physician compliance with this checklist and factors influencing its use.
Methods:
Guided by a recognized human factors and systems engineering approach, rounding observations and ad hoc resident and attending physician interviews were conducted at a tertiary children's hospital. Rounding observers documented 8-item checklist completion (nurse presence, family preference, introductions, assessment/plan, discharge goals, care team questions, family questions, and read back orders) and then interviewed physicians to elicit their perceptions of challenges and facilitators to FCR checklist use. We performed a directed content analysis of interview notes, iteratively categorizing data into known hospital work system components.
Results:
Of 88 individual patient rounds observed after checklist implementation, 90% included the nurse, and 77% occurred at the bedside. In an average patient rounding session, staff performed 82% of checklist items. Factors influencing checklist use were related to all hospital work system components, eg, physician familiarity with checklist content (people), visibility of the checklist (environment), providing schedules for rounding participants (organization), and availability of a mobile computer during rounds (technology).
Conclusions:
Multiple factors within hospital systems may influence FCR checklist use. Strategies, such as providing rounding schedules and mobile computers, may promote optimal engagement of families during rounds and promote pediatric patient safety.
... The audio recordings were also marked-up for interruptions, and other distractions unrelated to the patient case being presented. The total time was calculated by combining the duration of patient presentation and discussion, and excluding the time periods of interruptions, similar to the time coding performed by Cardarelli and colleagues [34]. ...
Background
Recent research has shown evidence of disproportionate time allocation for patient communication during multidisciplinary rounds (MDRs). Studies have shown that patients discussed later during rounds receive lesser time.
Objective
The aim of our study was to investigate whether disproportionate time allocation effects persist with the use of structured rounding tools.
Methods
Using audio recordings of rounds (N=82 patients), we compared time allocation and communication breakdowns between a problem-based Subjective, Objective, Assessment, and Plan (SOAP) and a system-based Handoff Intervention Tool (HAND-IT) rounding tools.
Results
We found no significant linear dependence of the order of patient presentation on the time spent or on communication breakdowns for both structured tools. However, for the problem-based tool, there was a significant linear relationship between the time spent on discussing a patient and the number of communication breakdowns (P<.05)––with an average of 1.04 additional breakdowns with every 120 seconds in discussion.
Conclusions
The use of structured rounding tools potentially mitigates disproportionate time allocation and communication breakdowns during rounds, with the more structured HAND-IT, almost completely eliminating such effects. These results have potential implications for planning, prioritization, and training for time management during MDRs.
... Moreover, memory aids such as checklists, hand-off tools, and structured communication strategies have reduced complications and hospital and intensive care unit readmissions [91,92]. Multidisciplinary rounds-which involve patients, their families, and the entire health care team-mitigate mortality risk in critically ill patients [93,94]. Organizational staffing of critical care units with "closed" management by dedicated critical care trained providers, in contradistinction to an "open" model of non-critical care-trained providers, as well as the use of tele-intensive care unit technology also correlates with lower mortality, morbidity, and shorter length of stay [95,96]. ...
... Moreover, memory aids such as checklists, hand-off tools, and structured communication strategies have reduced complications and hospital and intensive care unit readmissions [91,92]. Multidisciplinary rounds-which involve patients, their families, and the entire health care team-mitigate mortality risk in critically ill patients [93,94]. Organizational staffing of critical care units with "closed" management by dedicated critical care trained providers, in contradistinction to an "open" model of non-critical care-trained providers, as well as the use of tele-intensive care unit technology also correlates with lower mortality, morbidity, and shorter length of stay [95,96]. ...
The considerable global burden of surgery, combined with evidence of considerable variability in cardiothoracic surgical outcomes, and its associated costs create a “burning platform” to improve the delivery of health care. An important component of this effort involves a systematic, prioritized approach to risk assessment and management to improve safety, quality, and value in all aspects of surgical care. Each facility, health system, and individual practitioner has unique and important opportunities to learn, improve, and address these risks. Improvements in risk assessment and mitigation are founded on improved data mining, management, analysis, and widespread access by frontline health care professionals. Parallel improvements in technology and communication will enhance multidisciplinary teamwork and accelerate the transformation of networked, decentralized surgical care.
... Interventions targeting improvements in interprofessional communication within critical care teams, such as multidisciplinary rounds and daily goals, improve outcomes in the ICU (6)(7)(8)(9)(10)(11). To date, discussions of communication among healthcare providers caring for ICU patients have largely focused on communication among ICU physicians and/ or between ICU physicians and nurses (7,(12)(13)(14)(15)(16). ...
The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication.
Qualitative interview study. An inductive data analysis approach was taken.
Seven intensivist-led ICUs in four academic hospitals.
Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU.
None.
Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise.
Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU.
... 15 Several studies have demonstrated that interdisciplinary rounds improve learning and quality of care. [16][17][18][19] Currently, this is not standard practice. 20 ...
... While multidisciplinary rounds have been shown to be effective in certain settings, the mechanisms by which they work are not fully understood. Various aspects of multidisciplinary rounds have been studied, such as goals ( Riccobono & Xiao, 2009), logistics (sequence, time usage) (Cardarelli, et al. 2009), content of communications (Sen, et al. 2009), and costs. There has not been extensive study of the degree to which multidisciplinary rounds are indeed multi- disciplinary, and there is little guidance for practitioners regarding how to implement multidisciplinary rounds effectively. ...
Multidisciplinary rounds in the critical care environment have demonstrated improved communication, enhanced efficiency and better patient outcome. However, the mechanisms by which they work are not fully understood. Particularly, few studies have investigated the degree to which multidisciplinary rounds are indeed multi-disciplinary, and which factors contributed to their multidisciplinary nature. Very few tools have been developed to facilitate collaborative work for the rounding team. We attempt to fill some of these gaps by observing and evaluating multidisciplinary rounds in a Neonatal Intensive Care Unit. We observed morning rounds on 44 patients and analyzed auditing records of rounds on 62 patients. Analysis focused on participation and contribution of different disciplines, interactions between rounding members, and dimensions of the multidisciplinary nature of rounds. The analysis showed wide variation in the level of participation and contribution across disciplines. The main factors that contributed to rounds’ multidisciplinary nature fell into five categories, including number of participants, specific disciplines participating, and their interactions. A paper-based tool that was used to facilitate the rounds incorporated a significant amount of input from the nurses, but not other specialists. These findings suggest important implications in the implementation of multidisciplinary rounds and the development of information systems to facilitate collaboration.
... Dr Park and associates [1] reported an association between subclinical hypothyroidism (SCH) (defined as high thyroidstimulating hormone [TSH] concentration in the presence of normal T4) and postoperative atrial fibrillation. We read this article with extreme interest and would like to add some comments on the topic. ...
The United States health care system faces serious challenges in delivering value to patients and payers. Kim, Barnato, et. al. provide us with a valuable investigation reinforcing the importance of competence, collaboration, and communication in the intensive care unit through multidisciplinary rounds (MDR)1. Specifically, they dissect the contributions of intensivists and multidisciplinary care and demonstrate marked reduction in risk-adjusted mortality (12-22%) associated with both. On initial inspection this is “common sense”, but as we know, common sense is not so common, particularly when trying to change cultures and reallocate resources in complex systems.
This sophisticated study compliments that of Cardelli, Vaidya, et. al. who demonstrated median rounding time in a cardiac intensive care unit was 15 minutes and cost in salaries per patient rounded was $140.872. If intensive care units garner 25-33% of total hospital costs and an average intensive care unit bed costs more than $2500 per day one doesn’t need to be Warren Buffet to know that twice daily MDRs (30 minutes and about $300) would be a wise investment. Should one be skeptical of the value of MDR, consider that treatment of severe sepsis with Xigris (drotecogin) costs about $8000 per patient while reducing 28-day mortality by only 6.1% by comparison3.
We must scrutinize our efforts and allocation of resources in novel ways, like Kim, Barnato, et. al. have, and provide more value to our patients and payers. This analytic approach will be a cornerstone in reforming our health care system. Investigations such as this should assist in driving nails into the coffin of the “penny wise and pound foolish” approach known as “that’s the way we’ve always done it”.
1. Kim M, Barnato A, Angus M, et. al. The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality. Arch Intern Med. 2010;170(4):369-376
2. Cardarelli M, Vaidya V, Conway D, et. al. Dissecting Multidisciplinary Cardiac Surgery Rounds. Ann Thorac Surg 2009;88:809-813
3. Bernard G, Vincent J, Laterre P, et. al. Efficacy and Safety of Recombinant Human Activated Protein C for Sever Sepsis. NEJM 2001;344(10):699-709
... Dr Park and associates [1] reported an association between subclinical hypothyroidism (SCH) (defined as high thyroidstimulating hormone [TSH] concentration in the presence of normal T4) and postoperative atrial fibrillation. We read this article with extreme interest and would like to add some comments on the topic. ...
Objectives:
Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times.
Design:
Single-center improvement science study with observational and interventional phases from February 2, 2021, to July 31, 2021.
Setting:
Tertiary pediatric cardiac ICU.
Participants:
Cardiothoracic surgery and cardiac intensive care team members participating in daily "surgical" rounds.
Interventions:
Implementation of technology automation, creation of work instructions, standardization of patient presentation content and order, provider training, and novel role assignment.
Measurements and main results:
Sixty-one multidisciplinary rounds were observed (30 pre, 31 postintervention). During the preintervention period, identified inefficiencies included prolonged preparation time, redundant work, presentation variability and extraneous information, and frequent provider transitions. Application of targeted interventions resulted in a 26% decrease in indexed rounds duration (2.42 vs 1.8 min; p = 0.0003), 50% decrease in indexed rounds preparation time (0.53 vs 0.27 min; p < 0.0001), and 66% decrease in transition time between patients (0.09 vs 0.03 min; p < 0.0001). The number of presenting provider changes also decreased (9 vs 4; p < 0.0001). Indexed discussion duration did not change (1 vs 0.98 min; p = 0.08) nor did balancing measures (bedside rounds and surgical start times) change (8.5 vs 9 min; p = 0.89 and 38 vs 22 min; p = 0.09).
Conclusions:
Lean methodology can be effectively applied to multidisciplinary rounds in a joint cardiothoracic surgery/cardiac intensive care setting to decrease waste and inefficiency. Interventions resulted in decreased preparation time, transition time, presenting provider changes, total rounds duration indexed to patient census, and anecdotal improvements in provider satisfaction.
Introduction:
Inconsistent workflow, communication, and role clarity generate inefficiencies during bedside rounds in a neonatal intensive care unit. These inefficiencies compromise the time needed for essential activities and result in reduced staff and family satisfaction. This study's primary aim was to reduce the mean duration of bedside rounds by 25% within 3 months by redesigning the rounding processes and applying QI principles. The secondary aims were to improve staff and family experience.
Methods:
We conducted this work in an academic 50-bed neonatal intensive care unit involving 350 staff members. The change interventions included: (i) reinforcing essential value-added activities like standardizing rounding time, the sequencing of patients rounded, sequencing each team member rounding presentations, team preparation, bedside presentation content, and time management; (ii) reducing non-value-added activities; and (iii) moving value-added nonessential activities outside of the rounds.
Results:
The mean duration of rounds decreased from 229 minutes in the pre-implementation to 132 minutes in the postimplementation phase. The proportion of staff showing satisfaction regarding various components of the rounds increased from 5% to 60%, and perceived staff involvement during the rounds increased from 70% to 77%. Ninety-three percent of family experience survey respondents expressed satisfaction at being invited for bedside reporting and being involved in decision-making or care planning. The staff did not report any adverse events related to the new rounds process.
Conclusion:
Redesigning bedside rounds improved staff engagement and workflow, resulting in efficient rounds and better staff experience.
In a hospital's intensive care unit (ICU), multidisciplinary round (MDR) is a combination of care management with various healthcare providers from different clinical expertise meeting together to coordinate patient care, establish daily goals, and determine treatment plans. Such meetings require significant time and resource utilization from the providers. However, despite its significance, the workflow of MDR has not yet been rigorously studied. Using the data collected in ICUs at Mayo Clinic, this paper studies the MDR process by introducing a continuous time Markov chain (CTMC) model to systematically analyze the workflow and provide guidelines for efficiency improvement. In addition to evaluating current MDR process, a bottleneck analysis method is introduced to identify the task or activity whose improvement can lead to the largest gain in system performance. Based on the findings in bottleneck analysis, a potential MDR workflow redesign is proposed, which shifts resident's education time to a separate session out of normal rounding.
Objectives:
We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success.
Data sources:
Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles.
Study selection:
Original articles, review articles, and systematic reviews were considered.
Data extraction:
Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles.
Data synthesis:
"Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care.
Conclusions:
A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.
High-value cardiothoracic critical care (CCC) is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology.
The high-performing CCC system and culture should aim to learn quickly and continuously improve.
CCC demands a proactive, interactive, precise, and expert team, as well as continuity.
Identifying the high-risk patient and targeting perioperative strategies to anticipate and reduce complications are important components in achieving improved surgical outcomes. Various models are available which predict, to varying degrees, the risk of mortality and complications. These models increasingly assist clinicians in decision-making and the implementation of perioperative approaches and techniques to manage risk and reduce harm. Systematic and meticulous risk assessment and mitigation of modifiable risks should be incorporated into all aspects of surgical care.
The optimal care of pediatric patients with complex congenital heart disease requires collaboration and a multidisciplinary team approach from surgery, cardiology, anesthesiology, critical care, and other medical subspecialties. It is essential that an effectively functioning cardiac team be established in the care of complex congenital heart disease patients to reduce their morbidity and mortality. The vital components of a highly effective team not only include clinical excellence throughout all disciplines but must include excellence in leadership, trust, accountability, respect, and a shared mental model of the heart center’s mission and values. If these components are maximized, the quality of patient care excels, optimizing the lives of children with congenital heart disease.
In this chapter, we highlight the key characteristics of collaborative teams in healthcare and identify a variety of healthcare teams that differ by varying degrees of shared objectives, clarity of role specifications, and interdependencies. We then review sociotechnical design requirements for teamwork in healthcare settings, ending with two case studies that employed these concepts to demonstrate the dynamic and complex team collaboration in healthcare. We take the perspective that healthcare is a team sport. Effective collaboration of interdisciplinary teams has enabled stunning achievements in patient care, while breakdowns in communication and coordination all too often lead to adverse events. To support health professional teams, health information technologies (HIT) such as electronic health record (EHR) systems and mobile devices should be designed for effective communication and collaboration. Although much attention in health informatics has been focused on supporting the cognitive activities of individuals, improvements in safety and quality of care will depend on technologies that support teamwork and that account for the sociotechnical systems in which healthcare teams function. Understanding the sociotechnical design requirements and how teams work in healthcare settings can thus improve the design, implementation, and impact of health IT.
Clinical rounds are a critical time for determining a patient’s daily and long-term goals, for communicating these goals to a patients’ healthcare team and to family, and for teaching medical students and other clinicians. However, these discussions are highly variable ranging from highly structured monologues at some sites to free form dialogues in other units [1–7]. Best practices and standards for round discussions are still emerging. As discussed in Lane et al.’s [8] review of the literature, known barriers to round quality include interruptions, long rounding times, and poor information retrieval. Given rounds’ importance for team communication [9–11] and patient care, significant effort is being put forth to improve round quality. For example, tools such as scripts and checklists are proven to hasten the rounds process and increase the rounding teams’ satisfaction [1, 3, 5, 7, 12–14].
Multidisciplinary rounds in the critical care environment have demonstrated improved communication, enhanced efficiency and better patient outcome. However, the mechanisms by which they work are not fully understood. Particularly, few studies have investigated the degree to which multidisciplinary rounds are indeed multi-disciplinary, and which factors contributed to their multidisciplinary nature. Very few tools have been developed to facilitate collaborative work for the rounding team. We attempt to fill some of these gaps by observing and evaluating multidisciplinary rounds in a Neonatal Intensive Care Unit. We observed morning rounds on 44 patients and analyzed auditing records of rounds on 62 patients. Analysis focused on participation and contribution of different disciplines, interactions between rounding members, and dimensions of the multidisciplinary nature of rounds. The analysis showed wide variation in the level of participation and contribution across disciplines. The main factors that contributed to rounds’ multidisciplinary nature fell into five categories, including number of participants, specific disciplines participating, and their interactions. A paper-based tool that was used to facilitate the rounds incorporated a significant amount of input from the nurses, but not other specialists. These findings suggest important implications in the implementation of multidisciplinary rounds and the development of information systems to facilitate collaboration.
An analysis of outcomes, quality, and survey data was carried out to evaluate the impact of surgical multidisciplinary rounds (SMDR) at a community teaching hospital. Surgical inpatients were reviewed over a 4-year period. Real-time changes to clinical care, documentation, and programs were enacted during the rounds. SMDR contributed to reductions in length of stay (6.1 to 5.1 days), postoperative respiratory failure (15.5% to 6.8%), deep venous thrombosis/pulmonary embolism (2.8% to 2.3%), cardiac complications (7.0% to 1.6%), and catheter-associated urinary tract infection (5.2% to 1.5%), and increased Surgical Care Improvement Program All-or-None compliance (95.6% to 98.7%). Additionally, SMDR increased awareness of Accreditation Council for Graduate Medical Education core competencies among surgical residents and was associated with enhanced job satisfaction among participants. Twice-weekly SMDR is an effective care paradigm that has changed culture, improved care coordination, and facilitated rapid, sustained process improvement along multiple patient safety indicators and core measures.
OBJECTIVES:: Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU. DATA SOURCES:: Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012. STUDY SELECTION:: Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU. DATA EXTRACTION:: Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool. DATA SYNTHESIS:: The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians. CONCLUSIONS:: Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation.
Multidisciplinary rounding (MDR) reduces medical errors and improves the quality of care for hospitalized patients. The purpose of this study was to evaluate hospital length of stay, patient satisfaction, admission to a skilled care facility, and the use of home health care or hospice in patients who received MDR compared to those who did not. This retrospective study included the records of 3,077 thoracic surgical patients with cancer who were admitted to a midwestern National Cancer Institute-designated comprehensive cancer center from January 1, 2006, through July 1, 2011. Overall mean length of stay was 5.3 days in the MDR group compared to 6.5 days in the no MDR group. The MDR group also had significantly shorter mean length of stay compared to the no MDR group among patients who were discharged home from the hospital, admitted to hospice following a hospital discharge, discharged to a skilled care facility, or admitted to home healthcare services. No significant differences in satisfaction scores were reported in patients who received MDR compared to those who did not. MDR is an important aspect of inpatient oncology care, and staff should be identified to participate who have expertise relevant to patients' needs.
The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.
Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients' satisfaction and quality of care.
To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.
During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.
Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P < .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P < .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P < .001).
The multidisciplinary intervention resulted in better communication and collaboration among the participants.
Patient flow in a trauma center can be improved by multidisciplinary discharge rounds (MDR), but the content and logistics of MDR discussions have not been well quantified for purposes of improvement and adoption. We characterized the discussion content and time spent during MDRs and measured success rates in implementing communicated plans.
Bedside MDRs in seven patient care units were observed during consecutive working days in a major academic trauma center.
Discussions were timed and their content coded. Coding reliability was assessed with kappa statistics. Implementations of communicated plans were assessed during sequential working days.
MDRs over 23 days comprising 1,769 patient-discussions were observed. MDRs lasted a median of 34 minutes for a median of 78 patients. Kappa statistics for the discussions were 0.63 to 0.96. Each patient-discussion lasted a median of 13 seconds (range, 2 seconds-233 seconds), and 96% lasted less than a minute. Clinical topics were presented in 71.5%, new complications in 12%, discharge plans in 67%, surgical plans in 19%, and care advancement in 8% of them. Discussions >30 seconds duration were likely to contain exploration of care advancement, systems related, and clinical topics (p < 0.05). Advancement of care exploration correlated moderately with census of the trauma center (r = 0.53, p = 0.01). Ninety-four percent of the communicated plans were implemented with most delays caused by systems factors (82%).
The short duration and goal-focused communication may have made MDRs sustainable. Given the benefits of successful implementation of communicated plans and previously demonstrated improved patient outcomes, time for MDRs is well spent.
To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency.
Retrospective review with cost-effectiveness analysis.
A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program.
All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation.
A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service.
The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation.
We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.
To design and test a customizable system for calculating physician teaching productivity based on clinical relative value units (RVUs).
A 550-bed community teaching hospital with 11 part-time faculty general internists.
Academic year 1997-98 educational activities were analyzed with an RVU-based system using teaching value multipliers (TVMs). The TVM is the ratio of the value of a unit of time spent teaching to the equivalent time spent in clinical practice. We assigned TVMs to teaching tasks based on their educational value and complexity. The RVUs of a teaching activity would be equal to its TVM multiplied by its duration and by the regional median clinical RVU production rate.
The faculty members' total annual RVUs for teaching were calculated and compared with the RVUs they would have earned had they spent the same proportion of time in clinical practice.
For the same proportion of time, the faculty physicians would have generated 29,806 RVUs through teaching or 27, 137 RVUs through clinical practice (Absolute difference = 2,669 RVUs; Relative excess = 9.8%).
We describe an easily customizable method of quantifying physician teaching productivity in terms of clinical RVUs. This system allows equitable recognition of physician efforts in both the educational and clinical arenas.
To test the hypotheses that: (1) integrating information processing tasks using an electronic clinical information system (ECIS) decreases time to complete these tasks by hand; and (2) structured data entry encourages generation of more detailed records and capture of specific data elements even when entry is voluntary.
Prospective observational time analysis during medical documentation tasks. Retrospective analysis of clinical documentation completed by hand or electronically.
Eleven bed pediatric intensive care unit within an academic medical center.
Five pediatric intensive care medicine attending physicians.
Compared handwritten and electronic documentation to determine: (1) time spent entering data or composing notes; (2) number of descriptors documenting patients' physical exams; (3) users' preferences for structured or unstructured data entry; (4) frequency of documenting specific data elements related to nutritional support.
Documentation time varied by user but not charting method: it took 13 % less time to document using the ECIS but this was not significant. Electronic documents were more detailed than handwritten containing 50 % more descriptors (17.8 +/- 1.4 vs 11.6 +/- 1.4) overall and some data elements that were not handwritten: information related to nutritional supplementation was recorded in 13 % of electronic documents but in none of 89 handwritten documents.
Electronic and handwritten documentation consumed equal amounts of time. Structured entry, compared to handwriting, may encourage recording of specific or otherwise unincorporated data elements resulting in a more detailed record. This suggests that user interfaces and decision support components may influence both the types and complexity of clinical data recorded by caregivers.
Bedside clinical teaching, an essential component of clinical training, was widely practised during the 1960s and early 1970s but has since declined substantially.
To highlight the importance of bedside teaching, giving examples of its significance, and to discuss the factors that have led to its decline.
Review style.
There is much that can be gained from teaching at the bedside. It allows trainees to learn professionalism and to grasp the principles of communication with real patients. Unfortunately, the medical profession, like other fields of endeavour, has been invaded by computer technology. This has led to a decline in the frequency of bedside teaching and thus inflicted serious damage on the attainment of clinical skills by young doctors, despite their continuing interest in bedside teaching. Moreover, the increasing clinical, administrative and research duties of senior doctors have further contributed to this decline.
Every effort should be made to reinstate bedside teaching as a leading component of medical training.
OBJECTIVE: To delineate key clinical and administrative factors in starting a pediatric cardiac intensive care program and to introduce a scorecard concept to measure excellence in such a new program. Methods: Review of current clinical research data in pediatric cardiac intensive care and administrative business concepts for their application to the pediatric cardiac intensive care program. RESULTS: Although clinical concepts in cardiac intensive care are useful as basic philosophical strategies at the bedside, administrative principles are essential in operational strategies vital to the success of such a program. Using both clinical and business administrative concepts, a balanced strategy can be formulated. CONCLUSIONS: Starting a pediatric cardiac intensive care program is a difficult endeavor. A combined clinical and administrative approach is needed in starting and sustaining excellence in a pediatric cardiac intensive care program. Monitoring excellence in such a program warrants application of a scorecard system.
Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution's training mission. We hypothesized that daily multidisciplinary "discharge rounds" would improve patient flow and increase readiness.
A senior trauma center physician leads discharge rounds, focusing on each patient's plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit's discharge planner; the unit nursing staff; and physical, occupational, and speech therapists.
Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. "Bypass" status-inability to accept admissions-has been virtually eliminated. This effect has been sustained.
By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.
Sit-down patient rounding in hemodialysis units allows providers to focus collectively on each patient's needs and may affect patient outcomes positively. The objective was to examine whether sit-down rounding practices improve patient outcomes in a cohort of 644 adult hemodialysis patients from 75 outpatient dialysis clinics in 17 states throughout the United States who survived at least 6 mo after enrollment (average follow-up, 3.2 yr). Achievement of well-accepted 6-mo clinical performance targets of albumin (> or =3.5 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<60 mg(2)/dl(2)), dose (Kt/V > or =1.2), and vascular access type (fistula); hospitalization rates; and all-cause mortality served as outcomes. Monthly or more frequent sit-down rounds were conducted in 36 (48%) of 75 clinics, representing 287 (45%) of 644 patients. More frequent sit-down rounds were positively associated with an increased chance of achieving the 6-mo clinical performance target for albumin compared with less frequent rounds (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.12 to 3.15); patients who were treated at clinics with more frequent rounds also had nearly twice the odds of achieving more of the five performance targets (OR, 1.95; 95% CI, 1.11 to 3.42). After adjustment for potential confounders, patients who were treated at clinics with more frequent sit-down rounds were 32% less likely to be hospitalized (incidence rate ratio, 0.68; 95% CI, 0.51 to 0.91), had fewer hospital days per year (rate ratio, 0.50; 95% CI, 0.26 to 0.98), and were 29% less likely to die (relative hazard, 0.71; 95% CI, 0.53 to 0.95). Adjustment for some clinical performance targets attenuated the statistical significance of the association with hospitalization. More frequent sit-down rounds in hemodialysis units are associated with better patient outcomes, including an increased chance of meeting the albumin clinical performance target, decreased hospitalization, and decreased risk of mortality. This association may be due to the positive effect of collaborative discussion by the patient care team of short- and long-term care goals for individual patients.
Adoption of limits on resident work hours prompted us to develop a centralized, Web-based computerized rounding and sign-out system (UWCores) that securely stores sign-out information; automatically downloads patient data (vital signs, laboratories); and prints them to rounding, sign-out, and progress note templates. We tested the hypothesis that this tool would positively impact continuity of care and resident workflow by improving team communication involving patient handovers and streamlining inefficiencies, such as hand-copying patient data during work before rounds ("prerounds").
Fourteen inpatient resident teams (6 general surgery, 8 internal medicine) at two teaching hospitals participated in a 5-month, prospective, randomized, crossover study. Data collected included number of patients missed on resident rounds, subjective continuity of care quality and workflow efficiency with and without UWCores, and daily self-reported prerounding and rounding times and tasks.
UWCores halved the number of patients missed on resident rounds (2.5 versus 5 patients/team/month, p = 0.0001); residents spent 40% more of their prerounds time seeing patients (p = 0.36); residents reported better sign-out quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree). UWCores halved the portion of prerounding time spent hand-copying basic data (p < 0.0001); it shortened team rounds by 1.5 minutes/patient (p = 0.0006); and residents reported finishing their work sooner using UWCores (82.1% agree or strongly agree).
This system enhances patient care by decreasing patients missed on resident rounds and improving resident-reported quality of sign-out and continuity of care. It decreases by up to 3 hours per week (range 1.5 to 3) the time used by residents to complete rounds; it diverts prerounding time from recopying data to more productive tasks; and it facilitates meeting the 80-hour work week requirement by helping residents finish their work sooner.
To review published data on the team model of intensive care unit (ICU) care delivery.
Nonexhaustive, selective literature search.
Review of literature published in the English language.
Humans cared for in ICUs.
None.
The team model for delivery of ICU care reduces mortality, ICU length of stay, hospital length of stay, and cost of care. Convincing data suggest that merely having daily rounds led by an intensivist enhances patient care significantly. Further improvements can be obtained by maintaining a nurse-to-patient ratio of no greater than 1:2, adding critical care pharmacists, and providing dedicated respiratory therapists to the ICU team.
Current and looming shortages of all ICU healthcare providers is a barrier to universal implementation of the team model. Advocating for the ICU team model for critical care delivery requires local, regional, national, and international activities for success.
Multidisciplinary rounds (MDR) have become important mechanisms for communication and coordination of care. To guide design of tools supporting MDR, we reviewed the literature published from 1990 to 2005 about MDR on information tools used, information needs, impact of information tools, and evaluation measures. Fifty-one papers met inclusion criteria and were included. In addition to patient-centric information tools (e.g., medical chart) and decision-support tools (e.g., clinical pathway), process-oriented tools (e.g., rounding list) were reported to help with information organization and communication. Information tools were shown to improve situation awareness of multidisciplinary care providers, efficiency of MDR, and length of stay. Communication through MDR may be improved by process-oriented information tools that help information organization, communication, and work management, which could be achieved through automatic extraction from clinical information systems, displays and printouts in condensed forms, at-a-glance representations of the care unit, and storing work-process information temporarily.
Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost.
Our hospital is located in Northern Mississippi and has a 28 bed Medical-Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001-2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients.
Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode. Strategy for change: Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily "flow" meeting to assess bed availability; (3) "bundles" (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process.
Between baseline and re-measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973.
A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs.
To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use.
Cohort study, based on the SAPS 3 database in 275 ICUs worldwide.
16,560 adults.
Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant.
Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.
Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).
The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.
Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings.
An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.
Safe delivery of care depends on effective communication among all health care providers, especially during transfers of care. The traditional medical chart does not adequately support such communication. We designed a patient-tracking tool that enhances provider communication and supports clinical decision making.
To develop a problem-based patient-tracking tool, called Sign-out, Information Retrieval, and Summary (SynopSIS), in order to support patient tracking, transfers of care (ie, sign-outs), and daily rounds.
Tertiary-care, university-based teaching hospital.
SynopSIS compiles and organizes information from the electronic medical record to support hospital discharge and disposition decisions, daily provider decisions, and overnight or cross-coverage decisions. It reflects the provider's patient-care and daily work-flow needs.
We plan to use Web-based surveys, audits of daily use, and interdisciplinary focus groups to evaluate SynopSIS's impact on communication between providers, quality of sign-out, patient continuity of care, and rounding efficiency.
We expect SynopSIS to improve care by facilitating communication between care teams, standardizing sign-out, and automating daily review of clinical and laboratory trends. SynopSIS redesigns the clinical chart to better serve provider and patient needs.
The cost implications of and potential adverse events prevented by the interventions of a critical care pharmacist were studied.
A decentralized clinical pharmacist assigned to a surgical intensive care unit (ICU) documented all interventions made from mid-October 2003 through February 2004 using a standardized written form. The data were retrospectively evaluated and the following information was extracted: amount of time spent performing various clinical activities, how drug-related problems were identified (e.g., order entry versus chart review), and a general description of the interventions. The interventions were independently reviewed by two other clinical pharmacists to determine whether an actual or potential adverse drug event (ADE) would have occurred without the intervention, the probability that an ADE would have occurred without the intervention, the type of intervention, and potential cost avoidance of the intervention. Once the evaluations were completed, the data obtained from order entry and verification activities were compared with the data obtained during other clinical functions.
A total of 129 interventions were documented over 4.5 months. The majority of interventions were identified during chart review (40%) and patient care rounds (39%). The potential cost avoidance of the documented interventions was $205,919-$280,421. Interventions identified during patient care rounds and chart review were most likely to achieve the greatest impact on cost avoidance.
Among the interventions performed and documented by a clinical pharmacist in an ICU, patient care rounds and chart-review activities were associated with the greatest number of interventions and the greatest potential cost avoidance.
The ultimate goal of the electronic medical record is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. Drs. Pamela Hartzband and Jerome Groopman write that before blindly embracing electronic records, we should consider their current limitations and potential downsides.
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Salaries in healthcare. Available at: www.salary.com. Accessed August 6, 2008.
The history of medicine in the United States
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