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Journal of Nursing

Multidisciplinary Rounds In Various Hospital Settings

Venice Ababat, Jeremias Asis, Michelle Bonus, Chloe DePonte, David Pham [email protected], [email protected], [email protected], [email protected], [email protected]


ABSTRACT


            This paper focuses on the use of multidisciplinary rounds in various hospital settings with an emphasis on intensive care units. A comprehensive literature review on the studies that focused on the use of multidisciplinary rounds will be incorporated and referenced. Topics to be discussed in regard to application of multidisciplinary rounds are benefits, barriers, gaps in current literature, and recommendations for baccalaureate level nursing.


BODY


Interdisciplinary Rounds (IDRs), or multidisciplinary care conferences, have been defined as planning and evaluating patient care with health professionals from a variety of other health disciplines. Key activities that can be integrated into IDRs include summarizing patient health data, identifying patient/family problems, defining goals, identifying interventions, discussing progress toward goals, revising goals and plans we needed, generating referrals, reviewing discharge plans, and clarifying responsibilities related to implementation of the plan. IDRs can occur from daily or once, twice, or even three times a week, depending on the patients need and an average length of stay (Gagner, Goering, Halm, Sabo, Smith, & Zaccagnini, 2003). In this paper, other terms that will be used interchangeably with IDR’s and multidisciplinary care conferences are multidisciplinary rounds and rapid rounds. When used effectively, multidisciplinary rounds enhance communication between different disciplines and break down the barriers between healthcare providers, patients, and their family members. Improving the communication is an essential component to providing quality holistic care, especially in intensive care units, where patients come in with a variety of complex medical and psychosocial problems.


             Current practice of multidisciplinary rounds in one specific intensive care unit involves holding multidisciplinary rounds at 10 AM daily with the following members: the bedside registered nurse who presents the patient; physician on the patient’s case; respiratory therapist; pharmacist; nutritionist; social worker; physical therapist; case management; and trainees which include medical students.


BENEFITS


On examination of the literature one of the most obvious benefits of implementing multidisciplinary rounds in any clinical setting is the increase in communication and teamwork between members of the health care team. Addie Camelio, a social worker, explained that there was more teamwork when multidisciplinary rounds were utilized: “Instead of going back and reading notes, we have the entire time together, and we can work together to help the patient progress … We are able to catch up with each other and compare notes” (“Multidisciplinary Rounds at Bedside Involve Patients, Families”, 2009). In another article, it was reported that “structured communication between physicians and nursing staff was accomplished through the use of a systems-based framework [which] ensures effective information sharing with the health care team and establishes clear expectations for the team, the patients, and the patients’ families” (Bayer, Cobourne, Derubis, Muhlam, & Ulrich, 2011). Patients and family members have the chance to speak with the healthcare team, ask questions and receive explanations about the patient’s disease process. Oftentimes patients will have plenty of questions and they may not all be medical; offering them explanations in a timely manner with the appropriate clinician can ease much anxiety.


Furthermore, multidisciplinary rounds also provide a chance to detect any ethical concerns, such as decisions about health care directives and do-not-resuscitate directives, which


allow the health care team to view the patient holistically (Gagner et al., 2003).


            Multidisciplinary rounds were also found to be beneficial because of the ability to be used in almost any unit and clinical setting. For example, on review of the literature it was found that the various units utilizing multidisciplinary rounds were the neonatal intensive care unit, medical intensive care unit, cardiac intensive care unit, surgical intensive care unit, transplant intensive care unit, medical-surgical/telemetry units, and pediatrics unit. One differing factor between the use of interdisciplinary rounds between units was the amount of times rounds were held. Most interdisciplinary rounds on a low acuity unit were normally held twice a week, but in the intensive care unit they were carried out daily (Gagner et al., 2003). This diverse nature of rounds and being able to format the rounds to accommodate the unit shows a major benefit for others to follow on their unit.


            The articles reviewed also stated that multidisciplinary rounds increase patient safety. An article on comprehensive care rounds has identified poor communication as a major contributor to adverse events and compromised patient outcomes (Boos, Haney, Okah, Swinton, and Wolff 2010).  This statement was further enforced from a retrospective cohort study done by Kim and colleagues that collected data from 112 Pennsylvania hospitals and found that there is a “marked reduction in risk-adjusted mortality rate (12-22%) associated with both [intensivist staffing and multidisciplinary care]” (Lobdell, 2010).  Due to the changes made in involving more comprehensive rounding,  Aragon and colleagues (2006) showed that there was a “54% reduction in ventilator associated pneumonia, a 78% reduction in catheter-related bloodstream infections, and an 18% reduction in mean length of stay” in the medical intensive care unit at St. Joseph’s Hospital and Medical Center. Another article stated that there was a decreased incidence of decubiti ulcers to less than 1% for an entire surgical ICU population and less than 3% for patients in the ICU for more than 72 hours (Gagner, 2003).


Another benefit of interdisciplinary rounding and increased communication between all parties involved is decreased length of stay. When the patient is in the hospital for a decreased amount of time there is also a decreased need for invasive procedures, which in turn leads to a lower incidence of infection. A direct result of preventing invasive procedures is a decreased length of stay because the patient is less likely to acquire an infection. An article entitled, Rounds Cut LOS, Improve Patient Satisfaction, (2011) found that rounds help remove barriers to discharge by allowing the disciplines involved with patient care to collaborate and to address any issues in a timely manner. This improvement in communication between all parties involved allowed for faster identification of clinical issues, more timely referrals, implemenation of preventive nursing interventions, increased communication, ultimately leading to better clinical outcomes, increased patient/family satisfaction and decreased length of stay” (Gagner et al., 2003). Healthcare providers believed that members of the multidisciplinary team are more proactive than reactive with the use of multidisciplinary round, which results in a smoother hospital stay, a shorter length of stay, and happier patients (“Multidisciplinary rounds at bedside involve patients, families”, 2009). Furthermore, statistics have also shown that when multidisciplinary rounds are used there is a decrease in length of stay for the patients. This is apparent in the article Using Evidence and Process Improvement Strategies to Enhance Healthcare Outcomes for the Critically Ill: a Pilot Project (2006) which found that, within a 15-month period, the use of the selected strategies [multidisciplinary round] resulted in a 18% reduction in mean length of stay in the unit.


 


BARRIERS


            The two major barriers to multidisciplinary rounds in the research included time constraints and the nurses’ perception of the need to contribute to the decision-making process. In one study, charge nurses rather than staff nurses were more likely to participate in the rounding process because staff nurses perceived that the time of rounds was too close to the change of shift report (Cowan, Hays, Shapiro, and Vazirani, 2005). This trend carried on in another study where staff from other disciplines reported that they found rounds to be ineffective because of the limited number of patients that were addressed and the amount of time it took out of an already busy day (Cale, Geary, Quinn, and Whinchell, 2009). In informal poststudy discussions, members of a multidisciplinary team agreed that although their involvement in the patient decision-making process was vital to having shared anticipation of patient progress, they acknowledged that this was not always possible, especially with very high workloads (Cuthbertson, Flin, Mearns, & Reader, 2011).  A multidisciplinary round implemented in a pediatric unit found that it took 2.7 more minutes per patient during rounds than conventional rounds, although this study did not measure the time saved during the course of the day (Bochkoris, Hannon, Kwoh, Rosen, & Stenger, 2009).  Much of the articles reviewed found that although multidisciplinary rounds took more time than conventional rounds, there was a significant benefit in terms of patient outcomes, length of stay, and efficiency found from the systematic collaboration between disciplines.


            Perceptions of the value of taking time to participate in multidisciplinary rounds is tied to whether or not healthcare members were informed about the possible time-saving benefits of multidisciplinary rounds. One study found that nurses reported a lack of opportunity or need to contribute to the decision-making process; in addition, senior nurses were observed to make limited verbal contributions during rounds (Cuthbertson et al., 2011).  To change these ideals of the staff members, a 2006 study in a medical intensive care unit conducted early communication with staff members that outlined the rationale of the project and the explanation of the change. Subsequently, members were eager participants in the development and maintenance of successful outcomes (Aragon, Bedker, Corderella, Hatler, Howard, Mast, & Mitchell, 2006).  However despite such initial views, a staff satisfaction survey contained many positive comments about interdisciplinary rounds, including ideas to further enhance rounds (Gagner et al., 2003).


            Multidisciplinary teams may not be appropriate for every hospital unit. One experimental study in a telemetry unit found that interdisciplinary rounds did not decrease length of stay, though it did improve staff satisfaction. Average length of stay for interdisciplinary round teams were an average of 3.04 days, whereas non-interdisciplinary round teams had an average of 2.7 days (Chan, Katz, Nawaz, and Wild, 2004).  The authors of the study postulated that this may be because most of the telemetry patients were already on clinical pathways with an already set standardization of care where further input from the interdisciplinary unit had no additional benefit. More complex patients, such as those found in the intensive care unit, are more likely to benefit from the implementation of multidisciplinary rounds.


GAPS IN CURRENT FINDINGS


            When researching the topic of multidisciplinary rounds it was concluded that there was sufficient amounts of literature reviews regarding how previous rounds were utilized on the intensive care unit, but there was a lack of studies specifically stating the long-term use of rounds. Many articles were introducing multidisciplinary rounds into their units, but did not have any research statistics to support the long-term use of this new rounding method. Most units have used it for less than a period of one year or only used the method of surveying to determine the usefulness or satisfaction of patients and staff with regard to improvements of their rounding or new use of multidisciplinary rounds.


            One flaw in the literature review was that it was difficult to differentiate between the numerous terms and to formulate one definition for multidisciplinary rounds that could be used everywhere. For example, during the research process, it was found that the terms comprehensive care rounds, interdisciplinary rounds, rapid rounds, bedside rounds, and multidisciplinary rounds were used interchangeably. Conversely, another problem is that each multidisciplinary team has different members fulfilling different roles in the rounds. For example, in the article Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses (2005), a nurse practitioner is the leader in charge of rounds because they had more face-to-face contact than the physicians. However, in other articles, the unit’s nursing supervisor or case manager is the main coordinator of multidisciplinary rounds (Aragon et al., 2006). 


            There was also a lack of tightly controlled and randomized studies done on multidisciplinary rounds as evidenced by the majority of studies being of quasi-experimental designs. According to Burns, Gray, & Grove (2011), a quasi-experimental study facilitates the search for knowledge and examination of causality in which there is no control. In the literature most of the studies included pre- and post-conventional methods where the comparison is in the method of multidisciplinary rounds before and after improvements are made. The improvements are made based on feedback given from the surveys that are voluntarily filled out by the patients and the health care providers. This may lead to inaccurate or vague results that do not fully explain the effect of multidisciplinary rounds on the specific unit studied. On the other hand, many of the studies were of a descriptive design, which is used to gain more information about characteristics within a particular field of study; its purpose is to “provide a picture of a situation as it naturally happens” (Burns et al., 2011). Many of these articles lack quantitative results, which also make it difficult to determine how multidisciplinary rounds affect length of stay, patient satisfaction, communication, and patient mortality rates.
RECOMMENDATIONS FOR USE IN AN INTENSIVE CARE UNIT SETTING


From the implications gathered from these articles, it is clear that multidisciplinary rounds are more effective than the basic conventional report and those multidisciplinary rounds should be adopted by all intensive care units to maximize the quality of holistic care for their patients. According to the published research entitled, Interdisciplinary Rounds – Impact on Patients, Families, and Staff (2003), the Joint Commission on Accreditation for Health Care Organizations (JCAHO) Standards summarizes that “patient care, treatment, and rehabilitation should be planned, evaluated, and revised by an interdisciplinary collaborative team”. The American Nurses Association’s Code for Nurses and American Association of Critical Care Nurses’ Standards for Acute and Critical Care Nursing Practice states that “the complexity of today’s healthcare systems necessitates a multidisciplinary or collaborative approach to ensure delivery of high-quality care.” (Aragon et al., 2006).


            Another recommendation summarized from the literature are that intensive care units should implement multidisciplinary care conferences, because they “improve teamwork by bridging the communication gap between care providers, promote conflict resolution, reduce caregiver stress, and facilitate the transmission of more consistent health information to parents.” (Boos et al., 2010).


A “bundle”, or a set of protocol interventions, could be implemented because it has been shown to lower the incidence of certain disease processes commonly seen in the intensive care units. For example, the mnemonic HOTSPUD was used on the medical intensive care unit floor at St. Joseph’s Hospital and Medical Center to reduce the frequency of ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections. HOTSPUD stands for: Head of bed elevated 30 degrees; Oral care every two hours; Turn patient from side to back every two hours; Sedation vacation once every twenty-four hours; peptic Ulcer prophylaxis within twenty-four hours of start of mechanical ventilation; Deep vein thrombosis prophylaxis within twenty-four hours of start of mechanical ventilation (Aragon et al., 2006). From analysis of the article, intensive care units should invest in creating a general format of what should be mentioned during multidisciplinary rounds. For example, a hospital referenced in the article Innovative Solutions – Optimal Patient Outcomes as a Result of Multidisciplinary Rounds, created a checklist of certain topics that they felt were important to discuss during the rounding process. Some of the included topics are: reason for intensive care unit admission; which admission criteria does the patient still meet (if any); any nutritional needs needed; and “best practices” still required, such as head of bed elevated, deep vein thrombosis prophylaxis, PUD prophylaxis and blood glucose control (Knowles and Moroney, 2006).


            Successful implementation of a checklist format can only be implemented correctly if all relevant staff members participate in multidisciplinary rounds and are educated prior to use on this topic. Once a checklist or format is created for a specific unit, a training day should be scheduled. In one particular study, one nurse was responsible for educating the nurse managers, charge nurse and the staff about the proper use of multidisciplinary rounds. They explained, “We felt that by having one person help with training everyone, there would be less variability in what people were being shown and taught” (Knowles et al., 2006).  


            According to the article on comprehensive care rounds, most health care professionals assume that they practice effective communication and teamwork skills. But in reality, research shows that breakdown in teamwork and communication is common and, given the complexity of medical care and the limitations of human performance, is a source of errors and potential harm” (Boos et al., 2010). One way to counteract this problem would be to encourage members of the multidisciplinary team to participate in communication workshops to enhance their communication skills. However, more research is needed to test the effectiveness of communication workshops.


RECOMMENDATIONS FOR BACCALURATE LEVEL NURSING


            With any baccalaureate nursing program that is accredited by the Commission of Collegiate Nursing Education (CCNE), there are certain “essentials” that all graduates are expected to meet. Among them is essential XI, which involves the intra-professional communication and collaboration for improving patient health outcomes; it states, “communication and collaboration among healthcare professionals are critical to delivering high quality and safe patient care” (ACCN, 2008).


Nursing students can prepare for multidisciplinary rounds by participating in the rounds that occur on their assigned unit. This opportunity can prepare students to learn how to effectively communicate with the rest of the multidisciplinary team. Likewise, the team can benefit from student participation because a study has shown that trainee involvement in multidisciplinary rounds contributed to the development of the team’s shared awareness of patient progress. The development of a shared and accurate awareness between the healthcare team is important for patient safety. Trainee involvement can help with information sharing among the team and senior members can identify and fill in gaps in the trainee’s knowledge, ultimately contributing to an accurate shared awareness between all members (Cuthbertson et al., 2011). Medical students’ active participation in family-centered bedside rounds increased their experience with communication, confirmation of findings of patient data, and modeling professionalism and bedside manner (Cox, Evans, Moreno, Schumacher, Sigrest, and Young, 2011). Nursing students may likewise receive the same benefits in their active participation in multidisciplinary rounds with the healthcare team, the patient, and the family. Another benefit that was briefly mentioned in the research was that the use of multidisciplinary rounds allowed for increased participation.


 


References


American Association of Colleges of Nursing (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice. Retrieved from http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf


Aragon, J., Bedker, D., Corderella, J., Hatler, C., Howard, K., Mast, D., & Mitchell, G. (2006). Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: a pilot project. American Journal of Critical Care, 15(6), 549-554.


Bayer, K., Cobourne, T., Derubis, S., Muhlman, A., & Ulrich, A. (2011). EB73: developing skilled communication and true collaboration: improving interdisciplinary communication during rounds in the intensive care unit. Critical Care Nurse, 31(2), e24-5.


Bochkoris, M., Hannon, M., Kwoh, C. Rosen, P., & Stenger, E. (2009). Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics, 123 (4), e603.


 Boos, V., Haney, B., Okah, F., Swinton, C., & Wolff, D. (2010). The comprehensive care rounds: facilitating multidisciplinary communication among caregivers of complex patients in the neonatal intensive care unit. Advances in Neonatal Care : Official Journal of the National Association of Neonatal Nurses, 10(6), 301. 


Burns, N., Gray, J., & Grove, S. K. (2011). Understanding nursing research: building on evidence-based practice (5th ed.). Maryland Heights, Missouri:  Elsevier/Saunders.


Cale, D., Geary, S., Quinn, B., & Winchell, J. (2009). Daily rapid rounds: decreasing length of stay and improving professional practice. The Journal of Nursing Administration, 39(6), 293-298.


Continuity of care rounds: a novel approach for long-term stay icu patients... dynamics of critical care 2012, Vancouver, British Columbia, 2012. (2012). Dynamics, 23 (2), 35.


Cowan, M., Hays, R., Shapiro, M., & Vazirani, S. (2005). Effect of multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.     


Cox, E., Evans, M., Moreno, M., Schumacher, J., Sigrest, T.D., & Young, H. (2011). Medical student outcomes after family-centered bedside rounds. Academic Pediatrics, 11(5), 403-408.


Cuthbertson, B., Flin, R., Mearns, K., & Reader, T. (2011). Team situation awareness and the anticipation of patient progress during icu rounds. BMJ Quality & Safety, 20(12), 1035-1042.


Gagner, S., Goering, M., Halm, M., Sabo, J., Smith, M., & Zaccagnini, M. (2003). Interdisciplinary rounds: impact on patients, families, and staff. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 17(3), 133-144.


Knowles, C., & Moroney, N. (2006). Innovation and teamwork: introducing multidisciplinary team ward rounds. Nursing Management - UK, 13(1), 28-31.


 Lobdell, K. (2010). The value of multidisciplinary rounds. Archives of Internal Medicine, 170 (13), 1174-1175.


Multidisciplinary rounds at bedside involve patients, families. (2009). Hospital Case Management, 17(2), 23-24.


Rounds cut los, improve patient satisfaction (2011). Hospital Case Management, 19 (1):6, 10-12.

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