To improve communication systems, we implemented two main strategies: 1) the Daily Goals Communication Sheet to ensure that the entire team understands the documented plan for the patient each day, and 2) a standardized approach to daily multidisciplinary rounds to make them more effective and efficient.
Previous studies have demonstrated that implementation of daily goals sheets can reduce ICU length of stay, improve caregiver understanding of patient care goals, improve mortality rate, and reduce ICU costs (see references). Several draft templates of the Daily Goals Communication Sheet were tested, and the fellows were identified as the owner of the sheets during rounds. As part of the implementation, we established a system of communication with new residents each month prior to their rotation and during their orientation.
In order to change the culture of bedside rounds, we used several strategies and set a goal to decrease overall time for rounds. A “second attending” was established so the primary attending physician on service could remain uninterrupted during rounds. An implementation team was identified to develop a standard structure and then test it multiple times. Part of the structure was determining and reminding the team of the ground rules (see list below). Laminated rounds templates were placed at the bedside. Like the Daily Goals Communication Sheet, new residents were notified of the structure prior to their rotation and trained about their role during orientation. The program team recorded a video of morning rounds on one patient to use for training purposes. The video is available on the PICU intranet.
Ground Rules for Multidisciplinary Structured Rounds
- Do not report normal limits.
- Avoid repeating items already reported (it’s acceptable to say “other than the drips already reported…”).
- Refrain from non-essential interruptions, such as discussing other patients or signing forms.
- Resident is responsible for RT/RN information if they are not available.
- Fellow should report Daily Goals.
Results & Lessons Learned
Through staff feedback surveys, we learned that 87% of individuals surveyed felt that the Daily Goals Communication Sheet improved communication and patient care in the PICU. Challenges that we continue to work on include communication with consult services and adaptation for more patient/disease-specific goals.
The majority of staff reported that the standardized structure made rounds “better” or “much better”, and a smaller number reported rounds as being the same. No one said rounds were “worse” or “much worse”. Almost all staff members who gave feedback reported better team communication and/or efficiency, especially with making the long term plan clear, and including structured teaching and making that teaching useful. The time per patient decreased from baseline (11 minutes) to post-implementation (10 minutes) 10 months later.
We learned that it is challenging for some team members, such as respiratory therapists, to participate on rounds as well as to complete patient care tasks within the time they have available. After several months with the structure, it could still be more efficient and followed more consistently at night and on weekends. Some team members also find it challenging to balance teaching and problem-solving.