Implement Multidisciplinary Rounds

Multidisciplinary rounds (MDR) enable several key members of the team caring for patients to come together and offer expertise in patient care. Too frequently physicians alone prescribe care for patients without the input of other providers such as nursing, pharmacy, respiratory therapy, nutrition, physical therapy, occupational therapy, and social work. Even the most efficient physicians stand to benefit from the counsel of these providers to provide the best care for patients.
 
This intervention has proven successful in medical and surgical settings. Efficient patient care depends on close communication between the physicians, nursing, physical therapy, and discharge planners. Many times, the number of services involved and the workload of each service slows down communication in patient care. In trauma care, multidisciplinary rounds have been demonstrated to have a dramatic effect on patient flow. While maintaining their daily census, one team reported a 36 percent increase in patient volume and a 15 percent decrease in length of stay. "Bypass" status-inability to accept admissions was virtually eliminated. What is more, this effect has been sustained over time.[1]
 
Vazirani et al. demonstrated that using multidisciplinary rounds in an acute care medical unit improved satisfaction with care for physicians, nurses, and patients. In addition, overall quality of care is improved with 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. The multidisciplinary intervention resulted in better communication and collaboration among the participants.[2] 
 
References: 
  1. Dutton RP, Cooper C, Jones A, et al.  Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma. 2003 Nov;55(5):913-919.
  2. Vazirani S, Hays RD, Shapiro MF, et al.  Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005 Jan;14(1):71-77.

 

 

Convene A Multidisciplinary Rounds Conference

 

Convening a conference of involved parties may assist in the establishment of multidisciplinary rounds (MDR). There are some barriers to overcome depending on the type of unit.

 

Open units (non-intensivist-led units in which any physician may admit and write orders) generally will have more challenges to overcome in establishing multidisciplinary rounds. However our experience is that persistence will generate physician buy-in and encourage their respect for the rounding process. Rounds may have to begin without physician input and a summary of recommendations brought to their attention. Over time, many physicians begin to attend the rounds more regularly to learn about best treatment options.

 

Closed units (intensivist-led units, or units requiring critical care consultation, in which a “team” writes orders only) generally have greater ability to begin multidisciplinary rounds without resistance.

 

Both types of units will benefit from the changes however. Issues regarding multidisciplinary rounds that need to be resolved before the first meeting include who will participate in rounds, what is the focus, where rounds will occur, when (how often) they will take place, and how MDR will be conducted.

 
Who:
  • Intensivists, generalists, ICU nurses, pharmacists, respiratory therapists
  • Nutritionists, social workers, case managers
  • Family members
 
What:
  • Patient’s Preferences and Goals: These are essential to identify appropriate care that the patient would choose rather than the providers’ preferences.  In ICU care this will often involve meeting with family members who should be invited to attend certain MDR sessions.
  • Patient’s Care Needs: Once a patient’s preferences and goals are understood plans can be made to medically meet those needs. 
  • Acuity Assessment and Discharge Planning: Ongoing planning for discharge is critical to ensure the care plan follows through to the wards and then to rehabilitation and home.
 
Where:
  • Rounds are best held at the patient bedside.
  • Large teams may need to meet in a separate conference area.
 
When:
  • A daily MDR conference is optimal.
  • Two to three times weekly may be an acceptable alternative.
 
How:
  • MDR may be integrated into physicians’ daily patient care rounds.
  • If your ICU lacks a daily rounding structure, these rounds can occur independently from such a structure at a designated time.

 

Tips:

  • Agree to name a “captain of the ship” in the event multiple consultants are involved so that a coordinated and cohesive treatment plan is implemented.  This is usually one physician — the physician of record.  This individual writes orders on the patient based upon the recommendations elucidated during multidisciplinary rounds.
  • Identify and present issues to the physician at multidisciplinary rounds.
  • Expect the “captain of the ship” to rely upon MDR team members: a professional crew of many consultants (“shipmates and deck hands”) who make certain that things work properly and assure “smooth sailing.” 
  • Monitor the progress of each patient closely by maintaining detailed progress notes.  Check for concurrence with daily goals identified during multidisciplinary rounds.
  • Approach and redirect providers when protocols are not followed.  Have the ICU nurse manager or charge nurse consult with physicians and thereby improve compliance with quality of care goals.
  • Focus on discharge planning to assure safe, adequate follow-up care and the continuation of services into the outpatient setting

 

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