Multidisciplinary Rounds: Not MORE Work, But THE Work

Baptist Memorial Hospital - Memphis
Memphis, Tennessee, USA

Team
Dr. Emmel B. Golden, Jr., Intensive Care Unit Medical Director
Dr. Roy Fox, Intensivist
Dr. Michael Wilons, Intensivist
Mary Ann Northern, RN, BA, Performance Improvement Specialist, Key Contact
Jan Padgett, RN, Manager of Intensive Care Unit
Kathy Duncan, RN, Director of Critical Care
Larry Hopper, RRT, Director of Respiratory Care
Lynne Lancaster, RN, Infection Control Practitioner
Kathy Leake, RN, Nursing Staff Development
Joy Lindsey, RN, Case Manager
Angela Link, PharmD, Clinical Pharmacist
Medhat Elsabawy, PharmD, Clinical Pharmacist
Kathy Nunnikhoven, RD, Dietitian
Melanie Polzin, Intensive Care Unit Head Nurse
Paul Spreckelmeyer, Speech Pathologist
Cleolyn Young, Physical Therapist

Aim
To improve the care of BMH-Memphis patients in order to reduce harm and improve patient outcomes
 
Specific goals:
  • Reduce Intensive Care Unit (ICU) length of stay (LOS) by 20 percent 
  • Reduce LOS in patient care units (outside ICU) by 5 percent
  • Reduce average ventilator days by 50 percent
  • Reduce ICU mortality by 20 percent
  • Reduce ventilator-acquired pneumonia (VAP) rate by 25 percent
  • Reduce catheter-related bloodstream infection (CR BSI) rate by 25 percent
  • Reduce urinary tract infection (UTI) rate by 25 percent
  • Achieve greater than 95 percent compliance with all five critical components of the Ventilator Bundle
  • Achieve greater than 95 percent compliance with all five components of the Central Line Bundle

Measures
  • ICU LOS
  • Patient Care Unit LOS
  • ICU mortality rate
  • Average mechanical ventilator days
  • VAP rate
  • CR BSI rate
  • Ventilator bundle compliance
  • Central line bundle compliance
  • UTI rate

Changes
Over the past two years, we participated in the IHI Impact Critical Care Settings Collaborative. The ICU and Cardiovascular Intensive Care Unit (CVICU) multidisciplinary teams tested and implemented several changes that contributed to improved outcomes. Multidisciplinary rounds were the cornerstone for developing a culture of collaboration and improvement. Subsequently, key improvements, including multidisciplinary rounds, were spread outside the ICU to other patient care areas. 
  • Implemented nightly rounds in the 38 bed ICU with oncoming intensivist, float charge nurse and respiratory therapist.  Targeted ventilator bundle compliance, readiness to wean, and level of care/bed flow issues
  • Instituted full multidisciplinary rounds in the 38 bed ICU, led by the ICU Medical Director (an intensivist), on Monday, Wednesday and Friday mornings with focus on collaborative patient care planning with consults to appropriate disciplines, implementation of best practices, compliance with care bundles, assessment of readiness to wean, pain and sedation management, appropriate central line utilization, level of care and bed flow issues, and end-of -life issues.  Disciplines rounding included: Nursing, Respiratory Therapist, Speech Pathologist, Dietitian, Physical Therapist, Occupational Therapist, Clinical Pharmacist, Case Manager, Chaplain, Palliative Care, Infection Control, Pain Management Physician, Medical Director and Administrative House Supervisor.  Implemented follow up rounds lead by ICU nurse manager on other mornings
  • Developed and implemented a Patient Daily Goals sheet, patient information sheet and special intervention sheet that were all incorporated into the ICU Patient Plan of Care.  CVICU developed a similar plan of care that was geared to cardiovascular patients
  • Incorporated the Patient Daily Goal/Patient Plan of Care into the rounds
  • Incorporated independent redundancies into rounds; checked compliance with bundles
  • Spread full multidisciplinary rounds to CVICU and Cardiopulmonary Transplant Units (CPTU).  Rounds led by CVICU manager on Monday, Wednesday, and Friday mornings.  Rounds led by CVICU medical director (a cardiovascular surgeon) on Thursday mornings
  • Implemented “mini rounds” in CVICU/CPTU on weekends with Nursing and Respiratory Therapy to set daily goals, check compliance with ventilator bundle, assess readiness to extubate and address bed flow issues
  • Developed and implemented Interdisciplinary Care Plan with Daily Patient Goals for areas outside Critical Care
  • Spread multidisciplinary rounds to Patient Care Units outside Critical Care (step-down units, cardiac medicine and medical-surgical units), incorporating Patient Daily Goal sheet/Interdisciplinary Plan of Care into the rounds
    • Developed collaborative plan of care
    • Identified and documented daily patient goals, major safety issues
    • Identified/addressed barriers to discharge
    • Addressed compliance with Centers for Medicare and Medicaid Services (CMS) indicators and care bundles
    • Promoted evidence based protocol utilization (e.g., Heart Failure, Pneumonia, Pneumococcal and Influenza Immunization)
    • Identified and addressed gaps in care
    • Planned for orchestrated discharge
  • Included patient and family in rounds in areas outside ICU.  Developed and implemented a letter to educate patient and family to rounds
  • Developed and implemented a Quality Indicator/Care Bundle sheet (attached to plan of care)
  • Developed and implemented a rounding form to monitor compliance with bundle components, follow up with patient care issues and track multidisciplinary interventions
 
Summary of Results / Lessons Learned / Next Steps
Multidisciplinary rounds were key to developing a culture of collaboration and improvement in our Critical Care Units and Patient Care Units, allowing patient-centered care planning, prevention of harm, and improved patient outcomes.  The rounds provided independent redundancies for critical processes, facilitated implementation of evidence based practices, established daily patient goals, identified safety risks and prevented gaps and delays in care, all leading to decreased LOS, decreased mortality rate, decreased ventilator days and decreased rate of ventilator associated pneumonia and catheter related blood stream infection rates in the Critical Care Units. Preliminary results show a decreased LOS and UTI rate for patient care areas outside ICU. Initially, the disciplines were concerned that the rounds would just be extra work, but now they agree, “It is not more work; it is the work!”
 
Lessons Learned
  • Start small and expand/spread the rounds
  • Conduct small tests of change
  • Educate and constantly communicate with the staff
  • Define roles and expectations for rounds
  • Clear any changes, brought about during rounds, through the attending physician.  This is important in an open ICU model
  • Recruit a physician leader- beneficial, but not a requirement for successful rounds
  • Incorporate independent redundancies to ensure compliance with critical processes
  • Look for trends and identify opportunities to improve processes- e.g., medication reconciliation, anticoagulant management, DVT prophylaxis, etc. 
  • Celebrate success!
 
Contact Information
Mary Ann Northern, RN, BA
Performance Improvement Specialist
Baptist Memorial Hospital-Memphis
maryann.northern@bmhcc.org
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