Interprofessional Rounds in the ICU


Article Author:
Sandeep Sharma
Muhammad Hashmi


Article Editor:
Rotem Friede


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
10/11/2019 3:24:16 PM

Introduction

Interprofessional rounds in the intensive care unit (ICU) setting allow for scheduled discussion among various healthcare providers to review and discuss clinical information and develop concise care plans for critically ill patients. Rounding as a unit allows for each discipline of the healthcare team to address their goals, issues, and concerns. In addition, they give specialized input to the daily care plan. This specialty specific input may not be readily apparent to another specialty. The primary value of this design for a team focused rounding allows for efficient and transparent lines of direct communication between team members. Consequently, this reduces the negative impact of delays or misunderstanding in communication. Communication failure among health care providers is one of the most frequently cited causes of preventable harm to patients.[1]

Function

In an ICU setting, the interprofessional team may be composed of: physicians, advanced practice providers, bedside nurses, case managers, respiratory, physical and occupational therapists, pharmacists, chaplains and occasionally family members. Each member of the team offers a unique background of information, training, and technical skill which can improve patient care and ICU outcome. 

There are 2 types of physicians involved in an interprofessional team the primary physician and the consulting physician. In an ICU the primary physician is either the intensivist or the primary attending depending on the staffing model at the specific hospital. The consulting physicians represent many specialties of both medical and surgical healthcare. In most models, the primary physician leads the interprofessional team and functions to determine a direction for therapy based on the input of the team members. Specialists are present for consultation depending on the specific illnesses being treated and the organ systems involved. Advanced practice providers provide direct support to the decision processes of physicians and oversight by the physician is based on state regulations.

The bedside nursing team is the frontline healthcare provider in an ICU setting. Depending on hospital staffing models and acuity, a nurse is assigned to work directly with 1 to 4 patients; whereas, physicians care for many more patients. This ratio of patients allows for nursing staff to develop a rapport with patients and learn important information that can significantly alter the goals of care. This insight is valuable due to the brief nature of a physician's encounter with patients. Furthermore, nurses frequently have in-depth knowledge of the humanistic concerns of patients and their families due to both increased contact time and training. Also, the bedside nurse is responsible for carrying out many of the elements of the daily plan. This can range from medication administration, dressing changes, feeding, and hygiene, venipuncture, to protocol adherence. Consequently, effective communication and understanding of the treatment plan are crucial for successful implementation and completion.

Case managers and social service are trained to address the psychosocial aspects of a patient’s needs. They help facilitate the transition to the next level of care. They are critical for providing additional patient education on treatment options and helping to coordinate various service needs following discharge. This may include medical equipment and medications. Social workers and or chaplains also work to arrange support and grief counseling or other mental health services for patients and their families.

Many patients within an ICU setting require supportive pulmonary care. This may include mechanical ventilation or non-invasive respiratory support. While physicians may determine the type and setting of pulmonary support, it is the respiratory therapist’s role to constantly monitor and adjust settings based on endpoints provided by the physicians.

Pharmacists assist with pharmacotherapy decision making and dosing. They help reduce medication errors by identifying correct dosing and duration, proper monitoring of drugs and any possible medication associated interactions. Furthermore, infection control management, anticoagulation therapy, and sedation/analgesia utilization in ICUs is improved significantly when a pharmacist is directly involved in the interprofessional rounding team.

Family members may also participate in daily rounds, and they are a tremendous resource. Family can give insight to the patient’s preferences, likes, and dislikes. They can point out nuances specific to the patient. Involving the family in daily rounds allows for information sharing with the team and with the family. The collaborative decision-making process can allow for better follow through of medical care as well as decreasing associated anxiety and confusion about an illness and the recommended treatments.[2][3][4][5][6]

Clinical Significance

Patient length of stay is consistently demonstrated to decrease when an interprofessional team approach is used for rounding. On average, the length of stay is shown to decrease from 1.1 to 2.2 days per admission. Increased communication between providers and the inclusion of safety conversations in rounds leads to a reduction in adverse events and delays in initiation of appropriate therapy which translates into improved mortality rates. Other markers for morbidity including weaning days, total days of mechanical ventilation, and prevention of complications such as stress ulcers, deep vein thrombosis, falls, skin breakdown, infection, and readmissions also show significant improvement with the interprofessional approach. Staff satisfaction is also significantly improved with interprofessional rounds. This is based on satisfaction surveys with one study showing satisfaction increasing from 86% to 95% among ICU staff. Furthermore, participants in interdisciplinary rounds have a greater understanding of patient care, more effective communication, and better sense of teamwork than providers of traditional rounds.

The primary goal of healthcare providers within a hospital setting is to deliver standardized, evidence-based care and achieve maximum patient safety. Also, goals also include decreased adverse events, increased patient satisfaction, decreased length of stay, and decreased mortality. This challenge has proven particularly difficult within intensive care units as many of the most severely ill patients with complex medical pathologies and the poorest prognoses are admitted to these wards. However, through the implementation of interprofessional rounds and by using a collaborative team-based approach, patient outcomes can be optimized.[7][8]

Enhancing Healthcare Team Outcomes

While there is no single optimal structure, the consolidation of all team members for interdisciplinary rounds that occur at a set time on a regular schedule is considered best practice. Standardization of start time improves rounding effectiveness by facilitating greater participation among team members as they know when they will be needed. Rounds should emphasize a systematic coordinated approach to patient data presentation, the formation, and documentation of medical therapy plans, the order of team member input, and summary of overall goals of care for the day. In many ICUs, rounds occur each morning to establish the daily plan of care and allow the providers including nurses and pharmacists to work as a team to provide patient and family education, coordinate care, and monitor the patient's progress. A coordinated interprofessional team effort will lead to the best outcomes. [Level 5]


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Interprofessional Rounds in the ICU - Questions

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Interprofessional Rounds in the ICU - References

References

The practice of intensive care in Latin America: a survey of academic intensivists., Castro R,Nin N,Ríos F,Alegría L,Estenssoro E,Murias G,Friedman G,Jibaja M,Ospina-Tascon G,Hurtado J,Marín MDC,Machado FR,Cavalcanti AB,Dubin A,Azevedo L,Cecconi M,Bakker J,Hernandez G,, Critical care (London, England), 2018 Feb 21     [PubMed]
Impact of Structured Rounding Tools on Time Allocation During Multidisciplinary Rounds: An Observational Study., Abraham J,Kannampallil TG,Patel VL,Patel B,Almoosa KF,, JMIR human factors, 2016 Dec 9     [PubMed]
Aparanji K,Kulkarni S,Metzke M,Schmudde Y,White P,Jaeger C, Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds. BMJ open quality. 2018;     [PubMed]
Flannery AH,Thompson Bastin ML,Montgomery-Yates A,Hook C,Cassity E,Eaton PM,Morris PE, Multidisciplinary Prerounding Meeting as a Continuous Quality Improvement Tool: Leveraging to Reduce Continuous Benzodiazepine Use at an Academic Medical Center. Journal of intensive care medicine. 2018 Jan 1;     [PubMed]
Tiszai-Szucs T,Mac Sweeney C,Keaveny J,Bozza FA,O Hagan Z,Martin-Loeches I, Feasibility of Antimicrobial Stewardship (AMS) in Critical Care Settings: A Multidisciplinary Approach Strategy. Medical sciences (Basel, Switzerland). 2018 May 25;     [PubMed]
Masood U,Sharma A,Bhatti Z,Carroll J,Bhardwaj A,Sivalingam D,Dhamoon AS, A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit. Inquiry : a journal of medical care organization, provision and financing. 2018 Jan-Dec;     [PubMed]
Win TS,Nizamoglu M,Maharaj R,Smailes S,El-Muttardi N,Dziewulski P, Relationship between multidisciplinary critical care and burn patients survival: A propensity-matched national cohort analysis. Burns : journal of the International Society for Burn Injuries. 2018 Feb;     [PubMed]
Louzon P,Jennings H,Ali M,Kraisinger M, Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2017 Feb 15;     [PubMed]

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