Bedside Rounds Research Articles

A Universal, Trauma-Informed Approach to Pediatric Hospital Medicine.

Olivia, a 13-year-old neurologically intact patient with cerebral palsy, arrived from a routine abdominal procedure screaming in pain. The medical team was baffled as to why she experienced such agony despite receiving copious doses of morphine. We spoke with her adoptive parents to obtain more history. They revealed long-standing physical and sexual abuse before Olivia’s adoption 6 years ago and noted extreme distress to all medical procedures and prolonged surgical healing time. Although her parents hoped to give her a better life and ensure she received appropriate care for her condition, they felt helpless that Olivia was at risk for retraumatization (reexperiencing posttraumatic symptoms from her original traumas) each time she came to the hospital. The amplification of pain and delayed medical recovery secondary to a history of psychological trauma and adverse childhood experiences (ACEs) is well recognized.1–3 Health care institutions are aware of the need for the integration of trauma-informed care into practice, yet they struggle to find the right approach. Although screening for ACEs has been widely adopted as a trauma-informed practice, there are multiple concerns with ACEs screening, including operating from a deficit- versus strength-based model, risk for traumatization from screening, and limited follow-up resources.4 ACEs scores also do not fully capture trauma and posttraumatic stress symptoms, which may be better predictors of negative outcomes than ACEs alone. Many organizations have now implemented the Substance Abuse and Mental Health Services Administration guidelines of educating clinicians on realizing …

Inpatient Dermatology Best Practice Strategies for Educating and Relaying Findings to Colleagues.

Purpose of ReviewThis review examines the role of education and relaying findings to non-dermatologist colleagues when performing inpatient dermatology consults. We highlight best practices for communication and education.Recent FindingsNon-dermatologists receive minimal training on the diagnosis and the management of skin conditions. Efforts to teach dermatology in the inpatient setting via traditional didactics have been met with limited success, and hospitalists have indicated a desire to learn from specialists. Incorporating education into standard consultation practices including the note, one-on-one communication, and bedside rounds can efficiently improve teaching and patient care.SummaryOur key principles of consultation emphasize communication, use of pre-existing components of a consultation to teach, and close follow-up. Inpatient dermatologists can implement these simple but effective measures to encourage education and communication with primary teams for both in-person and telehealth consults.

Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals

Background: Antimicrobial stewardship programs (ASPs) consist of coordinated interventions designed to improve and measure appropriate antimicrobial use. Understanding the current structure of ASPs hospitals will support interventions for improvement or implementation of these programs. Objective: We aimed to describe the current status of ASP in hospitals in the state of São Paulo, Brazil. Methods: We conducted a cross-sectional survey regarding ASP of hospitals in São Paulo state, Brazil, from March to July 2018. Through interviews by telephone or e-mail, we asked participants which components of IDSA/SHEA and CDC guidelines had been implemented. Results: The response rate was 30% (28 of 93 hospitals) and 26 of the hospitals (85%) reported having a formal ASP. Policies, practices, and strategies of surveyed ASP are detailed in Table 1. The most frequently implemented strategies were (1) antimicrobial surgical prophylaxis guideline (100%), (2) empiric sepsis guideline (93%), and (3) presence of ASP team member during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring and adjustment program for patients on IV aminoglycosides (3%). Regarding metrics of the ASP, the most common indicator was the rates of antimicrobial resistance (77%). Overall, 18 hospitals (19%) used defined daily dose and only 29% used days of therapy. Moreover, 61% of hospitals reported their results to hospital the administration and 39% of hospitals reported their results to the prescribers. Conclusions: Most hospitals have a formal ASP, but there are opportunities for improvement. Future efforts should prioritize tracking and reporting ASP metrics.Funding: NoneDisclosures: None

"Baby Steps to Discharge": An Interprofessional, Developmental Milestone-Based Checklist for the Neonatal Intensive Care Unit.

"Baby Steps to Discharge": An Interprofessional, Developmental Milestone-Based Checklist for the Neonatal Intensive Care Unit.

Bedside Rounds in Intensive Care Units during the COVID-19 Pandemic and Beyond.

A survey-based pilot study was performed to examine the feasibility of videoconferencing to facilitate multidisciplinary rounds following the initiation of strict isolation and social distancing policies in a pediatric intensive care unit (PICU). The use of a mobile workstation was implemented as the central hub for rounding at the bedside by the attending physicians, while other members of the multidisciplinary and multispecialty team joined rounds from other locations with maintaining appropriate social distance. Fifty-eight staff members who participated in videoconferencing rounds completed the postimplementation survey. Eighty-eight per cent of staff agreed that the use of videoconferencing to facilitate rounds was an effective strategy to maintain social distancing between team members during the pandemic. Sixty-four percent of staff agreed that the use of videoconferencing improved participation of the PICU team and consultants by increasing access to rounds. Over 50% of staff agreed that the use of videoconferencing improved the efficiency of rounds and team productivity. Only 4% of staff responded that videoconferencing increased the duration of rounds and 37% responded that it decreased resident and team education. Fifty-five percent of staff agreed that videoconferencing was used to promote parental participation during this pandemic month. Videoconferencing was found to be a feasible solution to safely conduct multidisciplinary rounds while maintaining social distancing, and participants found it effective without interfering with normal workflow. Incorporating videoconferencing into traditional rounding practices may be advantageous following the pandemic to improve team and family access to rounds and workflow efficiency and rounding structure.

98. LOST IN TRANSLATION: SIMULTANEOUS SPANISH MEDICAL INTERPRETATION DURING FAMILY CENTERED ROUNDS FOR IMPROVED RESIDENT AND FAMILY ENGAGEMENT

Background Language barriers significantly contribute to medical errors compromising patient safety, quality of care, and resident engagement with patients. Spanish speakers account for the fastest growing population of patients within US pediatric hospitals. However, the communication needs of limited English proficiency (LEP) patients frequently remain unmet. PURPOSE: The purpose of this study is to implement equipment assisted simultaneous medical interpretation (EASMI) for Spanish speaking families on family centered bedside rounds (FCR) and determine family and trainee provider satisfaction. Methods In-person interpreters joined FCR at a tertiary care academic children's hospital. All medical discussion on FCR was interpreted simultaneously from English to Spanish. Interpreters wore a noise-cancelling microphone connected to a transmitter and family members were given a receiver with an earpiece. Qualitative interviews were performed with family members on their experience (N=25). Online qualitative and quantitative surveys were completed by medical students, residents, fellows, attendings, and nurses (N= 136). Results Surveys demonstrated 94% of physicians and 100% of nurses were “very satisfied” with EASMI. Common themes from the resident and fellow survey were improved efficiency of rounds, increased family engagement, improved understanding of the care plan, decreased communication errors and improving patient safety. After the intervention Spanish speaking families reported an increase in the domains of communication with physicians and nurses on the Child HCAHPS survey. Conclusion Medical interpretation for LEP patients and families is critical for improved healthcare and reduction in health disparities. Overall, EASMI is both an efficient and effective patient-centered intervention during pediatric FCR for increased trainee engagement with patients.

101. A RESIDENT-LED QUALITY IMPROVEMENT INITIATIVE TO INCREASE NURSING PRESENCE ON INPATIENT ROUNDS

Background Recently the Accreditation Council for Graduate Medical Education has placed increased emphasis on experiential quality improvement (QI) education for pediatric residents. In response to this focus, our residency program developed an immersive QI curriculum comprised of didactic teaching and a longitudinal resident-led project. Over the course of the academic year, our residents select an issue to target and design and execute a QI initiative to address it. Recognizing that nursing presence on rounds improves safety, communication, and family satisfaction but is challenged by competing clinical priorities, the 2018-2019 project focused on increasing nursing presence on bedside rounds for hospitalist patients. Aim Statement Increase nursing presence during pediatric hospitalist rounds to 80% over the second half of the academic year. Interventions Senior residents used the Institute for Healthcare Improvement's model for improvement to design and implement 4 plan-do-study-act (PDSA) cycles with multidisciplinary participation: 1) Visual aids to emphasize the importance of nurse participation on rounds, 2) notification of nurse prior to rounds, 3) nurse-centered rounding order and 4) scripted nurse participation at the start of rounds. Measures The percent of nurses in attendance on rounds was recorded for one month as pre-intervention data, after which PDSA cycles were begun and outcomes were assessed for the subsequent 6 months. Qualitative interviews analyzed nursing perceptions and guided interventions. Residents met monthly to hand off project leadership and review core QI concepts with mentorship from hospitalists. PDSA cycle timing and teaching content were adapted to maximize learning. Results Nursing attendance improved from a baseline of 34% to 87% after the interventions (Figure 1). Qualitative data identified nurse-centered rounding and early nursing input as key interventions. Conclusions and Next Steps Improvement in nursing attendance on rounds was seen throughout the PDSA cycles in this resident-led QI initiative. Creating a nursing-centered rounding schedule and eliciting nursing input at the start of rounds are noted to be key factors for increasing nursing presence. This project demonstrates feasibility of resident-led QI endeavors within an educational model that addresses core residency program requirements for education in quality and safety.

A-114 Predicting Long-Term Cognitive Outcomes From Acute Orientation Performance After Traumatic Brain Injury

Abstract Objective To evaluate how initial orientation, rate of change in orientation, and duration of post-traumatic amnesia (PTA) during inpatient rehabilitation predict cognitive functioning (overall cognition, episodic verbal memory, and executive function) 1 year and 2 years after sustaining a moderate-to-severe traumatic brain injury (TBI). Methods Participants were 101 adults aged 18–81 years (M age = 39 years; 67% male) receiving inpatient rehabilitation following new-onset moderate–severe TBI at a level I trauma center, acute inpatient hospital. Orientation data (initial orientation, rate of change in orientation, and duration of PTA) were collected during inpatient rehabilitation where each participant received serial assessments of their orientation with the Orientation Log (O-Log) during bedside rounds. The Brief Test of Adult Cognition by Telephone (BTACT) was administered to participants over the telephone at 1 year and 2 years post-injury to assess cognitive outcomes. Results Initial orientation during acute inpatient rehabilitation was significantly associated with overall cognition (p < .01), episodic verbal memory (p < .01), and executive function abilities (p < .01) at 1 year post-injury. Duration of PTA and rate of change in orientation were not significant predictors, and none of the orientation factors predicted cognition at 2 years post-injury. Conclusion Initial level of orientation is important to consider in the prediction of cognitive impairments one year following moderate–severe TBI. This supports the need to assess orientation early in the recovery process, particularly upon admission to acute rehabilitation.

Perspectives on Patient Experience: A National Survey of Hospitalists.

Despite efforts to improve patient experience (PX), little is known about the perspective of hospitalists regarding PX initiatives and priorities. A survey was distributed to hospitalist groups across the country assessing involvement in PX initiatives and their perceived effectiveness, what PX means to providers, and facilitators/barriers in improving PX. Ninety-nine percent of respondents had encountered some improvement activity around PX. The most prevalent were communication training, group Hospital Consumer Assessment of Healthcare Providers and Systems data, and interdisciplinary bedside rounding. Respondents rated most initiatives a 5 to 6 out of 10 for their effectiveness, with the perception of effectiveness increasing with respondents’ assessment of patient experience priority. Learning about others’ experiences in improving PX and learning about potential collaborations for quality improvement or research in these areas were areas of interest for future work. Qualitative work highlighted potential barriers in improving PX such as workload and staffing constraints, uncontrollable environmental factors, and unrealistic patient expectations. Improving PX is a priority, and there are many initiatives in place with perceived variable success and perceived barriers in improving PX.

Assessment and Management of Delirium in Critically Ill Veterans.

Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility. Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

Contemporary practice of standardised bedside teaching rounds.

SUMMARYBackgroundThe purpose of this article is to review the extant literature on bedside teaching rounds within the context of ward rounds performed with the entire clinical team at the patient’s bedside, and to assess the effects of standardisation of this process on patient and learner satisfaction, as well as other duty‐hour restrictions and patient care metrics in the academic inpatient setting. Ultimately, the intent of this review is to inform faculty development sessions for educators on the benefits and challenges of standardised rounding protocols.MethodsWe performed a search of PubMed, Scopus and CINAHL databases (from 2003 to August 2019). Randomised, controlled trials, pre‐ and post‐interventional studies and cohort studies, in English, were eligible for inclusion. Two reviewers independently searched, screened and analysed the studies, and a narrative synthesis was performed. Articles were evaluated methodologically using the Medical Education Research Quality Study Instrument (MERQSI).ResultsFive articles were included, with one randomised controlled trial, three cohort studies, and one pre‐ and post‐interventional study. The collective MERSQI score for the studies was 12.3. Patient satisfaction increased uniformly across studies when standardised practices were used. Attempts to improve learner satisfaction, however, achieved mixed results. In addition, the time of bedside rounds was found to decrease with standardised interventions overall.ConclusionIn light of generally positive albeit limited evidence for standardised rounding practices, faculty development initiatives might use these data to inform and educate faculty members regarding the use of standardised protocols for bedside rounds.

Sustaining improvements in relational coordination following team training and practice change: A longitudinal analysis.

Poor communication is a leading cause of errors in health care. Structured interprofessional bedside rounds are a promising model to improve communication. The aim of the study was to test if an intervention to improve communication and coordination in an inpatient heart failure care unit would result in lasting change. The relational coordination (RC) survey was administered to seven workgroups (i.e., nurses, physicians) at baseline (2015) and three subsequent years following the intervention (team training, leadership development workshops, and structured interprofessional bedside round implementation). Descriptive analysis and mixed-effects models were used to assess the impact of the intervention on improving RC. During the study period (2015-2018), 344 participants completed the survey for an overall response rate of 53.5% (n = 643). Postintervention, the RC index significantly increased from 3.79 to 4.08 (p < .001) and remained significantly higher over 2 years, with an RC index of 4.12 and 4.04, respectively (p < .001). The range of RC scores between and within workgroups narrowed over time, with nonrotating workgroups showing the most improvements. Findings indicate that positive changes as a result of the intervention have been sustained, despite high rates of turnover among all workgroups. Notably, positive change in RC was found to be more pronounced for nonrotating workgroups compared to team members who rotate within the hospital (i.e., pharmacists who rotate to other units every month). This intervention holds promise for teams seeking best practice models of "high-reliability" care organization and delivery. Sustained changes from this intervention represent an important area of future practice-based research.

Replace Red Man Syndrome With Vancomycin Flushing Reaction.

Imagine this scenario: a 14-year-old Native American boy is being treated with vancomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus . During the first infusion, he develops diffuse flushing, which resolves with a slower infusion rate and administration of diphenhydramine. During bedside rounds the next morning, the medical student managing the patient reports that overnight the patient developed red man syndrome. An uncomfortable pause follows as the medical team recognizes the awkwardness of the phrase and as the patient and his family try to understand what message is being conveyed by “red man syndrome”: a term that would seem, erroneously, to invoke race as a key component to its pathophysiology. Providing some historical context is important. In 1959, an article entitled “An anaphylactoid reaction to vancomycin” was published in the Journal of the American Medical Association .1 The pathophysiology of this reaction was hypothesized to involve vancomycin-induced release of histamine from mast cells. Because of this and other untoward effects (eg, oto- and renal toxicity), vancomycin (a name derived from the word vanquish), was not extensively used until the proliferation of methicillin-resistant S aureus occurred in the 1970s and 80s.2 Sometime during this …

Trainee-Directed Educational Pursuits and Advocacy During the COVID-19 Pandemic.

* Abbreviations: COVID-19 — : coronavirus disease 2019 SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 Despite its devastating effects on adult populations globally, the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on children has been comparatively mild.1 Whereas adult hospitals have been confronted with bed and ventilator shortages in the face of large upticks in patient volume, many pediatric institutions have remained largely immune to these stressors given the small percentage of children positive for coronavirus disease 2019 (COVID-19) warranting hospitalization.2,3 As pediatric trainees who once braced for the possibility of a rapid onslaught in cases warranting our direct care on the frontlines, we personally feel an overwhelming sense of relief that our pediatric patients are predominantly spared from the effects of the virus. Notwithstanding, widespread social distancing practices, stay-at-home restrictions, and school closures have transformed the current landscape of pediatric practice and have consequently impacted our patients and families as well as our residency training. Inherent in this shift has been a reduction in opportunities for hands-on learning for trainees as well as modifications to structured teaching. Pediatric residents have nonetheless rallied around these changes to the traditional residency curriculum and developed innovative ways to connect with and advocate for our patients while simultaneously promoting the advancement of medical education. Across clinical settings, trainees are engaging less in person because of decreased emergency department visits, lower inpatient censuses, fewer outpatient appointments, and reduced clinical … Address correspondence to Danielle G. Rabinowitz, MD, MM, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: danielle.rabinowitz{at}childrens.harvard.edu

Authentic feedback: supporting learners to engage in disciplinary feedback practices

How can learners be supported to engage productively in the kinds of feedback practices they may encounter after they graduate? This article introduces a novel concept of authentic feedback to denote processes which resemble the feedback practices of the discipline, profession or workplace. Drawing on the notion of authentic assessment, a framework for authentic feedback is proposed with five dimensions: realism, cognitive challenge, affective challenge, evaluative judgement and enactment of feedback. This framework is exemplified and interrogated through two cases of authentic feedback practice, one in the subject of digital media in an Australian university, the other focussed on bedside rounds in medicine at a university in Hong Kong. The framework enables the identification of both highly authentic aspects of feedback, and aspects that could be made more authentic. The framework informs the design of feedback practices that carry the potential to bridge university and workplace environments.

Patient Perceptions and Real-Time Observations of Bedside Rounding Team Communication: The Interprofessional Teamwork Innovation Model (ITIM)

Interdisciplinary rounds are designed to address barriers to teamwork, communication, and quality patient care. This study used multiple methods (observations, patient surveys) in two hospital sites to examine communication and teamwork in the Interprofessional Teamwork Innovation Model (ITIM). Observations of 68 ITIM teams that completed 685 patient visits were conducted in a 302-bed community-based acute care hospital (CH) and a 569-bed academic medical center (AMC) in one academic health care system. Patients were asked to complete surveys about their experience with their ITIM team. Length of stay (LOS) in the CH was significantly and negatively associated with team structures and communication processes. LOS in the AMC was associated with communication processes. Geographic cohorting was a system factor associated with teamwork and communication processes that affect patient care and quality. A variety of communication processes were operating in ITIM teams, including soliciting questions from patients and staff, politeness, rapport, speaking percentages, and team-oriented communication. Patients were satisfied with their ITIM experience, indicating that their encounters were collaborative and supportive and contributed to their care experience. This multimethod study illustrates the value of system-level approaches to structured patient-centered team care delivery and understanding the complexity of communication in team-based patient care. Findings suggest that when patients feel they are given opportunities to ask questions, speak without being interrupted, and have their questions answered, they tend to be satisfied with their experience of care. Health care leaders may consider ITIM to advance their mission of improving patient experiences and quality of bedside care.

The Effects of Interdisciplinary Bedside Rounds on Patient Centeredness, Quality of Care, and Team Collaboration: A Systematic Review.

Research indicates that having multiple healthcare professions and disciplines simultaneously at the patient's bedside improves interprofessional communication and collaboration, coordination of care, and patient-centered shared decision-making. So far, no review has been conducted, which included qualitative studies, explores the feasibility of the method, and looks at differences in definitions. The aim of the study was to explore available evidence on the effects of interdisciplinary bedside rounds (IBRs) on patient centeredness, quality of care and team collaboration; the feasibility of IBRs; and the differences in definitions. PubMed, Web of Science, and Cochrane databases were systematically searched. The reference lists of included articles and gray literature were also screened. Articles in English, Dutch, and French were included. There were no exclusion criteria for publication age or study design. The included (N = 33) articles were critically reviewed and assessed with the Downs and Black checklist. The selection and summarizing of the articles were performed in a 3-step procedure, in which each step was performed by 2 researchers separately with researcher triangulation afterward. Interdisciplinary bedside round has potentially a positive influence on patient centeredness, quality of care, and team collaboration, but because of a substantial variability in definitions, design, outcomes, reporting, and a low quality of evidence, definitive results stay uncertain. Perceived barriers to use IBR are time constraints, lack of shared goals, varied responsibilities of different providers, hierarchy, and coordination challenges. Future research should primarily focus on conceptualizing IBRs, in specific the involvement of patients, before more empiric, multicentered, and longitudinal research is conducted.

Evaluation of a nurse practitioner-led project to improve communication and collaboration in the acute care setting.

Effective communication between patients and the health care team is essential. The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey measures discharged patients' perceptions of their hospital experience, including nurse and doctor (physician) communication. These scores affect hospital reimbursement for Medicare and Medicaid patients. In 2015, the project facility was penalized for low HCAHPS scores, causing a loss in revenue. The facility's medical-surgical unit scores were still failing in 2016. A quality improvement project on Interprofessional Bedside Rounds (IBR) was designed and implemented, and the effect of hiring nurse practitioners (NPs) to the unit's hospitalist service was also examined. Analysis of variance was used to detect significant changes in nurse and doctor HCAHPS communication scores from baseline in 2016, after NPs were hired in 2017, and post-IBR in 2018. The Interprofessional Collaborative Competency Attainment Scale (ICCAS) was also used to measure changes in staff competencies. The IBR intervention was conducted with the NP, nurse, and doctor present. It was structured to promote effective communication and patient engagement. Hospital Consumer Assessment of Health Care Providers and Systems scores improved, with nurse scores increasing from 2016 (79%) to 2017 (86%) to 2018 (90%) (p = .310). Doctor scores improved from 2016 (69%) to 2017 (88%) but slightly decreased to 2018 (85%) (p = .040). Interprofessional Collaborative Competency Attainment Scale results showed a 29% improvement in staff's perceived ability to collaborate (p = .000). Results indicate that the addition of NPs greatly improved HCAHPS communication scores. To improve communication, medical-surgical units should consider a team-based approach that includes NP leadership for implementing evidence-based interventions such as IBR.

80 Burn Rehabilitation: How Do You Minimize Delays?

Abstract Introduction Timely rehabilitation is vital to the functional outcomes of burn patients. The rehabilitation department at our ABA certified Burn Center determined there was a need for a more effective method to coordinate daily care in the Burn Progressive Care Unit (BPCU). The purpose of this performance improvement project was to evaluate whether our Burn Center had a problem with delays in rehabilitation and if so, develop a plan to reduce disruptions. Methods Lean Six Sigma Process Improvement Methodology guided the team in this project. A 5-question needs assessment Pre-Rehabilitation Worksheet (Pre-RW) was used to evaluate the problem. The Pre-RW asked if there was a delay; reason for delay; length of delay; communication between services; body region, and the number of cutaneous functional units (CFUs) involved. The team then analyzed data from the Pre-RWs using descriptive statistics and a Pareto chart. Results from the Pre-RWs were used to prioritize changes that would mitigate delays. Rehabilitation staff then completed Post-RWs. Pre- and Post-RW results were compared to determine if the changes decreased delays in rehabilitative care. Results From April 24 to August 5, 2018, 140 Pre-RWs were completed in the BPCU; 24 were incomplete/omitted. Rehabilitation encounters that were delayed or canceled were 37.9% (n=53). Of these, 64% were delayed but eventually completed. The top 3 reasons for delay were: dressings down for morning rounds (DFR, 26%); wound care in progress (19%); patient refusal (16%). In 47% of the encounter delays the patients had over 15 CFUs involved. Improvements were made as follows: DFR assessment became part of the bedside rounds process; wound care orders were placed prior to 9 a.m.; patients were offered evening wound care. Communication improved through the use of a whiteboard, hands-free voice-call badges, and a time frame for coordinating the plan of the day. Following the improvements, Post-RWs (n=131) were collected from May 1 to July 30, 2019. 23.8% of all encounters were delayed or canceled. Of these, 51% were delayed but performed. The 3 chief reasons for delay were patient refusal, 38%; untimely dressing changes, 19%; and medical issues, 13%. In 84% of the deficit encounters 0–15 CFUs were involved. Conclusions Our burn center was able to define a problem with delays in rehabilitation and mitigate delays. This project demonstrates that deliberate changes decrease delays in rehabilitation. Applicability of Research to Practice Care of the burn patient requires a structured interdisciplinary, systems approach. Burn centers can improve outcomes by adopting a plan to improve coordination of services.

Mixed methods quality evaluation of structured interprofessional medical ward rounds.

Standardised structure and content of interdisciplinary medical ward rounds can promote patient safety and patient-centred teamwork. To evaluate interdisciplinary ward rounds using a Structured Interdisciplinary Bedside Rounding (SIBR) intervention. The study involved multi-method, repeat measures with a non-equivalent control group. Non-participant observations were collected at: 1 and 6 months, on an intervention ward that introduced SIBR; and a control ward that continued traditional rounds. Focus group and survey data were also collected on the intervention ward. Participants were clinicians (medicine, nursing and allied health) working in two general medicine wards at a tertiary hospital in Melbourne, Australia. Seventy-eight patient rounds were observed at Time 1, and 239 at Time 2. The SIBR ward rounds had all clinician disciplines represented, whereas allied health and nurses were present for less than 20% of non-SIBR rounds. Interdisciplinary participation and frequency of desired clinician behaviours increased, and variability in duration of time per patient decreased, on the SIBR rounds. Longitudinal data reflected decreased performance of some SIBR behaviours in the intervention ward, while some desired behaviours increased in the control ward. Qualitative survey and focus group data indicated many positive views, but fit with broader ward routines impacted SIBR implementation. The overall recommendation by staff was that SIBR should continue. The results provide insights into the adoption of SIBR behaviours and illustrated diffusion of behaviours across wards. Highlighting successes and identifying barriers can help meet challenges for ongoing improvement.