Interprofessional Rounds Research Articles

Physician experiences of team-based clinical microsystems: implications for the future of inpatient interprofessional communication.

Healthcare clinical microsystems are small, goal-oriented groups of healthcare professionals that work together on a regular basis to provide care to discrete patient populations. They often include team-based frameworks such as bedside interprofessional rounds, geographic colocation of healthcare team members, interprofessional staff leadership, and unit-level data sharing. In inpatient settings, microsystems improve interprofessional communication and collaboration. In this qualitative study, we examined physician experiences of clinical microsystems and the mechanisms underpinning interprofessional communication in this environment. We interviewed 51 resident and hospitalist physicians. Thematic analysis of physician experiences revealed three key themes: (a) Clinical microsystem effect on workflow, (b) Open forum and work relationships, and (c) Face-to-face vs technology-based communication. Physicians described strong interprofessional relationships based on frequent face-to-face communication. Familiarity with healthcare team members, often resulting from being co-located to the same units, created a comfortable work environment, advanced patient care, and accelerated workflow. Physicians preferred in-person communication with interprofessional colleagues over technology-based communicationand described how in-person interactions enriched subsequent technology-led interactions. As the use of technology-based communication grows in inpatient settings, decreasing face-to-face interactions and facilitating dispersed care, understanding and implementing optimal conditions for effective interprofessional communication is essential.

Interprofessional Team Staffing in U.S. Intensive Care Units.

There is a paucity of data, and no consensus, about the composition of interdisciplinary teams of healthcare worker (HCW) that provide care in intensive care units (ICU). Delineate the nature and variation of HCW staff composition in US adult ICUs before the COVID-19 pandemic. A national survey of 574 adult ICUs inquired about ICU staffing. Two sets of survey items asked about: (a) "availability to provide care" in ICU for 11 HCW types, collapsed into six groupings, and (b) presence in formal ICU clinical rounds of nine HCW types, collapsed into six groupings; bedside nurses were assumed to be involved in both categories. Analysis was descriptive, seeking to examine the predominant and full range of staffing patterns. Of surveyed ICUs: 94% were in metropolitan areas, 63% in teaching hospitals, 74% had >250 beds, 66% cared for mixed adult patient types (e.g. medical-surgical), median ICU bed count was 20 (interquartile range 12-25), 27% used some form of telemedicine. In addition to bedside nurses, the core staffing group comprised intensivists, respiratory therapists and pharmacists; in 88% of ICUs all were available to provide care. However, there were 28 different combinations of the six groupings (intensivists, respiratory therapists, pharmacists, attending physician support, advanced bedside nurse support, nurse aides), with the most common one, present in 38% of ICUs, including all six. 96% of ICUs had interprofessional rounds at least five days a week; 78% had them on weekends. Among the ICUs with rounds, 61% of weekday rounding teams included all of intensivists, respiratory therapists and pharmacists. Nutrition, rehabilitation and social support practitioners each participated in rounds in 35-80% of ICUs, and altogether in 28% of ICUs. Except for intensivists, all HCW types participated much less commonly in weekend than in weekday rounds. ICU care almost always included a core team of bedside nurses, intensivists, respiratory therapists, and pharmacists. Beyond that core, great variability was seen in the presence of many other HCW types. Almost all ICUs had interprofessional rounds, with three-quarters also having them on weekends.

Health Professions Students' Reflections About Principles of Interprofessional Collaboration after Shadowing Interprofessional Palliative Care Rounds.

Future healthcare professionals are educated on collaborative practice methods through interventions that may include shadowing. While shadowing allows students to learn from and about other health professions, it often fails to offer an opportunity for the student to work and collaborate with other health professionals. This study sought to investigate themes regarding interprofessional students' experiences during a palliative care shadowing activity and their understanding of collaborative patient-centered care, social determinants of health, and health disparities. Twenty-eight students representing 13 health professions from the Interprofessional Palliative Care program at Jefferson Center for Interprofessional Practice and Education at Thomas Jefferson University submitted reflection essays at the conclusion of their shadowing experience. Four hundred ninety-eight sentences from 28 essays were analyzed via qualitative directed content analysis. Coding categories were determined a priori using definitions of collaborative practice from the 2023 Interprofessional Education Collaborative (IPEC) competencies and definitions of social determinants of health from Healthy People 2030. Thirty-two percent of sentences described IPEC competencies, 18% described social determinants of health/ health disparities, 4% included student emotional reactions, and 2% included student descriptions of the development of their professional role. These results suggest that shadowing offers an opportunity to identify and learn interprofessional competencies in interprofessional palliative care curricula, as made evident through student reflection assignments.

Creating Optimal Clinical Learning Environments Through Interprofessional Bedside Rounding Models: Lessons From the iPACE Story.

The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and implemented at Maine Medical Center in 2016 as part of the Accreditation Council for Graduate Medical Education's Pursuing Excellence in Clinical Learning Environments (CLE) demonstration project. The model is based on the belief that, in optimal CLEs, residents are trained in team-based, interprofessional collaborative care and use clinical care experiences to innovate in the areas of patient safety and quality of care. The model's inclusion of systems engineering principles, such as design thinking, allows teams to design, customize, and iteratively improve their own iPACE model.The iPACE model was further developed and disseminated with support from an American Medical Association Reimagining Residency grant and from the MaineHealth health system's medical education and clinical leadership. iPACE started as a small pilot project on a single inpatient unit and has evolved to become the standard for inpatient team rounds at the bedside. iPACE has received positive feedback from patients, demonstrated benefits to care team members and resident education, and proven its value to the health system through sustained reductions in length of stay and cost of care metrics. The iPACE project has fulfilled MMC's original goal of intentionally redesigning its CLEs to expose residents to high-functioning interprofessional teams with the goal of improving patient care and safety. The model has shown direct learner benefits through increased faculty observation and improved quality of feedback. Interprofessional bedside rounding models like iPACE have the potential to imprint learners with the skills and behaviors essential to provide collaborative patient-centered care. Strategies exist that improve resident and faculty engagement in bedside rounding models like iPACE and should be employed to encourage teaching and learning at the bedside.

Two Approaches of ‘Proactive Consultation’: Towards Well-Functioning Clinical Ethics Consultation

AbstractIn recent years, the global need for clinical ethics consultation services (CECS) has increased to address ethical challenges, dilemmas, and moral distress in clinical environments. In Japan, many hospitals have introduced CECS over the past decade, but few such services work effectively because of the small number of consultations. To address this, we propose two proactive ethics consultation methods: inter-professional ethics rounds and patient note reviews. This paper provides a detailed explanation of these methods, complete with scenarios based on actual cases. These methods can make CECS ‘well-functioning’ by shifting the starting points of consultation from consultees to CECS providers. We then examine the impact and value of proactive ethics consultation as well as four critical factors for its success including attitude, positioning, and competency of proactive consultation teams. We believe our suggestions will provide valuable insights for future clinical ethics consultations and stimulate academic debate about what constitutes a ‘well-functioning’ CECS.

Evaluating Pharmacy Students’ Teamwork Attitudes in Virtual COVID-19 Emergency Department Simulations: A Pilot Study

ObjectiveThis study explores the impact of virtual simulation training on the transformation of teamwork attitudes among pharmacy students in a simulated severe COVID-19 pneumonia scenario in the emergency department. MethodsFrom July 2022 to January 2023, 16 pharmacy students, along with other health care students, participated in interprofessional simulation rounds. Each pharmacy student was assigned specific days for participation, using either a 3-dimensional computer or a virtual reality headset to manage a patient with severe COVID-19 pneumonia in the virtual emergency department. The TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) was used for pre- and post-training assessments. ResultsThe mean baseline T-TAQ score was 119.44 ± 10.63, showing a significant post-training improvement to a mean score of 130.88 ± 8.98 (Hedges’ g = 1.52). Stratification by academic year and device type revealed no significant impact on the learning experience. Remarkable enhancements in teamwork attitudes were observed after training, specifically in team structure, situation monitoring, mutual support, and communication domains. ConclusionThese findings indicate that virtual simulation training in scenarios such as severe COVID-19 effectively augments teamwork attitudes among pharmacy students, preparing them for collaborative practice in high-stakes emergency medicine settings.

A Scoping Review of Student Pharmacist Participation on Interprofessional Rounds.

Interprofessional rounding is a common, yet unrequired, part of the pharmacy experiential curriculum. Little is known about the optimal interprofessional rounding structure for student pharmacists. A scoping review was performed to assess the amount and type of information available regarding student pharmacist participation on interprofessional rounding teams. A comprehensive review of five databases was completed through May 12, 2023. A total of 20 studies met the inclusion criteria. All of the assessments performed were quasi-experimental, and the majority were non-comparative studies that described the type and amount of student interventions. A review of outcomes found that all of the studies could be grouped into two overarching categories: those that assessed the benefits of interprofessional rounding to student pharmacist competencies or satisfaction and those that assessed the benefits of student pharmacists to patient care. The benefits of interprofessional rounding on student pharmacist learning and satisfaction were assessed by qualitative analysis, surveys, and student ability assessments. The benefit of student pharmacist participation in interprofessional rounds to patient care was assessed solely by a review of clinical intervention type and quantity. Thirteen of the studies described the frequency of student pharmacist participation in rounding. Of these studies, eight described daily rounding, and five described non-daily rounding. There are few studies that describe student pharmacist participation on interprofessional rounds and assess the benefits of that participation to either the patient or the student. There is a need for more high-quality studies to determine whether there is an optimal interprofessional rounding schedule.

Use of Rounding Checklists to Improve Communication and Collaboration in the Adult Intensive Care Unit: An Integrative Review.

Intensive care units are complex settings that require effective communication and collaboration among professionals in many disciplines. Rounding checklists are frequently used during interprofessional rounds and have been shown to positively affect patient outcomes. To identify and summarize the evidence related to the following practice question: In an adult intensive care unit, does the use of a rounding checklist during interprofessional rounds affect the perceived level of staff collaboration or communication? An integrative review was performed to address the practice question. No parameters were set for publication year or specific study design. Studies were included if they were set in adult intensive care units, involved the use of a structured rounding checklist, and had measured outcomes that included staff collaboration, communication, or both. Seven studies with various designs were included in the review. Of the 7 studies, 6 showed that use of rounding checklists improved staff collaboration, communication, or both. These results have a variety of practice implications, including the potential for better patient outcomes and staff retention. Given the complexity of the critical care setting, optimizing teamwork is essential. The evidence from this review indicates that the use of a relatively simple rounding checklist tool during interprofessional rounds can improve perceived collaboration and communication in adult intensive care units.

Exploration of ‘micro’ level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory

BackgroundMacro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The ‘micro’ level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored. ObjectiveExplore ‘micro’ level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory. MethodA qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique). ResultsThree micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation. ConclusionClinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Factors influencing nurses' use of sedation interruptions in a critical care unit: a descriptive qualitative study.

This study examined critical care nurses', physicians', and allied health professionals' perceptions of factors that support, inhibit, or limit the use of sedation interruption (SI) to improve the use of this integral component of care for mechanically ventilated patients. We conducted a theory-based, descriptive qualitative study using semi-structured interviews with critical care registered nurses, respiratory therapists, a pharmacist, and a physician in a hospital in Ontario, Canada. The interview guide and analysis were informed by the Theoretical Domains Framework and transcripts were analyzed using content analysis. We identified 9 facilitators and 20 barriers to SI use by nurses. Facilitators included the innovation (importance of protocols) and potential adopters (comfort with the skill). The barriers were the potential adopters' (nurses) knowledge gaps regarding the performance and goal of SI and the practice environment (lack of time, availability of extra staff, and lack of multidisciplinary rounds). This study identified facilitators and barriers to SI for mechanically ventilated patients. Implementation efforts must address barriers associated with nurses, the environment, and contextual factors. A team-based approach is essential, as the absence of interprofessional rounds is a significant barrier to the appropriate use or non-use of SI. Future research can focus on the indications, contraindications, and goals of SI, emphasizing a shared appreciation for these factors across disciplines. Nursing capacity to manage a patient waking up from sedation is necessary for point-of-care adherence; future research should focus on the best ways to do so. Implementation study designs should use theory and evidence-based determinants of SI to bridge the evidence-to-practice gap. http://links.lww.com/IJEBH/A178.

What is impacting clinical pharmacists’ participation in an interprofessional ward round: a thematic analysis of a national survey

ABSTRACT The ward round (WR) is an important opportunity for interprofessional interaction and communication enabling optimal patient care. Pharmacists’ participation in the interprofessional WR can reduce adverse drug events and improve medication appropriateness and communication. WR participation by clinical pharmacists in Australia is currently limited. This study aims to explore what is impacting clinical pharmacists’ participation in WRs in Australian hospitals. A self-administered, anonymous national survey of Australian clinical pharmacists was conducted. This study describes the outcomes from qualitative questions which were analyzed thematically in NVivo-2020 according to Braun and Clarke’s techniques. Five themes were constructed: “Clinical pharmacy service structure”, “Ward round structure”, “Pharmacist’s capabilities”, “Culture” and “Value”. A culture supportive of pharmacist’s contribution with a consistent WR structure and flexible delivery of clinical pharmacy services enabled pharmacists’ participation in WR. Being physically “absent” from the WR due to workload, workflow, and self-perception of the need for extensive clinical knowledge can limit opportunities for pharmacists to proactively contribute to medicines decision-making with physicians to improve patient care outcomes. Bidirectional communication between the interprofessional team and the pharmacist, where there is a co-construction of each individual’s role in the WR facilitates consistent and inter-dependent collaborations for effective medication management.

SIN-BARRSS – Developing a mnemonic to support nurses’ participation in interprofessional ward rounds in intensive care: An appreciative inquiry for quality improvement

ObjectivesTo develop and pilot a mnemonic to increase the willingness and ability of bedside nurses to contribute to patient reviews in the daily interprofessional ward round. Research methodology/designAppreciative inquiry quality improvement study, using ethnographic observations and appreciative inquiry discussions, augmented by quantitative data collection of basic facts. SettingLarge (44 beds) critical care unit in the United Kingdom. Main outcome measuresInterprofessional development and acceptance of mnemonic; successful preparation for pilot; use and usability of mnemonic; improvements in bedside nurses’ contributions to ward round discussions (frequency and focus). Result/findingsInterprofessional development of a usable and useful mnemonic was successful, pilot implementation showed promising levels of take up and acceptance. Compared to before the quality improvement project bedside nurses were more willing and able to participate in ward round discussions, did so more often, and used the mnemonic script with insight and flexibility. ConclusionsThe implementation of a mnemonic supported bedside nurses’ contributions to the ward round. This could provide a framework for introducing similar programmes to other intensive care units. Appreciative inquiry methodology could be replicated in other settings to aid the improvement of interprofessional ward rounds, or to address other quality improvement priorities. Implications for clinical practiceA mnemonic can provide a structure which supports bedside nurses’ contributions in ways that make good use of bedside nurses’ professional expertise and most up to date knowledge of patients’ clinical state. Furthermore, a well-designed mnemonic can be used flexibly and provides an outline script that supports less experienced and less confident nurses to make well-focused and well received contributions to rapid interprofessional discussions. In turn, this can increase these nurses’ confidence and capability. More experienced and confident nurses, and ward round leaders, can use the same mnemonic flexibly as an aide memoir that guards against missing information and insights that could affect the quality and safety of patient care.

Development of individual competencies and team performance in interprofessional ward rounds: results of a study with multimodal observations at the Heidelberg Interprofessional Training Ward.

Interprofessional training wards (IPTW) aim to improve undergraduates' interprofessional collaborative practice of care. Little is known about the effects of the different team tasks on IPTW as measured by external assessment. In Heidelberg, Germany, four nursing and four medical undergraduates (= one cohort) care for up to six patients undergoing general surgery during a four-week placement. They learn both professionally and interprofessionally, working largely on their own responsibility under the supervision of the medical and nursing learning facilitators. Interprofessional ward rounds are a central component of developing individual competencies and team performance. The aim of this study was to evaluate individual competencies and team performance shown in ward rounds. Observations took place in four cohorts of four nursing and four medical undergraduates each. Undergraduates in one cohort were divided into two teams, which rotated in morning and afternoon shifts. Team 1 was on morning shift during the first (t0) and third (t1) weeks of the IPTW placement, and Team 2 was on morning shift during the second (t0) and fourth (t1) weeks. Within each team, a tandem of one nursing and one medical undergraduate cared for a patient room with three patients. Ward round observations took place with each team and tandem at t0 and t1 using the IP-VITA instrument for individual competencies (16 items) and team performance (11 items). Four hypotheses were formulated for statistical testing with linear mixed models and correlations. A total of 16 nursing and medical undergraduates each were included. There were significant changes in mean values between t0 and t1 in individual competencies (Hypothesis 1). They were statistically significant for all three sum scores: "Roles and Responsibilities", Patient-Centeredness", and "Leadership". In terms of team performance (Hypothesis 2), there was a statistically significant change in mean values in the sum score "Roles and Responsibilities" and positive trends in the sum scores "Patient-Centeredness" and "Decision-Making/Collaborative Clinical Reasoning". Analysis of differences in the development of individual competencies in the groups of nursing and medical undergraduates (Hypothesis 3) showed more significant differences in the mean values of the two groups in t0 than in t1. There were significant correlations between individual competencies and team performance at both t0 and t1 (Hypothesis 4). The study has limitations due to the small sample and some sources of bias related to the external assessment by means of observation. Nevertheless, this study offers insights into interprofessional tasks on the IPTW from an external assessment. Results from quantitative and qualitative analysis of learners self-assessment are confirmed in terms of roles and responsibilities and patient-centeredness. It has been observed that medical undergraduates acquired and applied skills in collaborative clinic reasoning and decision-making, whereas nursing undergraduates acquired leadership skills. Within the study sample, only a small group of tandems remained constant over time. In team performance, the group of constant tandems tended to perform better than the group of random tandems. The aim of IPTW should be to prepare healthcare team members for the challenge of changing teams. Therefore, implications for IPTW implementation could be to develop learning support approaches that allow medical and nursing undergraduates to bring interprofessional competencies to team performance, independent of the tandem partner or team.

Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study

Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care. A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation. Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions. Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.

Individuelle Kompetenzen und Team-Performance in klinischen Lernsettings der interprofessionellen Zusammenarbeit erfassen: Die empirische Entwicklung des Interprofessionelle Visiten Individual und Team Assessment Tools (IP-VITA)

BackgroundInterprofessional training wards (IPTW) can contribute to the development of interprofessional competencies. In order to evaluate the acquisition of competencies, instruments are needed that record both team performance and individual competencies in the clinical teaching setting in third-party assessment. This paper describes the Interprofessional Ward Round Individual and Team Assessment-Tool, IP-VITA (“Interprofessionelle Visiten Individual und Team Assessment Tool”) and its development. MethodBased on the empirical exploration of the three observation instruments “Teamwork Assessment Scale” (TAS), “McMaster-Ottawa Scale” and “Individual Teamwork Observation and Feedback Tool” (iTOFT) in at least four rounds each at the HIPSTA (with n=8 students and trainees each), a preliminary version of the IP-VITA was created. This preliminary version was then refined in subsequent empirical steps: a consensual validation in the research team was followed by a “member check“ with the clinical colleagues of the HIPSTA, the input from external experts and an empirical test in an alternative setting. ResultsThe IP-VITA is an empirically developed multimodal instrument to assess the interprofessional competencies of trainees and students as well as their team performance in clinical settings with patient interaction. It comprises three parts. In part A, structural data, the persons involved and the essential patient characteristics are recorded. Part B consists of 12 items and a free-text field for recording behaviour at the individual level. Part C also consists of 12 items and evaluates behaviour at team level. DiscussionThe IP-VITA instrument was developed specifically for the context of evaluating interprofessional ward rounds in a clinical educational setting. The instrument takes into account the ambiguous position of the assessment of interprofessional collaboration between individual competence and team performance. Beyond the HIPSTA, it can be used as a formative assessment instrument, and it may also be useful for summative assessments.

Interprofessional Art Rounds

Art Rounds is an interprofessional workshop that uses art to develop nursing and medical students' observation skills and empathy. The workshop's joint emphasis on interprofessional education (IPE) and visual thinking strategies (VTS) is intended to improve patient outcomes, strengthen interprofessional collaboration, and maintain a climate of mutual respect and shared values. Interprofessional teams of 4 to 5 students practice faculty-guided VTS on artworks. Students then apply VTS and IPE competencies in observing, interviewing, and assessing evidence during 2 encounters with standardized patients (SPs). Students also write a chart note that includes differential diagnoses with supportive evidence for each of the 2 SPs. Art Rounds focuses on students' observation of details and interpretation of images and SPs' physical appearance; evaluation strategies include grading rubrics for the chart notes and a student-completed evaluation survey.

Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool

Nurse-led rounding checklists are a common strategy for facilitating evidence-based practice in the intensive care unit (ICU). To streamline checklist workflow, some ICUs have the nurse or another individual listen to the conversation and customize the checklist for each patient. Such customizations assume that individuals can reliably assess whether checklist items have been addressed. To evaluate whether 1 critical care nurse can reliably assess checklist items on rounds. Two nurses performed in-person observation of multidisciplinary ICU rounds. Using a standardized paper-based assessment tool, each nurse indicated whether 17 items related to the ABCDEF bundle were discussed during rounds. For each item, generalizability coefficients were used as a measure of reliability, with a single-rater value of 0.70 or greater considered sufficient to support its assessment by 1 nurse. The nurse observers assessed 118 patient discussions across 15 observation days. For 11 of 17 items (65%), the generalizability coefficient for a single rater met or exceeded the 0.70 threshold. The generalizability coefficients (95% CIs) of a single rater for key items were as follows: pain, 0.86 (0.74-0.97); delirium score, 0.74 (0.64-0.83); agitation score, 0.72 (0.33-1.00); spontaneous awakening trial, 0.67 (0.49-0.83); spontaneous breathing trial, 0.80 (0.70-0.89); mobility, 0.79 (0.69-0.87); and family (future/past) engagement, 0.82 (0.73-0.90). Using a paper-based assessment tool, a single trained critical care nurse can reliably assess the discussion of elements of the ABCDEF bundle during multidisciplinary rounds.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS®). To enhance team performance, we piloted TeamSTEPPS® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

Nurse-Driven Interprofessional Rounds: Improving Care Coordination and Length of Stay.

Inpatient oncology units care for patients with some of the most complex medical conditions outside of the intensive care unit. These patients benefit from structured care coordination. Reduced ability to admit patients to oncology beds contributes to delays in specialty care. This quality improvement initiative established nurse-driven interprofessional rounds (IPRs) to reduce length of stay (LOS), improve discharge time of day, and enhance care coordination, patient flow, and access to care in the community. Care coordination during enhanced IPRs (eIPRs) included estimation of discharge dates, comparison of LOS to a standard geometric mean LOS, and discussion of clinical milestones and barriers to progression and discharge. Data analysis evaluated the effect of eIPRs on key outcomes. Although LOS variance was reduced by 15.8% and 44.1% in all-unit and hematology-oncology discharges, respectively, the results were not significant. Discharges by 2 pm improved significantly for all-unit and hematology-oncology populations, respectively. Patient flow measured by accepted patient transfers requesting hematology-oncology services improved significantly.

Impact of Interprofessional Teamwork on Aligning Intensive Care Unit Care with Patient Goals: A Qualitative Study of Transactive Memory Systems.

Rationale: Although aligning care with patient goals is fundamental to critical care, this process is often delayed and leads to conflict among patients, families, and intensive care unit (ICU) teams. Interprofessional collaboration within ICU teams is an opportunity to improve goal-aligned care, yet this collaboration is poorly understood. A better understanding of how ICU team members work together to provide goal-aligned care may identify new strategies for improvement. Objectives: Transactive memory systems is a theory of group mind that explains how high-performing teams use a shared memory and collective cognition. We applied this theory to characterize the process of interprofessional collaboration within ICU teams and its relationship with goal-aligned care. Methods: We conducted a secondary analysis of focus group (n = 10) and semistructured interview (n = 8) transcripts, gathered during a parent study at two academic medical centers on the process of ICU care delivery in acute respiratory failure. Participants (N = 70) included interprofessional ICU and palliative care team members, surrogates, and patient survivors. We used directed content analysis, applying transactive memory systems theory and its major components (specialization, coordination, credibility) to examine ICU team collaboration. Results: Participants described each ICU profession as having a specialized role in aligning care with patient goals. Different professions have different opportunities to gather knowledge about patient goals and priorities, which results in dispersion of this knowledge among different team members. To share and use this dispersed knowledge, ICU teams rely on an informal coordination process and "side conversations." This process is a workaround for formal channels (e.g., health records, interprofessional rounds) that do not adequately convey knowledge about patient goals. This informal process does not occur if team members are discouraged from asserting their knowledge because of hierarchy or lack of psychological safety. Conversely, coordination succeeds when team members recognize each other as credible sources of valued knowledge. Conclusions: We found that ICU team members work together to align care with patient goals and priorities, using transactive memory systems. The successful function of these systems can be disrupted or promoted by ICU organizational and cultural factors, which are potential targets for efforts to increase goal-aligned care.