Morning Rounds Research Articles

Implementation of hematology oncology lecture series for nursing staff.

e21005 Background: Westchester Medical Center has an oncology unit that provides care for hundreds of patients annually. Inpatient cancer patients often have especially complex medical treatment plans that require interdisciplinary collaboration and specialized knowledge of oncologic conditions. There is a need to implement formal teaching tailored to nursing staff devoted to topics in hematology and oncology. Our goal was to develop a monthly lecture series for nursing that deepened their understanding of cancer treatments, enabling them to assess and monitor patients with greater expertise. Methods: Topics were chosen based on relevance and are listed in the table. Speakers included full-time faculty, fellows and residents, pharmacists, and medical students. Ten lectures were completed and scheduled approximately once monthly in the mornings just prior to sign out for nursing shift change. Nursing staff were asked to complete a set of questions prior to each lecture (Pre-Test) They were given the same set of questions after each lecture (Post-Test) to determine whether there was an improvement in understanding of the topic. Informational handouts were distributed at the end of each lecture to provide participants with a summary of key points. A survey administered at the conclusion of the lecture series was collected to assess attitudes towards the lectures. Results: Overall test scores improved after each lecture was given, as demonstrated in the table: Pre and Post Lecture Test Scores. Additionally, feedback regarding the lectures was positive. 100% agreed that they gained a better understanding of topics related to hematology oncology and 92% agreed that participation in these lectures has improved their ability to function collaboratively on interprofessional healthcare teams. Conclusions: A didactic lecture series is a valuable component of hematology oncology education for nursing staff and will improve quality of care of the oncology service. Some limitations of this lecture series concerned nursing staff scheduling conflicts and their availability for lecture attendance. Possible interventions in the future may include setting aside time dedicated for monthly lectures and scheduling lectures for afternoons to avoid conflicts with shift changes and morning rounds. Nevertheless, our findings highlight the value of continued education in empowering nursing staff to deliver quality care to hematology oncology patients.[Table: see text]

Caregiver Satisfaction with Medical Providers' Communication: Comparison Between Spanish-Speaking Caregivers with Limited English Proficiency (LEP) and Caregivers Who Are English-Proficient (EP).

Barriers to communication have been observed with patients and families who prefer a language other than English for medical conversations, referred to as individuals with limited English proficiency (LEP). We used the pediatric Family Satisfaction with ICU 24R (FS-ICU) survey to assess communication satisfaction for English-proficient (EP) and Spanish-speaking LEP caregivers. We added additional questions related to attendance at morning rounds, frequency of provider updates, interpreter use, and general satisfaction with communication. This was a single-center, prospective, observational cohort study in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CICU) of a tertiary, academic, free-standing children's hospital. Caregivers of children < 18 years old admitted for at least 48 h to the PICU or CICU between June and September 2022 were eligible for enrollment. 24LEP and 74 EP caregivers completed the survey questions. The LEP group had lower household income and education levels and higher incidence of public insurance. FS-ICU scores for both LEP and EP caregivers suggested high satisfaction, without significant difference between the groups. However, qualitative analysis revealed dissatisfaction for LEP caregivers related to information, inclusion, and language barriers. EP caregivers had more positive references to information and emotional connection but indicated dissatisfaction around consistency and responsiveness. 18%of LEP caregivers reported regularly attending rounds, versus 67% of the EP group (p value < .001). 39% ofLEP versus 52% of EP caregivers reported multiple daily updates, although the difference was not statistically significant. 29% of LEP respondents reported nonfluent MD/NPs using an interpreter never, rarely, or some of the time. There was no difference in satisfaction scores between LEP and EP caregivers. LEP caregivers had lower socioeconomic status based on public insurance and reported income and education level. Qualitative data allowed more nuanced understanding of communication satisfaction, which correlated with LEP caregivers' reported lower attendance at morning rounds, inconsistent interpreter use, and a trend toward less frequent provider updates.

Tele-ICU Management of a Trauma Patient at a Peripheral Center

Methods: A 23-year-old male was admitted to a peripheral center following a fall from a tractor. Examination at admission revealed a conscious, stable patient with significant chest pain. The tele-ICU (intensive care unit) was called, and when they received the patient, he was stabilized and managed immediately. The tele-ICU connection was provided through the Command Center in Apollo Hospitals, Jubilee Hills, Hyderabad, India, which is connected to multiple spoke locations at peripheral centers using audio-visual aids. An intensivist is available 24 h daily to provide critical care services to the peripheral centers through audio-visual aids. The tele-ICU connection is provided to the peripheral centers through commercial audio-visual and bedside data transfer devices. The tele-ICU team supervised the primary survey remotely via a central monitor, viewing the patient’s vitals along with the audio/video calling capabilities of the cameras as a part of the tele-ICU program. Results: Chest X-rays showed bilateral pneumothorax, lung compression, and multiple rib fractures. The team at the peripheral center was immediately advised to institute bilateral intercostal drainage (ICD). High-resolution CT chest (HRCT) reveals extensive right and minor left pneumothorax, bilateral lung contusions, a right clavicle medial end fracture, and multiple rib fractures. Ultrasonography of the abdomen showed altered splenic echo texture and moderate left pleural effusion. Flail chest and paradoxical breathing pattern warranted endotracheal intubation. The patient was ventilated for 4 days. On day 3, the patient experienced an air leak from the left ICD, increased drain output, and decreased hemoglobin. The tele-ICU team consulted the cardiothoracic surgeon regarding the air leak and followed their advice to attach a vacuum bottle to the ICD. The patient’s breathing improved gradually. Mechanical ventilator settings (i.e., tidal volume, respiratory rate, and peak airway pressures) were reviewed daily by the tele-ICU team during the regular morning and evening rounds. In addition, the ventilator and the bedside monitor were continuously monitored from the Command Center through video conferencing, which is integrated with electronic software and regularly captures the patient’s vitals. After 4 days of mechanical ventilation, the patient was extubated and started on oxygen therapy. Oxygen was gradually tapered and stopped. After 8 days of uneventful hospitalization, the patient was discharged. Conclusion: Studies show that telemedicine can provide expert-guided mentoring for life-saving procedures, including pre-hospital assessment and triage for polytrauma, tube thoracotomies, and extended focused assessment with sonography in trauma (eFAST). Technology may help resource-constrained places adopt telemedicine and its benefits.

A Novel Continuous Real-Time Vital Signs Viewer for Intensive Care Units: Design and Evaluation Study.

Clinicians working in intensive care units (ICUs) are immersed in a cacophony of alarms and a relentless onslaught of data. Within this frenetic environment, clinicians make high-stakes decisions using many data sources and are often oversaturated with information of varying quality. Traditional bedside monitors only depict static vital signs data, and these data are not easily viewable remotely. Clinicians must rely on separate nursing charts-handwritten or electric-to review physiological patterns, including signs of potential clinical deterioration. An automated physiological data viewer has been developed to provide at-a-glance summaries and to assist with prioritizing care for multiple patients who are critically ill. This study aims to evaluate a novel vital signs viewer system in a level 1 trauma center by subjectively assessing the viewer's utility in a high-volume ICU setting. ICU attendings were surveyed during morning rounds. Physicians were asked to conduct rounds normally, using data reported from nurse charts and briefs from fellows to inform their clinical decisions. After the physician finished their assessment and plan for the patient, they were asked to complete a questionnaire. Following completion of the questionnaire, the viewer was presented to ICU physicians on a tablet personal computer that displayed the patient's physiologic data (ie, shock index, blood pressure, heart rate, temperature, respiratory rate, and pulse oximetry), summarized for up to 72 hours. After examining the viewer, ICU physicians completed a postview questionnaire. In both questionnaires, the physicians were asked questions regarding the patient's stability, status, and need for a higher or lower level of care. A hierarchical clustering analysis was used to group participating ICU physicians and assess their general reception of the viewer. A total of 908 anonymous surveys were collected from 28 ICU physicians from February 2015 to June 2017. Regarding physicians' perception of whether the viewer enhanced the ability to assess multiple patients in the ICU, 5% (45/908) strongly agreed, 56.6% (514/908) agreed, 35.3% (321/908) were neutral, 2.9% (26/908) disagreed, and 0.2% (2/908) strongly disagreed. Morning rounds in a trauma center ICU are conducted in a busy environment with many data sources. This study demonstrates that organized physiologic data and visual assessment can improve situation awareness, assist clinicians with recognizing changes in patient status, and prioritize care.

ERASURE: early autologous blood pleurodesis for postoperative air leaks—a randomized, controlled trial comparing prophylactic autologous blood pleurodesis versus standard watch and wait treatment for postoperative air leaks following thoracoscopic anatomic lung resections

BackgroundThe prolonged air leak is probably the most common complication following lung resections. Around 10–20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or “blood patch”. The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged.MethodsPatients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day.DiscussionThe early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting.Trial registrationGerman Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022

Does Rounding Order Bias Discharge Efficiency? Predictors of Discharge Timing on an Academic Urology Service.

No previous works have analyzed whether the order in which surgical teams see patients on morning rounds affects discharge efficiency at teaching hospitals. We obtained perioperative urologic surgery timing data at our academic institution from 2014 to 2019. We limited the analysis to routine postoperative day 1 discharges. Univariate and multivariate analyses were performed to determine whether various hospital and patient factors were associated with discharge timing. We analyzed 1,494 patients. Average discharge order time was 11:22 a.m. and hospital discharge 1:24 p.m. Univariate regression revealed earlier discharge order time for patients seen later in rounds by 4 minutes per sequential room cluster (p = .013) and by 12 minutes per cluster when excluding short-stay patients. Multivariate analysis revealed discharge order placement did not vary significantly by rounding order. However, time of hospital discharge did (p < .001), likely due to speed of discharge in the designated short-stay units. Attending physician was the most consistent predictor in variations of discharge timing, with statistical significance across all measured outcomes. Patients seen later in rounding progression received earlier discharge orders, but this relationship does not remain in multivariate modeling or translate to earlier discharge. These findings have helped guide quality improvement efforts focused on discharge efficiency.

Assessing the health literacy of caregivers in the pediatric intensive care unit: a mixed-methods study.

Limited health literacy is associated with increased hospitalizations, emergency visits, health care costs, and mortality. The health literacy levels of caregivers of critically ill children are unknown. This mixed-methods study aims to quantitatively assess the health literacy of caregivers of children admitted to the pediatric intensive care unit (PICU) and qualitatively describe facilitators and barriers to implementing health literacy screening from the provider perspective. Caregivers of patients admitted to our large, academic PICU (between August 12, 2022 and March 31, 2023) were approached to complete a survey with the Newest Vital Sign (NVS), which is a validated health literacy screener offered in English and Spanish. We additionally conducted focus groups of interdisciplinary PICU providers to identify factors which may influence implementation of health literacy screening using the Consolidated Framework for Implementation Research (CFIR) framework. Among 48 surveyed caregivers, 79% demonstrated adequate health literacy using the Newest Vital Sign screener. The majority of caregivers spoke English (96%), were mothers (85%), and identified as White (75%). 83% of caregivers were able to attend rounds at least once and 98% believed attending rounds was helpful. Within the PICU provider focus groups, there were 11 participants (3 attendings, 3 fellows, 2 nurse practitioners, 1 hospitalist, 2 research assistants). Focus group participants described facilitators and barriers to implementation, which were mapped to CFIR domains. Timing of screening and person administering screening were identified as modifiable factors to improve future implementation. We found the health literacy levels of PICU caregivers in our setting is similar to prior assessments of parental health literacy. Participation in morning rounds was helpful for developing understanding of their child's illness, regardless of health literacy status. Qualitative feedback from providers identified barriers across all CFIR domains, with timing of screening and person administering screening as modifiable factors to improve future implementation.

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative

Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates. To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates. This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023. A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018. Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods. Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease. This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

Does Implementing Calendars Outlining Inpatient Chemotherapy Schedules in Patient Rooms Improve Patient's Experience?

Background: Patients who receive inpatient chemotherapy for malignancy are dealing with both a physically and mentally challenging admission. Their chemotherapy regimen is predetermined and usually only discussed during rounds. Often times, patients feel overwhelmed and may miss the outline of their schedule. Furthermore, patients families may not be able to attend morning rounds and may miss the proposed schedule. This can lead to a feeling of loss of control in both the patient and their family, and thus, frustration. First year medicine residents are also overwhelmed with a large patient load and having to keep track of multiple chemotherapy regimens. We are hoping that by providing a calendar that outlines patient's anticipated chemotherapy schedule, we may be able to give patients a small sense of control back and help residents provide the best care to their patients. Ultimately, we hope that this leads to a better inpatient experience. Methods: Patients admitted to the hematology/oncology floor at Henry Ford Health Hospital in Detroit, Michigan over three months were screened, and those receiving inpatient chemotherapy were selected. Within this group, any patient that was getting inpatient chemotherapy for longer than three days was asked if they would like to participate in the study. If the patient agreed, they were provided a calendar that outlined their chemotherapy schedule. Calendars were updated if any adjustments were made to the schedule. At the end of their inpatient stay, patients filled out a questionnaire asking if the calendar helped them understand their schedule better. The primary resident caring for the patient was also asked if the calendar helped them keep track of their patient's schedule. Results: Overall, patients responded positively to the calendars. We have preliminary data on ten patients and four providers from three months. On average, on a scale of 1-10 (with 1 indicating not helpful at all, and 10 indicating extremely helpful) patients rated the calendars helping them at a level of 7.5. Patients found that the calendars particularly helped their families who were not able to come visit in the hospital. Providers found the calendars extremely helpful, rating the calendars at a level of 10. We will continue to collect data and update our results. Conclusions: Implementing patient calendars in inpatient rooms helps patients keep track of their chemotherapy schedules and leads to a positive inpatient experience. We are hoping to implement this as a standard of care in all inpatient rooms on the hematology/oncology floor.

Clustering analysis of noise sources in healthcare facilities

Hospital environmental noise can impact the comfort of both workers and patients, causing sleep disturbances and hindering the recovery process. Environmental noise in hospitals is typically due to the mixture of various sound sources, including staff, outdoor noises, and mechanical equipment. Patients and staff experience different effects from noise contributions: the former's recovery process is influenced, while the latter's communication efficiency is compromised. Conventional measurements are based on equivalent continuous sound pressure levels. However, the latter does not provide any kind of details about the hospital's sound context. Unsupervised acoustic measurements have been already used in many fields, but still in a few healthcare scenarios. For this reason, a clustering technique has been used to deepen the conventional noise analysis. The Gaussian Mixture Model (GMM) is used to identify and quantify the contributions of the main types of sound sources. This analysis has been conducted within two four-bed bays: one in active conditions and the other unoccupied. The GMM analysis involves the noisiest period of the day, the morning round. The results demonstrate the GMM's ability to overcome conventional practices by providing significant insight into environmental noise, even in active conditions. In the active room, noise sources were tagged and measured. The spectral matching, based on the empty room's outcomes and standard references, represents the benchmark to assess the reliability of the method.

Challenging Organizational Factors Associated With Admission Delay to Intensive Care Unit-A Novel Quality Indicator.

Delays in admitting patients to the intensive care unit (ICU) can defer the timely initiation of life-sustaining therapies and invasive monitoring, jeopardizing the success of the treatment. Nevertheless, the availability of research on interventions that reduce or minimize admission delays is limited. The current study aimed to assess the factors related to delays in admission times of critically ill patients transferred to the ICU. A software was designed to follow-up, compare and measure the defined intervals of the time to admission, implemented at the ICU for 6 months. Measurements included 5 time intervals, referral department, and work shift at admission. Data from 1004 patients admitted to the ICU between July 2017 and January 2020 were analyzed in a retrospective observational study. Precisely, 53.9% of total patients were referred from the hospital emergency department, and 44% were admitted during the evening shift. Significant differences were found in time intervals between shifts, showing the morning round had the longer total admission time (median: 67.8 min). Analysis showed that admission time was longer at times of full capacity compared to times of available bed (mean: 56.4 and 40.2 min, respectively; U = 68,722, p < .05). Findings demonstrated a significant shortening of time to admission after implementing a new time monitoring software by the Institutional Quality Control Commission (U = 5072, p < .001). Our study opens doors for potential studies on applying effective initiatives in critical care settings to improve patient care and outcomes. Additionally, it generates new insights regarding how clinicians and nursing teams can jointly develop and promote multidisciplinary interventions in intensive care work environments.

A qualitative study of how team characteristics and leadership are associated with information sharing in multidisciplinary intensive care units

BackgroundBetter information sharing in intensive care units has been associated with lower risk-adjusted mortality. This study explored how team characteristics and leadership are associated with information sharing in 4 intensive care units in a single large urban, academic medical center. MethodsA qualitative study was conducted to understand how team characteristics and leadership are associated with information sharing. Qualitative data were conducted through ethnographic observations. One postdoctoral research fellow and one PhD qualitative researcher conducted nonparticipant observations of a Medical, Surgical, Neurological, and Cardiothoracic intensive care unit morning and afternoon rounds, as well as nurse and resident handoffs from May to September 2021. Field notes of observations were thematically analyzed using deductive reasoning anchored to the Edmondson Team Learning Model. This study included nurses, physicians (ie, intensivists, surgeons, fellows, and residents), medical students, pharmacists, respiratory therapists, dieticians, physical therapists, physician assistants, and nurse practitioners. ResultsWe conducted 50 person-hours of observations involving 148 providers. Three themes emerged from the qualitative analysis: (1) team leaders used variable leadership techniques to involve team members in discussions for information sharing related to patient care, (2) predefined tasks for team members allowed them to prepare for effective information sharing during intensive care unit rounds, and (3) a psychologically safe environment allowed team members to participate in discussions for information sharing related to patient care. ConclusionInclusive team leadership is foundational in creating a psychologically safe environment for effective information sharing.

Time Spent on Medical Round Activities, Distance Walked, and Time-Motion in the General Medicine Department at Hamad General Hospital in Qatar.

Background The daily morning round is a routine activity performed by medical teams. During the morning round, updates on the patient's clinical condition, new laboratory results, and other test results are reviewed and discussed between team members, the patient, and at times the family. Completing these tasks takes time. The design of the patient location differs between hospitals, and significant distance between patients can considerably affect round times. This study assesses physicians' time spent on clinical activities,the distance traveled, and the time they spend walking between patients during daily morning rounds to identify better reorganization methods to reduce wasted time. Methodology The survey was self-administered and had no intervention needing ethical approval. The research team's leader engaged two observers (a general practitioner from another department and a general internal medicine department case manager) to collect the data. The general practitioner was a medical graduate doctor, while the bed manager was not a medical college graduate. They observed 10 rounds over 10 non-consecutive days from July 1 to July 30, 2022. They recorded daily activities during the daily morning round, including time spent with patients, family conversations, bedside education, medication, social issues, and the time and distance required to move from patient to patient and from one location to location. The informal conversations about age, work history, and other small talk were recorded and converted into quantitative data. In each round, records were given to a statistician for rechecking. Subsequently, the records were imported into a Microsoft Excel spreadsheet for further statistical analysis. For continuous variables, the data were summarized as mean, median, and standard deviation. For categorical variables, the data were summarized as counts or proportions. Results On average, the duration of the daily morning round was 161.7 ± 17.3 minutes. The average number of patients seen by the general internal medicine round team was 14. The median patient encounter time per patient was 14 minutes (11-19 minutes), with an average of 12 minutes. An average of 8.6 employees participated in the 10-day rounds. The physician spent 41.2% of the time in direct contact with the patient during the morning round, 11.4% in maintaining electronic medical records, and 18.20% in bedside teaching.Additionally, 7.1% of the round time was spent because of interruptions by clinical and non-clinical staff other than team members or family members who were not in the room. Furthermore, a team member walked an average of 763 ± 54.5 m (667-872 m) per round, costing 35.7 minutes (22.1%) of the total round time. Conclusions The daily morning round time wassignificantly longer compared with the reported round times. Relocating patient beds to a common location reduced the rounding time by 22.30%. Disruption, teaching, and medical instruction must also be considered and shortened to reduce the morning round time.

ABCDEF Bundle

The ABCDEF bundle was created 10 years ago after new data through clinical practice guidelines emerged via the Society of Critical Care Medicine (SCCM). This bundle provided a novel way for interprofessional teams in intensive care units (ICUs) to work together to focus on pain reduction, appropriate sedation for delirium prevention, increased mobility to reduce ventilator days, and improved sleep hygiene.A lot has happened in the decade since the ABCDEF bundle’s inception. Updated in 2018, the ABCDEF bundle continues to be our driving force and the reference standard around which much of our work is centered in our critical care units. According to data released by SCCM,1 implementing this ICU Liberation Bundle (A-F)2 decreases the likelihood of hospital death within 7 days by 68%, reduces delirium and coma days by 25% to 50%, reduces physical restraint use by more than 60%, cut ICU readmissions in half, and reduces discharges to nursing and rehabilitation facilities by 40%.Quick ways to implement the ABCDEF bundle during your morning rounds:

Developing an Inpatient Relationship Centered Communication Curriculum (I-RCCC) rounding framework for surgical teams

BackgroundMorning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience.Study designA mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients’ expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop.ResultsNeeds assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents “about half of the time” to 100% of them “always”. Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%.ConclusionThe Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.

The Effect of a Single Intravenous Corticosteroid Administration on Pain after Knee Arthroscopy: A Prospective, Double-Blind, Non-Randomized Controlled Clinical Trial

Knee arthroscopy is a standard surgical procedure that is nowadays widely performed as day-case surgery. The aim of the study was to observe the effect of a single dose of intravenous corticosteroid on pain after undergoing knee arthroscopy for non-bony procedures. A prospective, double-blind study design was adopted. Patients undergoing knee arthroscopy for non-bony procedures were prospectively assigned into two equal groups: control (those who were not given steroids) and treatment (those who were given eight milligrams of dexamethasone intravenously 15 min prior to the inflation of the tourniquet). The pain was assessed pre-operatively on admission and on the first post-operative day during the morning round in five different movements using a visual analogue scale (VAS). A total of 60 patients were included in the study. There was no significant difference in the pre-and post-operatively scores between both groups. The treatment group experienced a significant reduction in post-operative morphine requirements, with 80% of patients who did not receive dexamethasone requiring post-operative morphine compared to only 53.3% of patients who did (p = 0.027). Pre-operative intravenous administration of a single dose of dexamethasone may decrease opioid requirements for adequate pain control after knee arthroscopy.

HCAHPS: having constant communication augments hospital and patient satisfaction

Background and aimThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has become a standardised instrument to measure hospitalised patients’ perception of care. Our hospital’s HCAHPS scores for the...

Initial Development of an Automated Platform for Assessing Trainee Performance on Case Presentations.

Oral case presentation is a crucial skill of physicians and a key component of team-based care. However, consistent and objective assessment and feedback on presentations during training are infrequent. To determine the potential value of applying natural language processing, computer software that extracts meaning from text, to transcripts of oral case presentations as a strategy to assess their quality automatically and objectively. We transcribed a collection of simulated oral case presentations. The presentations were from eight critical care fellows and one critical care attending. They were instructed to review the medical charts of 11 real intensive care unit patient cases and to audio record themselves, presenting each case as if they were doing so on morning rounds. We then used natural language processing to convert the transcripts from human-readable text into machine-readable numbers. These numbers represent details of the presentation style and content. The distance between the numeric representation of two different transcripts negatively correlates with the similarity of those two transcripts. We ranked fellows on the basis of how similar their presentations were to the attending's presentations. The 99 presentations included 260 minutes of audio (mean length: 2.6 ± 1.24 min per case). On average, 23.88 ± 2.65 sentences were spoken, and each sentence had 14.10 ± 0.67 words, 3.62 ± 0.15 medical concepts, and 0.75 ± 0.09 medical adjectives. When ranking fellows on the basis of how similar their presentations were to the attending's presentation, we found a gap between the five fellows with the most similar presentations and the three fellows with the least similar presentations (average group similarity scores of 0.62 ± 0.01 and 0.53 ± 0.01, respectively). Rankings were sensitive to whether presentation style or content information were weighted more heavily when calculating transcript similarity. Natural language processing enabled the ranking of case presentations on the basis of how similar they were to a reference presentation. Although additional work is needed to convert these rankings, and underlying similarity scores, into actionable feedback for trainees, these methods may support new tools for improving medical education.

Supporting transgender and gender diverse medical students

“Is he wearing a dress? Men shouldn't wear dresses.” It was the first comment by a patient during morning rounds. The medical student he was referring to had introduced themself with they/them pronouns several days earlier. This real-life scenario, which one of us (NWF) recently experienced, is all too common for transgender and gender diverse (TGD) medical students. As the patient started to ask if the student was “really” a man, the attending physician spoke up to say that the patient's behaviour was inappropriate and would not be tolerated.

Complications of Haemoperitoneum due to Sexual Encounter in Pregnancy: A Case Study

Haemoperitoneum secondary to a rupture of tortuous vessels from the serosal surface of the right uterine fundal region after coitus is a rare but life-threatening condition. This case demonstrates that even a very rare diagnosis should be considered, especially when dealing with patients with atypical presentations. This case report evidences a 31-year-old woman in her first pregnancy, presenting to our hospital triage at night for abdominal pain after sexual intercourse at a gestational age of 33 weeks and 4 days, and there was no history suggestive of endometriosis or fibroids. Apart from mild pain and slight pallor, she was stable. Her initial CTG was normal, but we noted two unprovoked decelerations about 8 and 10 hours after admission. During the morning rounds review, intra-abdominal bleeding was highly suspected and an emergency caesarean section was arranged. The on-call surgeon was also alerted, and a class I caesarean section was performed through the midline sub-umbilical incision. About 800 ml of intraoperative hemoperitoneum was noted upon opening the peritoneum. A male infant weighing 2.3 kg was delivered. Clear liquor was noted. Meanwhile, a small defect of about 1 cm in diameter with active bleeding from the underlying tortuous vessel was noted over the right posterior wall of the fundus. The underlying myometrium was intact and there was neither through nor through tear nor perforation. Discussion: The precise mechanism for postcoital haemoperitoneum due to rupture of uterine subserosal vessels is not known, but it is hypothesized that: pregnancy-with the increased friability of the tissues and fixation of the genital tract coincident with gestation; vigorous intercourse; coital positions; vaginismus and genital disproportion are the possible explanations. A complete gynaecological history, including endometriosis, fibroids, pelvic inflammatory disease, and any recent surgical procedures, is required to make a diagnosis. Ruptured ectopic pregnancy and ruptured corpus luteal cyst are on the top of the list of diagnoses in the early stage of pregnancy. The majority of such cases do not voluntarily admit the preceding act of coitus during initial presentation, and care must be taken to elicit a detailed sexual history. Interestingly, spontaneous haemoperitoneum in pregnancy complicated by endometriosis may occur during pregnancy. Conclusion: The study concludes that pregnant women with a history of the recent coitus present with acute abdominal pain, even in the absence of vaginal bleeding, haemoperitoneum has to be considered. On the other hand, idiopathic or spontaneous bleeding should be kept in mind even if there is no possible explanation.