Rounding Tool Research Articles

The Educational Experience Improvement Collective for Inpatient Medicine Healthcare Professional Trainees at a University-Affiliated Veterans Affairs Medical Center

Background: Rotation evaluations reflect the resident-perceived value of clinical experiences in graduate medical education. In this study, we sought to improve the quality of education for internal medicine residents during their inpatient medicine rotation. Methods: Program stakeholders critically appraised a core medicine rotation at a university-affiliated U.S. Veterans Affairs Medical Center utilizing end-of-rotation evaluations by residents. Thematic analysis identified three areas for improvement: culture, communication, and workload. Solutions were developed to address each theme: (1) site-specific orientation was provided to new trainees, (2) real-time notification of admissions occurred via secure messaging platform, and (3) an assistive rounding tool was integrated into the electronic medical record. Outcome measures of education were obtained via end-of-rotation evaluations by residents. Results: This study included 198 pre-intervention and 58 post-intervention evaluations by trainees from October 2022 through December 2023. Using a 5-point Likert scale, the quality of education improved from good to very good (3.26 to 4.02, +15%, p < 0.001) over the course of one year. All four subcategories also improved: diversity/quality of pathology (0.33; +7%), supervision (0.50; +10%), workload (0.42; +8%), and learning value (0.51; +10%). When the five categories are compared immediately pre-intervention (fourth quarter of 2022-2023 academic year) to full post-intervention (second quarter of 2023-2024 academic year) using a paired t-test, the change was statistically significant (p = 0.007). Conclusions: Significant educational enhancements were achieved over time for a core rotation in a residency program using solutions developed from interconnected themes found in learner evaluations.

Increasing High-Value, Cost-Conscious Care Family Rounding Discussions Via an Educational Rounding Tool.

Family-centered rounds (FCR) are an important time to engage in high-value, cost-conscious care (HV3C) discussions. However, research suggests HV3C conversations occur in a minority of FCRs. Best-practice support tools can improve provider performance, but no research has evaluated whether an HV3C-focused tool may increase pediatricians' HV3C FCR discussions. This study aimed to assess if an educational and practice-based HV3C Rounding Tool's introduction would increase providers' HV3C FCR performance and competence. This study involved a hospitalist teaching service at a tertiary-care hospital. Evidence-based HV3C Rounding Tool and Quick Reference interventions were designed for use on FCRs, using a validated tool to measure baseline and postintervention HV3C performance. Underlying family, nursing presence/participation, and other factors' impacts upon HV3C performance were also explored. Anonymous baseline and postintervention surveys compared providers' perceived competence and comfort engaging families in HV3C discussions, as well as the tools' usefulness. Out of the 197 baseline and 157 intervention encounters recorded, the tools respectively increased from 3.8 to 5.8 HV3C performance measures addressed (P < .001), with 80% of performance measures showing significant improvement (P < .002). Aside from family presence for select performance measures, the tools had an independent, significant, positive effect upon HV3C performance. Users generally reported the tools as helpful and easy to use, noting significant increases in faculty role-modeling and trainee competence practicing HV3C. Introduction of HV3C Rounding and Quick Reference tools were generally perceived as helpful and beneficial, resulting in an increase of providers' HV3C discussions and care delivery during FCRs.

755 Utilizing a Structured Critical Care Rounding Tool for Retrospective Morbidity and Mortality Review

755 Utilizing a Structured Critical Care Rounding Tool for Retrospective Morbidity and Mortality Review

Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

Quality improvement initiative to improve communication domains of patient satisfaction in a regional community hospital with Six Sigma methodology

BackgroundCommunication gaps, whether incomplete or fragmented communication, have been the cause of many disasters in human civilisation. Coordination of healthcare is directly related to proper communication and handoffs among multidisciplinary...

Growing Novice Nurses to Perianesthesia Care: Formation of a Post-Anesthesia Care Unit (PACU) Fellowship

PurposeTo provide a proof of concept of a structured, replicable perianesthesia fellowship program for nurses with less than 2 years of experience and new graduate nurses. DesignAn immersive learning experience was implemented as a pilot quality improvement project using the Plan-Do-Study-Act method. MethodsThis 24-week fellowship program used blended learning approaches and the Tiered Skill Acquisition Model (TSAM) to develop foundational Post Anesthesia Care Unit (PACU) skills. Nurse Fellows (4) acquired knowledge in stages, with each week in the program reinforcing and building upon the prior week's learnings. Settings included an initial 10 weeks in the ambulatory PACU, then the acute care PACU (weeks 11-20), and the final 4 weeks were spent in the primary unit where the Fellow would transition into a PACU Staff RN. Through each phase, the Professional Practice Department’s Clinical Mentor Nurse promoted preceptor development, facilitated learning experiences and provided bimonthly evaluations of the Nurse Fellow’s progress via our institution's clinical rounding tool. We used the Nursing Anxiety and Self-Confidence Associated with Clinical Decision Making (NASC-CDM) scale to assess novice nurses’ anxiety and self-confidence associated with making clinical decisions at designated intervals. FindingsAll Nurse Fellows completed the program and remained in PACU positions 2 years post-fellowship. They reported discomfort and increased stress transitioning to different PACUs; however, they later indicated reduced anxiety and greater confidence in clinical decision-making, as noted in subsequent evaluations of the NASC-CDM scale. ConclusionsPerianesthesia fellowship programs incorporating blended learning, skill reinforcement, and formal mentoring on a primary PACU unit build confidence and competence in the novice nurse, making this once-excluded population of nurses a viable option for recruitment directly into the PACU environment.

Impact of a Rounding Tool and Clinical Champion on Trauma Patient Screening, Brief Intervention, and Referral to Treatment for Alcohol Use Disorder.

Early identification and treatment of alcohol misuse among trauma patients is the standard of care for trauma centers. Yet, trauma programs face significant barriers in adherence to sustained alcohol misuse screening. This study aims to evaluate the impact of a rounding tool and clinical champion on screening, brief intervention, and referral to treatment compliance rates for alcohol use disorder in trauma patients. This is a single-center, retrospective cohort design measuring the impact of a nursing rounding tool and clinical champion on screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients older than 14 years. Retrospective reviews were conducted over a 5-year period from 2017 to 2021 for all admitted trauma patients as defined by the National Trauma Data Standard. More than 5,000 trauma patients were included during the study period. The nurses' rounding tool and clinical champion intervention led to an increase in the alcohol use disorder screening rate from an average of 59% for the first 3 months of the study (May to July 2017) to 95% for the last 3 months of the study (March to May 2021). Our findings show that a dedicated clinical champion and nurse rounding tool increase compliance for screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients.

Implementation of a Central Line Rounding Tool

Implementation of a Central Line Rounding Tool

CLABSI Reduction Strategy: Utilizing Weekly Rounds with an Interdisciplinary Team.

Introduction: Central line-associated bloodstream infections (CLABSIs) in pediatric ICU patients lead to a wide variety of adverse outcomes, including increased mortality and morbidity, longer length of stay in the hospital, and greater healthcare costs.1 Pediatric cardiac ICU patients are at a significantly higher risk for these healthcare-associated infections because of an increase in risk factors, such as congenital anomalies, presence of surgical wounds, compromised immune function post cardiopulmonary bypass, and the presence of multiple invasive medical devices.2 After noting an increase in the pediatric cardiac ICU CLABSI rate, an interdisciplinary team was formed to approach the problem. Objectives: The primary aim was to decrease the pediatric cardiac ICU’s CLABSI rate by 25% in 8 months by engaging an interdisciplinary team with identifying and addressing CLABSI maintenance bundle concerns in real time on the unit. Methods: An interdisciplinary team with representatives from nursing, unit leadership, intensive care physicians, infection prevention, nurse practitioners, vascular access team, and quality improvement utilized initial Plan-Do-Study-Act (PDSA) cycles to develop a rounding tool that identified threats to the CLABSI prevention bundle with patient-specific interventions to consider implementing. Weekly interdisciplinary rounds were then conducted on all central lines. Additional PDSA cycles focused on addressing unit-specific gaps in education and increasing awareness of best practices for central line care and maintenance. These included addition and delineation of space to separate clean and dirty supplies, hygiene supplementations to the care bundle, eRecord handoff updates, and both in-person and online educational offerings. Results: Preliminary data suggested a decrease in CLABSI rate during the initial 4-month intervention period (Fig. 1). The focus on central line care has also led to more consistent and robust observations for bundle compliance. In 2021, zero CLABSIs were noted for the initial 4 months after intervention contributing to a unit record of 243 days CLABSI-free. We would like to call attention to 2 points in Figure 1. Point two represents the initiation of weekly interdisciplinary CLABSI rounds. Point three represents 2 premature infants, atypical for unit census, on extracorporeal membrane oxygenation with hemodialysis catheters that required off-label use of Prismaflex. Conclusions: Engagement of a microsystem’s interdisciplinary team to focus efforts on identifying and addressing real-time concerns to central lines has led to a short-term decrease in CLABSI rate. Sustaining this decrease in CLABSIs will require continual reassessment of the effectiveness of strategies utilized. Additional PDSA interventions as a result of the weekly rounds are being investigated, including the use of antimicrobial sheets for high-risk patients, the creation of unit-specific prepackaged sterile central line dressing kits, and transitioning from alcohol to chlorohexidine scrubs for hub accessing.Fig

Using a Standardized Rounding Tool to Improve the Incidence of Spontaneous Awakening and Breathing Trials.

Spontaneous awakening and breathing trials have been associated with shorter durations of mechanical ventilation and intensive care unit lengths of stay. Inconsistent spontaneous awakening trials and spontaneous breathing trials, mechanical ventilation weaning strategies, and interdisciplinary rounding processes contributed to prolonged mechanical ventilation duration and length of stay in a 44-bed adult medical intensive care unit. Methods A standardized rounding tool that focused on coordinating spontaneous awakening and breathing trials, and on their outcomes, was integrated into daily multidisciplinary rounds in a medical intensive care unit. Aggregated patient data from the 4-month project implementation phase were compared with historical data collected for 2 months before project implementation. During the 2-month preintervention phase, 613 adult patients were managed in the medical intensive care unit and 41 patients required mechanical ventilation, whereas during the 4-month intervention phase, 1271 patients were managed in the unit and 96 patients required mechanical ventilation. The project was associated with a 24% (0.89-day) reduction in the mean length of stay (3.72 vs 2.83 days) and a 46.3% (2.81 day) reduction in mechanical ventilation duration (6.06 vs 3.25 days) when comparing August 2019 to January 2020. A standardized rounding tool emphasizing a coordinated process for spontaneous awakening and breathing trials was associated with a shorter length of stay and duration of mechanical ventilation among patients in the medical intensive care unit. An evidence-based approach to weaning from mechanical ventilation and standardized rounding may be a cost-effective way to reduce mechanical ventilation duration and length of stay in a medical intensive care unit.

Effect of an Interdisciplinary Stroke Consult Service on the Transition to Postacute Rehabilitation

ObjectiveTo evaluate the effect of a physiatry-led stroke consult service on access and time to intensive postacute rehabilitation. DesignProspective observational study. SettingUrban Joint Commission Comprehensive Stroke Center. ParticipantsAdult (older than 18 years) acute stroke hospital discharges between January 1, 2018, and December 31, 2020 (N=1190). InterventionsWeekday huddle rounds were interdisciplinary, which created a pathway to ensure patients with stroke received comprehensive rehabilitation care followed by a virtual rounding tool, allowing clinicians to evaluate plan of care facilitation using the electronic medical record. Main Outcome MeasuresProportion of acute stroke discharges to home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) and onset days to IRF transfer. ResultsDuring the 3-year study period, sociodemographic characteristics, stroke severity at admission, and mortality rates did not change significantly.Discharges of patients with acute stroke patient to IRFs increased 5.9%, from 24.2% in 2018 to 30.1% in 2020. A total of 11% of patients were discharged to SNF in 2018 compared with 8.7% in 2020. Proportion of patients with acute stroke discharged to home decreased 4.9%, from 49.6% in 2018 to 44.7% (P=.0325). For patients with ischemic stroke, the average onset days to IRF transfer decreased 7.5% between 2018 and 2020, from 8 days to 7.4 days. For patients with hemorrhagic stroke, the average onset days decreased 17.5%, from 12 days in 2018 to 9.9 days in 2020. The decrease in onset days were not statistically significant for either stroke type (P=.3794). ConclusionsImplementation of huddle rounds and a virtual rounding tool by a physiatry-led stroke consult service significantly increased referrals to IRFs, with a concomitant decrease in referrals to SNFs or directly home. Next steps include validating model efficacy, with the goal of implementation at stroke centers in the United States.

Standardization of rounds on a general paediatric ward: Implementation of a checklist to improve efficiency, quality of rounds, and family satisfaction.

The purpose of this study was to develop a standardized rounding tool for use on the general paediatric ward and to determine if its use can improve quality of rounds as well as patient and parent satisfaction. The study used a pre- and post-intervention prospective observational methodology. The intervention consisted of the implementation of a Checklist Rounding Tool (CRT) entitled the 'Paediatric Inpatient Rounding Checklist (PIRC)' which outlined items deemed essential to discuss during rounds for all patients admitted to the paediatric ward. The PIRC was created by the research team after reviewing the literature and it was peer reviewed by a panel of expert paediatricians. Performance on rounds based on discussion of checklist items as well as patient and parent satisfaction were evaluated by an external observer both pre- and post-PIRC implementation. Four of the five less frequently addressed checklist items were discussed significantly more post-intervention. The Rounds Quality Score was significantly improved after checklist implementation, the pre- and post-intervention scores being 8.24 and 9.61/10, respectively (P-value <0.001). Patient and parent satisfaction were rated higher with the use of the checklist. There was no difference in the duration of rounds between the pre- and post-implementation phases. In summary, utilization of a standardized rounding tool on an inpatient paediatric ward led to improvement in quality of rounds as well as patient and parent satisfaction.

633 Use of an ICU Rounding Tool Enhances Critical Care Learning for Trainees on a Burn Surgery Rotation

Abstract Introduction An institutional Burn Intensive Care Unit (ICU) Rounding Tool was implemented for both quality improvement data collection and trainee education. Forms are completed by trainee team members daily for all critically ill patients prior to teaching rounds. Gathered data are structured to facilitate evaluation of patient volume status, sepsis risk and ventilator management. The forms are then used to guide discussion among students, residents, mid-level providers, fellows, attending surgeons and other members of the multi-disciplinary rounding team. We conducted a series of interviews with trainees regarding their user experience to assess the tool’s educational utility. Methods A convenience sample of residents who had recently completed their Burn Surgery rotation were interviewed in a structured format. Questions focused on the form’s ease of use and comprehensibility. Emphasis was placed on the extent to which it stimulates learning while rounding. Additional feedback was sought for the purpose of improving the tool for continued use. Results Participants were post-graduate year one or two resident physicians training in General Surgery, Urology, Emergency Medicine or Anesthesia. Prior experience and comfort with ICU level care ranged from very little to moderate. All interviewees found the tool helpful in their patient assessments, though the current layout of the form was a frustration for many. Overall, they unanimously found the forms beneficial for preparation of patient presentations and felt that utilization during rounds facilitated learning. Conclusions Interviews with trainees on their burn surgery rotation demonstrate that implementation of an ICU Rounding Tool has provided educational benefit, particularly for those less experienced in intensive care. Feedback from this cohort will be used to improve the tool’s usability. Our next steps will include a more formal survey of all trainees involved since the inception of this project.

Managing Falls: Implementation of a Three-Intervention Initiative to Improve Quality of Care for Patients With Cancer.

All healthcare institutions prioritize falls as a major safety issue. Falls are of particular concern on inpatient oncology units where patients are substantially at risk for injury related to falls. This article describes a multifaceted fall-prevention initiative that can be implemented on oncology units using evidence-based interventions in the key areas of communication, toileting, and hourly rounding. The Visual Rounding Tool for communication around hourly rounding and proactive toileting is also introduced. Based on a root cause analysis and literature review, the inpatient oncology unit-based committee launched a three-intervention initiative, carried out during three consecutive months, to address patient falls. Fall rates decreased using the three- intervention initiative. Systematic improvement in processes enabled an increased occurrence of communication between nurses and assistive personnel, increased use of the Visual Rounding Tool for proactive toileting and hourly rounding, and a significant but short-lived decrease in call light use.

Evaluating the effects of a high-tech call system on patient-staff communication.

Evaluating the effects of a high-tech call system on patient-staff communication.

Required data elements for interprofessional rounds through the lens of multiple professions

ABSTRACT The lack of a proper system for ongoing open interprofessional communication among care providers increases miscommunications and medical errors. Seamless access to patient information is important for care providers to prevent miscommunication and improve patient safety. A shared understanding of the information needs of different care providers in an interprofessional team is lacking. Our purpose is to identify care providers’ information needs from the perspective of different professions for communication, shared understanding about the patient, and decision-making. We conducted semi-structured interviews with 10 subject matter experts representing eight professions, including dentistry, dietetics, medicine, nursing, occupational therapy, pharmacy, physical therapy, and social work in a 465-bed academic hospital at a large urban Midwestern city. We used an in-house rounding tool presenting physicians’ information needs and a hypothetical patient scenario to collect participants’ feedback. Interview notes were coded using direct content analysis. We identified 22 additional essential data elements for an interprofessional rounding tool. We categorized those into six domains: discharge-related, social determinants of health, hospital safety, nutrition, interprofessional situation awareness, and patient history. A well-designed validated rounding tool that includes an interprofessional team of care providers’ information needs could improve communication, care planning, and decision-making among them.

Systematic Rounding Tool for Nurse Practitioner Students.

Systematic Rounding Tool for Nurse Practitioner Students.

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team. We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered. Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%. Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.

Project Neurotransmission: Improving Neurology Communication and Teaching with a Rounding Tool (184)

Project Neurotransmission: Improving Neurology Communication and Teaching with a Rounding Tool (184)

Development and Testing of an Electronic Multidisciplinary Rounding Tool.

Patients hospitalized with neurologic and medical issues in the neuroscience critical care unit have widely varying and complex disease states that can change rapidly. The large amount of data that must be reviewed regularly by medical staff members presents a challenge to the provision of high-quality care to these patients. In an effort to lessen the burden, the authors' team implemented an electronic multidisciplinary rounding tool, which facilitates team communication by allowing accurate and concise review of patient information. The rounding tool is part of an ongoing quality improvement project and has been in use for 4 years. Nurses have reported that the tool provides a comprehensive summary of the patient's hospital stay that facilitates handoff during shift changes. A survey of nursing staff members demonstrated high levels of satisfaction with the tool during both multidisciplinary rounds and handoffs.