Team Rounds Research Articles

Creating an integrated tracheostomy care pathway for patients in an Irish regional hospital setting - the feasibility and effectiveness of a dedicated tracheostomy team

Introduction: Temporary tracheostomy is increasingly used earlier in the management of the general critical care population. With rising numbers of temporary tracheostomies, more patient are being transferred from the Intensive Care Unit (ICU) to general wards, so the care pathway for inpatients has to be considered in both ICU and ward environments (Paul, 2010). International guidelines emphasise that the timely involvement of the multidisciplinary team (MDT) is essential for the good aftercare of patients with a tracheostomy (Global Tracheostomy Collaborative). A number of studies have documented the benefits of a dedicated or outreach tracheostomy MDT to support patient care and weaning from tracheostomy. Reduction in length of stay, time to decannulation, and incidence of adverse events have been reported. Impacts on quality of patient care have not been well documented (Garruba, Turner & Grieveson, 2009). In the Irish context, dedicated tracheostomy teams are less common in regional hospital settings. Little is known about their potential to improve patient outcomes. Objectives: The aim of this project was to: 1. Explore the feasibility of creating a dedicated tracheostomy team in an Irish regional hospital setting 2. Examine the potential for this team to improve outcomes and experience for patients with temporary tracheostomy in a regional hospital setting Method: With the support of a local quality improvement forum, a process mapping exercise was completed examining the journey for the patient with a temporary tracheostomy in a regional hospital setting. An audit of patient charts was completed, and outcomes at various stages of the patient journey were documented. Potential points for co-ordination of MDT care along the patient journey were identified, based on a comparison with international guidelines. A dedicated tracheostomy team was convened, based on need identified from audit findings, and staff resources available. The team consisted of Consultant Intensivist, Physiotherapy, Speech & Language Therapy, Intensive Care Nursing, and Respiratory Nursing. A once weekly MDT tracheostomy ward round was established. Repeat audit of patient charts was completed to evaluate the impact of above. Results: It is feasible to create and maintain a dedicated tracheostomy team in this regional hospital setting. Challenges were encountered, particularly in relation to availability of staff, but these can be addressed through planning and flexibility. The implementation of the team and ward rounds led to improvements in: - clarity of plan for weaning and decannulation - cuff management - time to assessment for basic communication support - time to assessment for speaking valve - time to swallow assessment Conclusion: A dedicated tracheostomy team can contribute to improvements in quality of care for the patient with temporary tracheostomy in a regional hospital setting. Due to the heterogenity of this clinical population, a larger sample size is required to explore its effectiveness, with regards to reducing length of hospital and ICU stay. Process mapping is a useful form of clinical audit. In this instance, multiple potential points for co-ordination of MDT care along the patient journey were identified, which could be addressed with further quality measures going forward.

User-Centered Collaborative Design and Development of an Inpatient Safety Dashboard

Patient safety remains a key concern in hospital care. This article summarizes the iterative participatory development, features, functions, and preliminary evaluation of a patient safety dashboard for interdisciplinary rounding teams on inpatient medical services. This electronic health record (EHR)-embedded dashboard collects real-time data covering 13 safety domains through web services and applies logic to generate stratified alerts with an interactive check-box function. The technological infrastructure is adaptable to other EHR environments. Surveyed users perceived the tool as highly usable and useful. Integration of the dashboard into clinical care is intended to promote communication about patient safety and facilitate identification and management of safety concerns.

265 - Establishment of an Institutional Heart Failure Registry as a Cornerstone to Readmission Reduction Efforts

Background: Accurately identifying patients hospitalized for heart failure (HF) is essential to prevent readmissions and subsequent Centers for Medicare and Medicaid Services (CMS) imposed penalties. A previous study at our institution revealed that only 54% of HF admissions were identified prior to discharge. Using an institutional registry, we aimed to actively capture HF admissions and hypothesized that identification and enrollment into our Hospital Readmissions Reduction Program (HRRP) would reduce the 30-day all-cause readmission rate. Methods: An internal HF registry of approximately 4500 patients was created using previous index HF admissions, verified post discharge by HF Diagnosis Related Groups (DRGs), from January 2013 to December 2015. Hospitalized registry patients were captured on a daily census and reviewed during interdisciplinary team rounds to determine if the admission was for HF. Once the admitting diagnosis of HF was confirmed, the patient was enrolled into the HRRP. Evidence-based HRRP interventions included patient education and scheduled follow-up within 14 days of hospital discharge. Identified HF patients also received postdischarge transitional care interventions, such as telephonic follow-up and home care visits. Results: Program data was reviewed from September 2016 to February 2017. The total number of HF index admissions was 337 with 228 admissions identified and enrolled into the HRRP. Accuracy of identification was 67.7%. Using an institutional HF registry increased identification of HF inpatients by 25.4%. Results are shown in Table 1. There was a statistically significant difference in the readmission rate for patients identified and enrolled in the HRRP as opposed to patients that were not identified. Compared to our previous identification study, the readmission rate decreased by 20.5% from 17.6% to 14.0%. Conclusion: Utilizing an institutional registry improved our identification accuracy among hospitalized HF patients. Evidence-based HRRP interventions led to a reduction in the 30-day all-cause readmission rate among HF patients who were identified through the registry. Barriers to identification included short length of stay, competing diagnoses and inadequate documentation. Hospitals can easily create and incorporate an internal registry into existing readmission reduction efforts.

Nonpharmacological Interventions for Sleep Promotion in the Intensive Care Unit.

Nonpharmacological Interventions for Sleep Promotion in the Intensive Care Unit.

Role of the Clinical Pharmacist in Reducing Preventable Adverse Drug Events

According to so many previous studies, lack of sufficient information during prescribing steps may lead to medication errors. Thus, the presence of the clinical pharmacist during routine rounding process in the ward with intervention of patient care plan may reduce the probability of adverse drug events (ADEs).This study evaluate role of the clinical pharmacists, as a member of medical team with the physician, on ADEs and report their interventions in the internal medicine unit. This study was designed to compare between two groups of patients, those receiving care from a rounding team (physician, nurse, and clinical pharmacist) (study or intervention group with 51 patient); and those receiving care from a rounding team (physician and nurse, but without any pharmacist) (control group with 49 patient). The primary outcome measure was preventable ADEs and secondary one involves the time of staying in the hospital and onset of response to therapy. Patients were randomly selected, followed a single-blind design, and evaluated by a senior physicians and clinical pharmacists who document their medical interventions.Specialist physicians accepted (60) of (77) recommendations (i.e. do modifications in drug therapy depending on clinical pharmacist interventions). The most common intervention was recommending dosage or frequency of medication (32.4%), followed by addition of medication (19.5%).The rate of preventable ordering ADEs in the study unit was 77% lower than in the control unit (P<0.05). There was no significant difference (p>0.05) in the cost of drug therapy between patient groups. Patients with ADEs in the control group had an average of 1.5 day longer staying period at the hospital; which was not differ significantly (p>0.05) from the study group.In summary, presence of clinical pharmacist during tour as a full member of the patient care team in internal medicine ward was associated with a substantially lowered rate of ADEs which caused by prescribing errors. Types of errors indicate the need for activation of the clinical pharmacist's interventions.
 Key words: adverse drug events (ADEs), clinical pharmacist.

Accuracy of Laboratory Data Communication on ICU Daily Rounds Using an Electronic Health Record.

Accurately communicating patient data during daily ICU rounds is critically important since data provide the basis for clinical decision making. Despite its importance, high fidelity data communication during interprofessional ICU rounds is assumed, yet unproven. We created a robust but simple methodology to measure the prevalence of inaccurately communicated (misrepresented) data and to characterize data communication failures by type. We also assessed how commonly the rounding team detected data misrepresentation and whether data communication was impacted by environmental, human, and workflow factors. Direct observation of verbalized laboratory data during daily ICU rounds compared with data within the electronic health record and on presenters' paper prerounding notes. Twenty-six-bed academic medical ICU with a well-established electronic health record. ICU rounds presenter (medical student or resident physician), interprofessional rounding team. None. During 301 observed patient presentations including 4,945 audited laboratory results, presenters used a paper prerounding tool for 94.3% of presentations but tools contained only 78% of available electronic health record laboratory data. Ninty-six percent of patient presentations included at least one laboratory misrepresentation (mean, 6.3 per patient) and 38.9% of all audited laboratory data were inaccurately communicated. Most misrepresentation events were omissions. Only 7.8% of all laboratory misrepresentations were detected. Despite a structured interprofessional rounding script and a well-established electronic health record, clinician laboratory data retrieval and communication during ICU rounds at our institution was poor, prone to omissions and inaccuracies, yet largely unrecognized by the rounding team. This highlights an important patient safety issue that is likely widely prevalent, yet underrecognized.

Team Interactions and Health IT Use during Hospital Multidisciplinary Rounds

Multidisciplinary rounds (MDRs) are an important form of team-based process in health care. Team members coordinate patient care and make decisions on care plans jointly. Health IT used during MDRs should be designed to facilitate the team interactions given the specific context or work system where MDRs occur. This study examines and compares team interactions and health IT use in three hospital services (contexts): hospitalist, cardiology and critical care. There were few differences in team interactions and health IT use across services. However, health IT use was different for different rounding tasks and team members. Therefore, health IT should be designed to support team interactions and users’ needs during MDRs in different contexts.

Quantitative and economic analysis of clinical pharmacist interventions during rounds in an acute care psychiatric hospital.

Introduction:Clinical pharmacists have become an integral part of multidisciplinary medical teams, including in the area of psychiatry. Previous studies have shown that having pharmacists in multidisciplinary medical teams has led to improved medication use, reduction of adverse drug events, and improved patient outcomes. The purpose of this study is to conduct a quantitative and economic analysis of the impact of clinical pharmacist interventions during hospital rounds in an acute care psychiatric hospital setting.Methods:This is a retrospective analysis of 200 clinical pharmacist interventions documented between September 2013 and September 2014. Clinical pharmacist interventions were classified into several categories and types. Only clinical pharmacist interventions made during multidisciplinary team rounds were included in the study. Descriptive statistics were used for the quantitative analysis of clinical pharmacist interventions. The acceptance rate was calculated. Only the accepted clinical interventions were included in the economic analysis. Economic outcome involved an assessment of cost saving and cost avoidance.Results:The most frequent types of clinical pharmacist interventions were discontinuation of medications (38.5%), laboratory monitoring (26%), and medication order modification (13.5%). The most common reason for drug discontinuation was polypharmacy. Clinical pharmacist interventions were associated with a 92.5% acceptance rate. Two hundred clinical pharmacist interventions were associated with $6760.19 medication cost saving and $62 806.67 cost avoidance.Discussion:Clinical pharmacist interventions during rounds in an acute care psychiatric hospital setting mostly involve medication order modification and laboratory monitoring. They are also associated with significant cost saving and cost avoidance.

Ward Rounds With or Without an Attending Physician: How Interns Learn Most Successfully

ObjectiveTo explore pediatric interns' perspectives on the educational value of general pediatric ward rounds, in particular their rounding experiences with and without an attending physician. MethodsQualitative study using individual interviews of pediatric interns (2013–2014) rotating on 2 general pediatric inpatient services at different institutions with different rounding team structures. In accordance with grounded theory methodology, data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into themes. ResultsTwenty pediatric interns participated in 25 interviews. Data analysis yielded 4 themes: what is being learned; learning environment on rounds; learning and work; and ways of learning. Senior residents generally taught practical aspects of patient care and attending physicians taught broader concepts with references to the medical literature. Rounds without an attending physician were perceived as less formal and promoted collaborative discussions with senior residents. Interns were more uncomfortable during rounds with an attending physician but appreciated how that facilitated their learning. Although patient care tasks provided opportunities for experiential learning, interns frequently perceived them to impede learning during rounds. Intern learning during ward rounds occurred via self-directed learning, interactive learning, and through caring for patients. Brief, clinically relevant teaching pearls and questioning clinical reasoning in a respectful manner were helpful. ConclusionsInterns learn different content and learn in different ways depending on the presence or absence of an attending physician at rounds. There might be educational value from rounding with teams that include and do not include an attending physician.

Accessing and engaging women from socio-economically disadvantaged areas: a participatory approach to the design of a public health intervention for delivery in a Bingo club.

BackgroundOur aim was to use participatory methods to investigate the feasibility and acceptability of using Bingo clubs for the design and delivery of an evidence-based physical activity and/or healthy eating intervention to socio-economically disadvantaged women. This paper describes the participatory process that has resulted in a physical activity intervention for women aged >55 years, ready for pilot-testing in a Bingo club setting.MethodsStudies using different quantitative and qualitative approaches were conducted among customers and staff of a Bingo club in a city of 85,000 inhabitants in central Scotland. These were designed to take the views of different stakeholders into account, with a view to enhancing uptake, engagement and effectiveness with any proposed intervention.ResultsSixteen relevant studies were identified in a literature review that generated ideas for intervention components. A questionnaire completed by 151 women in the Bingo club showed that almost half (47 %) aged >55 years were not meeting physical activity guidelines; evidence backed up by accelerometer data from 29 women. Discussions in six focus groups attended by 27 club members revealed different but overlapping motivations for attending the Bingo club (social benefits) and playing Bingo (cognitive benefits). There was some scepticism as to whether the Bingo club was an appropriate setting for an intervention, and a dietary intervention was not favoured. It was clear that any planned intervention needed to utilise the social motivation and habitual nature of attendance at the Bingo club, without taking women away from Bingo games. These results were taken forward to a 5-h long participative workshop with 27 stakeholders (including 19 Bingo players). Intervention design (form and content) was then finalised during two round table research team meetings.ConclusionsIt was possible to access and engage with women living in areas of socio-economic disadvantage through a Bingo club setting. A physical activity intervention for women >55 years is realistic for recruitment, will address the needs of potential recipients in the Bingo club, appears to be feasible and acceptable to club members and staff, and has been designed with their input. A pilot study is underway, investigating recruitment, retention and feasibility of delivery.

Enhanced Understanding of the Levels of Palliative Care in Pharmacy Students Through Participating in Clinical Training in Hospitals

Objective: A palliative care knowledge survey was conducted involving pharmacy students to examine their perceived usefulness and the educational effect of clinical training in hospitals. Methods: A questionnaire sheet was distributed to fifth-year pharmacy students before and after clinical training. The questionnaire consisted of questions to clarify the details of palliative care-related training in hospitals and students’ knowledge of such care. The respondents were divided into 2 groups: those who participated in palliative care team (PCT) rounds (group A: 57) and those who did not (group B: 57). Results: The mean total correct answer rate markedly increased after training in group A, from 37.9 to 47.1% (P < .01). Such an increase was also observed in the domains of philosophy and pain in this group (P < .01). In contrast, group B did not show differences in the mean correct answer rate between before and after training; there was no significant increase in the rate in any domain. Conclusion: Pharmacy students’ knowledge was enhanced by participating in the PCT, confirming the usefulness of such participation during training as part of palliative care education.

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested taxonomy.

Interdisciplinary rounds (IDR) have been described to improve outcomes. However, there is limited understanding of optimal IDR design. To systematically review published reports of IDR to catalog types of IDR and outcomes, and assess the influence of IDR design on outcomes. Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Journals Ovid, Cumulative Index to Nursing and Allied Health Literature (EBSCOhost), and PubMed from 1990 through December 2014, and hand searching of article bibliographies. Experimental, quasiexperimental, and observation studies in English-language literature where physicians rounded with another healthcare professional in inpatient medicine units. Studies were abstracted for study setting and characteristics, and design and outcomes of IDR. Twenty-two studies were included in the qualitative analysis. Many were of low to medium quality with few high-quality studies. There is no clear definition of IDR in the literature. There was wide variation in IDR design and team composition across studies. We found three different models of IDR: pharmacist focused, bedside rounding, and interdisciplinary team rounding. There are reasonable data to support an association with length of stay and staff satisfaction but little data on patient safety or satisfaction. Positive outcomes may be related to particular components of IDR design, but the relationship between design and outcomes remains unclear. Future studies should be more deliberately designed and fully reported with careful attention to team composition and features of IDR and their impact on selected outcomes. We present a proposed IDR definition and taxonomy for future studies. Journal of Hospital Medicine 2016;11:513-523. © 2016 Society of Hospital Medicine.

Patient-Centered Structured Interdisciplinary Bedside Rounds in the Medical ICU.

We examined the effects of introducing patient-centered structured interdisciplinary bedside rounds in the medical ICU with respect to rounding efficiency, provider satisfaction, and patient/family satisfaction. A prospective, nonblinded, nonrandomized, parallel group study from June 21, 2016, to August 15, 2016. The medical ICU at a tertiary care academic medical center. A consecutive sample of adult patients, family members, and healthcare providers. The patients and healthcare providers were arbitrarily assigned to either the patient-centered structured interdisciplinary bedside rounds or nonstructured interdisciplinary bedside round care team. Healthcare providers on the patient-centered structured interdisciplinary bedside rounds team were educated about their respective roles and the information they were expected to discuss on rounds each day. Rounds completion data and satisfaction questionnaires from healthcare providers, patients, and family members were obtained from both patient-centered structured interdisciplinary bedside rounds and nonstructured interdisciplinary bedside round teams. Data were obtained from 367 patient-centered structured interdisciplinary bedside rounds and 298 nonstructured interdisciplinary bedside round patient encounters. Family members were present during 31.1% rounding encounters on the patient-centered structured interdisciplinary bedside rounds team and 10.1% encounters on the nonstructured interdisciplinary bedside round team (p < 0.01). Total rounding and interruption times were significantly shorter on patient-centered structured interdisciplinary bedside rounds compared with nonstructured interdisciplinary bedside round patients, 16.9 ± 10.0 versus 22.4 ± 14.9 and 2.0 ± 2.2 versus 3.9 ± 5.5 minutes, respectively (both p < 0.01). Mechanical ventilation, patient-centered structured interdisciplinary bedside rounds, and attending style independently contributed to the earlier completion of rounds (all p < 0.01). Surveys of 338 healthcare provider encounters on the patient-centered structured interdisciplinary bedside rounds team compared with 301 nonstructured interdisciplinary bedside round encounters showed perceptions of improved communication of patient management plans, increased input from the entire team, and clarity on task assignments (all p < 0.05). The attending physicians provided teaching points on 51.2% of patient-centered structured interdisciplinary bedside rounds compared with 33.9% of nonstructured interdisciplinary bedside round patient encounters (p < 0.01). For the patients and family members surveyed, 38 patient-centered structured interdisciplinary bedside rounds, and 30 nonstructured interdisciplinary bedside round, there were no differences in measures of satisfaction. Patient-centered structured interdisciplinary bedside rounds provide a venue for increased rounding efficiency, provider satisfaction, and consistent teaching, without impacting patient/family perception.

Improving Outcomes for Infants with Single Ventricle Physiology through Standardized Feeding during the Interstage.

Congenital heart disease is identified as the most common birth defect with single ventricle physiology carrying the highest mortality. Staged surgical palliation is required for treatment, with mortality historically as high as 22% in the four- to six-month period from the first- to second-stage surgical palliation, known as the interstage. A standardized postoperative feeding approach was implemented through an evidence-based protocol, parent engagement, and interprofessional team rounds. Five infants with single ventricle physiology preprotocol were compared with five infants who received the standardized feeding approach. Mann-Whitney U tests were conducted to evaluate the hypotheses that infants in the intervention condition would consume more calories and have a positive change in weight-to-age z-score (WAZ) and shorter length of stay (LOS) following the first and second surgeries compared to infants in the control condition. After the protocol, the change in WAZ during the interstage increased by virtually one standard deviation from 0.05 to 0.91. Median LOS dropped 32% after the first surgery and 43% after the second surgery. Since first- and second-stage palliative surgeries occur within the same year of life, this represents savings of $500,000 to $800,000 per year in a 10-infant model. The standardized feeding approach improved growth in single ventricle infants while concurrently lowering hospital costs.

Do we really know how much we are feeding our patients?

Background: Nutrition support is important in critical illness, and accurate recording is particularly important to determine whether nutritional goals are met both from a caloric and volume perspective. Objective: To assess accuracy of enteral feeding records, to increase nursing education and to improve nutritional documentation. Methods: An uncontrolled, prospective, pre- and post-intervention study was completed as part of a quality improvement initiative. This study was performed in a 950-bed university hospital (Philadelphia, Pennsylvania) and focused in a 25-bed, closed intensive care unit (ICU) with a multidisciplinary rounding team of intensivist, nurse, pharmacist, dietitian and respiratory therapist. Nurse researchers reviewed 188 patient electronic medical records (EMR) and compared the data to volume data saved on enteral feeding pump. Data analysis revealed inconsistencies between the pump readings and EMR. The need for a prospective intervention was recognized and implementation of this intervention included pump calibration and teaching modules aimed at improving enteral feeding protocols. During post-intervention, another 234 records were reviewed. Results: The intervention of an education program reduced the documented discrepancy between the pump readings and charted volumes from 44 to 33%. A correlation analysis also showed a tighter relationship post-intervention (rpost = 0.84 vs. rpre = 0.76, both had a p < 0.01). Conclusion: This study highlights the importance of accurate nutritional monitoring in the ICU and demonstrates that educational interventions can improve enteral feeding protocols. Pump calibrations, frequent interrogation and vigilant nutritional documentation can improve enteral nutrition delivery. Future studies are needed to determine if the effects are sustainable and if further education will further improve documentation and delivery.

Impact of Infectious Diseases Team Consultation on Antimicrobial Use, Length of Stay and Mortality

Infectious disease (ID) clinicians and multidisciplinary teams may have a beneficial impact on patient outcomes. This study was conducted to determine the impact of dedicated ID team rounding in an adult noncardiac intensive care unit (ICU) on antimicrobial costs, length of stay and mortality. The authors instituted dedicated ICU ID team rounds at a large tertiary care hospital ICU ("intervention"), with the ID team conducting rounds in the ICU every weekday. The authors compared the cost of antimicrobial agents, total hospital and ICU length of stay and inpatient mortality for the 6-month period before and after institution of these rounds between those seen versus those not seen by the ID team. Among 386 patients analyzed, 206 were admitted in the preintervention and 180 in the postintervention period. Among those seen by the ID team, there was an 18% decrease in total antimicrobial cost (P < 0.0001), 40% decrease in ICU length of stay (P = 0.1), 33% decrease in overall hospital length of stay (P = 0.03) and 34% decrease in mortality (0.04) from preintervention to postintervention period. Among those not seen by ID, there was a 39% decrease in cost among those not seen by ID (P < 0.0001), but length of ICU or hospital stay and mortality were not significantly different. Institution of dedicated ID team rounding in the ICU leads to substantial decreases in antimicrobial costs, hospital length of stay and inpatient mortality among those patients seen by the team.

Minimizing Patient Safety Events Through a Multidisciplinary Approach to Human Milk Management

Optimization of nutrition is key in infant development and it is well documented that human milk is the ideal form of nutrition for infants during the first year of life. However, unaltered maternal human milk may not be sufficient to meet the nutritional demands of premature infants. Under these circumstances, addition of a fortifier to the maternal human milk has become standard practice. In one newborn/infant intensive care unit (N/IICU) located in Philadelphia, fortification and modification of human milk is handled within the Human Milk Management Center (HMMC). A multidisciplinary team rounds weekly on all infants receiving fortified or modified human milk. Feeding orders and maternal milk supply are discussed to ensure the feeding is ordered correctly, the final caloric concentration is correct and a backup feeding order is in place for low maternal milk supply. Through this multidisciplinary discussion, the team has been able to identify and resolve potential errors from reaching the patient. Improvement in patient safety while providing human milk remains of utmost importance and the central goal of the HMMC collaborative.

Capsule Commentary on Leykum et al., the Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients' Outcomes.

T oday’s inpatient providers are caring for ever-sicker patients during shorter hospitalizations, with reduced resident duty hours, while leading the charge for quality improvement and value-based care. In this changing clinical landscape, the daily routines of inpatient teams must be fine-tuned to optimize efficiency, reliability, and safety. Clinical reasoning is often used as the framework for discussions of how providers conceptualize and treat individual patients, but it can oversimplify or neglect the reality of the many competing tasks carried out by providers on busy services. This study by Leykum et al. introduces the concept of Bsensemaking^ as a tool for inpatient teams to use in organizing and carrying out their daily tasks. The authors used measures of sensemaking to assess how teams prioritized, processed, and cared for multiple sick patients simultaneously, and found that higher markers of sensemaking were associated with improved patient outcomes, including fewer complications and shorter lengths of stay. In many ways, the most surprising finding of the study was just how infrequently the low bar for sensemaking was met. The majority of observed teams never conducted rounds Bpurposefully,^ as defined by the authors, and most teams had low sensemaking scores when rated on discussions of complex patients. It is not hard to imagine the many possible differences between teams with high and low sensemaking scores; teams that are explicit, flexible, and purposeful in daily work might also communicate more effectively both with other providers and with their patients, be more responsive to feedback, and be open to outside ideas. The question that remains is whether interventions to encourage sensemaking would make a difference in patient outcomes for teams that did not naturally function this way. There is a growing body of literature on how rounding structure can affect resident education in the new duty-hours climate. As we consider how this core of our daily work affects trainees and patients alike, sensemaking may be a foundation around which we can evaluate and refine our practice. The authors can now investigate whether teams with low sensemaking scores are able to improve patient outcomes by improving these measures of sensemaking.

Nurse Knowledge ExchangePlus: Human-Centered Implementation for Spread and Sustainability

Kaiser Permanente implemented a new model of nursing communication at shift change-in the bedside nursing report known as the Nurse Knowledge Exchange (NKE) in 2004-but noted variations in its spread and sustainability across medical centers five years later. The six core elements of NKEplus were as follows: team rounding in the last hour before shift changes, pre-shift patient assignments that limit the number of departing nurses at shift change, unit support for uninterrupted bedside reporting, standardization for report and safety check formats, and collaboration with patients to update in-room care boards. In January 2011 Kaiser Permanente Southern California (KPSC; Pasadena) began implementing NKEplus in 125 nursing units across 14 hospitals, with the use of human-centered design principles: creating shared understanding of the need for change, minimum specifications, and customization by frontline staff. Champion teams on each nursing unit designed and pilot tested unit-specific versions of NKEplus for four to eight weeks. Implementation occurred in waves and proceeded from medical/surgical units to specialty units. Traditional performance improvement strategies of accountability, measurement, and management were also applied. By the end of 2012, 100% of the 64 medical/surgical units and 47 (77.0%) of the 61 specialty units in KPSC medical centers implemented NKEplus-as had all but 1 of the specialty units by May 2013. The mean KPSC score on the NKEplus nursing behavior bundle improved from 65.9% in 2010 to 71.3% in the first quarter of 2014. The mean KPSC Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for nurse communication improved from 73.1% in 2010 to 76.4% in the first quarter of 2014 (p < . 001). Human-centered implementation appeared to help spread a new model of nursing handoffs and change the culture of professional nursing practice related to shift change.

The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients' Outcomes.

Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients. Our purpose was to assess the association between inpatient physician team sensemaking and hospitalized patients' outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. Eleven inpatient medicine teams' daily rounds were observed for 2 to 4 weeks. Rounds were audiotaped, and field notes taken. Four patient discussions per team were assessed using a standardized Situation, Task, Intent, Concern, Calibrate (STICC) framework. Inpatient physician teams at the teaching hospitals affiliated with the University of Texas Health Science Center at San Antonio participated in the study. Outcomes of patients admitted to the teams were included. Sensemaking was assessed based on the order in which patients were seen, purposeful rounding, patient-driven rounding, and individual patient discussions. We assigned teams a score based on the number of STICC elements used in the four patient discussions sampled. The association between sensemaking and outcomes was assessed using Kruskal-Wallis sum rank and Dunn's tests. Teams rounded in several different ways. Five teams rounded purposefully, and four based rounds on patient-driven needs. Purposeful and patient-driven rounds were significantly associated with lower complication rates. Varying the order in which patients were seen and purposefully rounding were significantly associated with lower LOS, and purposeful and patient-driven rounds associated with lower ULOS. Use of a greater number of STICC elements was associated with significantly lower LOS (4.6 vs. 5.7, p = 0.01), ULOS (0.3 vs. 0.6, p = 0.02), and complications (0.2 vs. 0.5, p = 0.0001). Improving sensemaking may be a strategy for improving patient outcomes, fostering a shared understanding of a patient's clinical trajectory, and enabling high reliability.