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Rounding at the Critical Care Bedside

A clinical nurse manager brings the patient into the critical care plan.

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As dawn breaks, the critical care unit (CCU) at Sentara Bayside Hospital, Virginia Beach, VA, is abuzz with chatter, the tapping of fingertips on keyboards and flurries of staff movement, all in concert with one another. I call it controlled chaos with a purpose, as we are all here for one thing: our patients. And while every day is different, today is an especially unique day. Today is the day we start bedside multidisciplinary rounds.

Pushing Through Change

As clinical manager of the CCU, I have a fabulous staff who humor me whenever I utter the word "change" or the phrase "Let's just try it." While life on our CCU wasn't always so lighthearted, we came to an understanding that change is not always a negative experience.

We stumbled upon one of our many "let's just try it" ideas during a Customer Service Summit by our organization. A presentation centered on bedside shift report to include the patient and hourly rounding started the wheels turning, and bedside multidisciplinary rounds (MDRs) were born.

When I discussed the bedside MDRs with my key leaders, the charge nurses who are clinical nurse IIs, and suggested including the patient and family, there was some eye rolling and lip biting.

I realized this was a hard sell. Change is difficult, as is involving the patient in their care. We had never included the patient and family before, why do it now?

Because our world is changing, healthcare is evolving and we must adapt. Patients are more informed and involved in the electronic world. They can search a diagnosis on the Internet and research many treatment options. The expectation from our clients is information and communication.

Why wouldn't we want to include the patient in their care? Why are we so afraid to share information about the patient with the patient? Because it can be uncomfortable.

Making It Happen

We started with RN buy-in and got it, easily - nurses want to communicate with their patients. The struggle is often bringing the entire team together at one time.

Daily MDRs now occur at 10 am and consist of our intensivist, charge RN, bedside RN, pharmacist, dietitian, chaplain and respiratory therapist. Our objective is to review the patient status, plan of care and recommendations. We collaboratively discuss the plan and goals.

A nurse leads the charge, entering each room prior to rounds and communicating with the patient. She explains what we are doing, who is on the team and asks if the family may stay or if they should be invited to step out to protect the patient's privacy.

As we enter each patient room the physician generally starts the introduction followed by the RN, unit manager and then ancillary department representatives. The RN gives an overview of the patient's name, diagnosis, history and systems review. The pharmacist, physician, manager and respiratory therapist all have computers on wheels and can view the patient's chart.

The RN follows a standardized list of patient information to include, such as the plan of care and head to toe assessment. All team members add their input, discuss skin care concerns, removal of any lines or Foleys needed and the plan of the day.

The physician also gives a summary, explaining any abnormal labs or X-rays to the patient and/or family. With the rolling computers, physicians are often able to review the labs and X-rays on the screen with the patient.

We allow ample time for the patient to respond and ask any questions, and before departing the room we ask, "Do you have any questions for us?" and "Is there anything else I can do for you?"

Communicate & Collaborate

Our aha moment came about the third week into our rounds. We had an elderly patient who was visited daily by her daughter, who listened quietly during the daily MDRs. Still, she approached our team and said, "Can you explain to me how my mom is doing and if she is getting better?" She was almost in tears as she uttered the words.

First we were stunned at the questions because she had been at her mother's bedside every day. After a long pause, our physician summed up her mother's condition and prognosis in less than 1 minute. We saw the daughter's relief spread across her face. She stood up straighter, she smiled, and you could tell the information had sunk in by her calmness and heartfelt thank-you.

Six months have now passed and we are more comfortable with our rounding. We still occasionally have those aha moments and receive a multitude of thank-yous.

I polled the CCU nurses after the fourth month of MDRs to learn their perception of the rounds were going, if they found them helpful, if they thought they were too time-consuming, and if we should go back to the previous method and not include the patients.

To my surprise, there was not one negative comment. I even tried to play devil's advocate and suggest we go back to the other way and was met with a resounding, "No."

So here we are, continuing on our journey of bedside MDRs and communication, all striving to improve the patient experience and provide exceptional care.

Deb Brown is CCU clinical manager at Sentara Bayside Hospital, Virginia Beach, VA.


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Joan,
In response to your question regarding Intensivist buy in, My Medical Director of the ICU is very engaged in patient/family communication. His support has helped with many of our successes. I would not say all of our MD's are as fond of the concept but do participate. We do have a dedicated Pharmacist daily. They are very important on rounds. We round on 13-14 patients a day, it generally takes 1 hour.
Thank you for the responses.
Deb

Deb  Brown,  RN Clinical Manager,  SBHJune 10, 2011
Virginia Beach, VA



This was a great article. I am also looking for a script of questions for the nurses to hourly rounding. I don't feel the usual med-surg scripts are enough for ICU patients. Anybody have any ideas?

Denise Smeal Clearfield HospitalJune 06, 2011
Clearfield, PA



How did you get buy in from the intensivist? Do you have a dedicated pharmacist who can make rounds with you?How many patients do you round on and how long do you do it?

Joan  Romero June 04, 2011
Sherman Oaks , CA




     

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