Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit

Abstract

Objective To improve communication during daily rounds using sequential interventions. Design Prospective cohort study Setting Multidisciplinary pediatric intensive care unit in a university hospital. Subjects The multidisciplinary rounding team in the pediatric intensive care unit, including attending physicians, physician trainees, and nurses. Interventions Daily rounds on 736 patients were observed over a nine month period. Sequential interventions were timed 8–12 weeks apart: (1) Implementing a new resident daily progress note format, (2) creating a performance improvement `dashboard,' and (3) documenting patients' daily goals on bedside whiteboards. Measurements and Main Results Following all interventions, team agreement with the attending physician's stated daily goals increased from 56.9% to 82.7% (p < 0.0001). Mean agreement increased for each provider category: 65.2% to 88.8% for fellows (p < 0.0001), 55.0% to 83.8% for residents (p < 0.0001), and 54.1% to 77.4% for nurses (p < 0.0001). In addition, significant improvements were noted in provider behaviors following interventions. Barriers to communication (bedside nurse multitasking during rounds, interruptions during patient presentations, and group disassociation) were reduced, and the use of communication facilitators (review of the prior day's goals, inclusion of bedside nurse input, and order read back) increased. The percentage of providers reporting being `very satisfied' or `satisfied' with rounds increased from 42.6% to 78.3%, (p < 0.0001). Conclusions Shared agreement of patients' daily goals among key healthcare providers can be increased through process-oriented interventions. Improved agreement will potentially lead to improved quality of patient care and reduced medical errors.

A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU*

“…They found that 75% of goals discussed on rounds and goal-related actions were documented in the medical record. Five studies suggested strategies to improve communication during rounds (27,29,(36)(37)(38). Communication Strategies.…”

“…Cummings et al (35) reported that providing pharmacists with a mobile computer improved information retrieval, thereby reducing time required by pharmacists to access the electronic health record and increasing their availability on rounds. A standardized rounding process achieved by structured presentation and explicit definitions of each healthcare provider's role during rounds was evaluated by three studies, which showed a significant increase in healthcare provider satisfaction (36,38) and quality of discussions (27,29). Five studies suggested strategies to improve communication during rounds (27,29,(36)(37)(38).…”

“…Critical Care Medicine www.ccmjournal.org (40) Aeeess to patient data (25,Faeilitator 48,60,64,65) Diseussion and Faeilitator doeumentation of goals (24, 37 56) Standardized rounds Faeilitator strueture and proeess (26,52,53,66) Cheeklist use (27,28,34,36,Facilitator 37,39,54,55) Pharmaeist partieipating on Faeilitator rounds (29,32,35,42,44,47) Multidisciplinary rounds (30,Faeilitator 33,38,46,66) Greater HCP autonomy Faeilitator (57)(58)(59) Explicit HCP roles ( Similarly, a multidiscipHnary team of providers, comprised of at least a nurse, physician, and pharmacist, promotes both effectiveness and safety of rounds by increasing healthcare provider satisfaction, focusing discussion content, and reducing the number of adverse events. An explicit definition of each healthcare provider's role in discussions helps to increase patientcenteredness and facilitate more effective discussions.…”

“…Weant et al (54) Weiss et al (37) Kim et al (48) Young et al (56) Purpose Design Described (49) Agarwal et al (45) DuBose et al (39) Hewson et al (40) Lyons et al (27) Narasimhan et al (41) Newkirk et al (46) Pronovost et al (43) Rehder et al (29) Rivkin et al (53) Stone et al (44) Vats et al (32) Wright et al (38) Described association between pharmacist participation and rate of adverse drug reactions Bradshaw et al (33) Described data accessed by HCP Stockwell et al (47) White et al (55) Ribal et al (52)[Sp]…”

Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU

“…PEACE Rounds were process oriented and designed to clarify goals of treatment (Rehder et al, 2012) and whenever possible, achieve consensus. Over a twelve month period, once a week the interprofessional team met for PEACE Rounds.…”