Even for the most experienced physicians, leading rounds in the often chaotic and always unpredictable environment of an ICU can present some unique challenges.
During the session, Herding Cats: Running Effective Rounds in the ICU, on Monday, October 9, a panel of critical care physicians discussed various techniques and tools for conducting rounds and teaching during rounds in the ICU.
The nuts and bolts
William Bender, MD, MPH, Assistant Professor at Emory University School of Medicine and ICU Medical Director at Emory Saint Joseph’s Hospital, began the session with an overview of the key characteristics of ICU rounds, including the composition of the care team and a favorable ICU rounding structure.
Much like everything else with health care, there tends to be a large amount of variability in the structure and delivery of ICU patient care rounds, Dr. Bender said. Some of it is, not surprisingly, driven by resource constraints, most often staffing related, but some of it is also driven by local culture. At the same time, there have been relatively few true standards or guidelines for how ICU rounds should be performed.
While a physician skilled in intensive care is obviously a key component for successful rounds, he said that the bedside nurse is perhaps the most essential participant for patient care rounds. Based upon local staffing practices, the bedside nurse spends anywhere between 33% and 100% of their time with each patient, Dr. Bender said.
“They can offer an incredible perspective on the current condition of the patient, how the patient has done to treatment responses, the overall care preferences of the patient, as well as outcome expectations—what the patient is thinking, what the family is thinking as they go through their ICU stay,” Dr. Bender said.
The rounding team should also include the critical care pharmacist to assist clinicians with pharmacotherapy decision-making and dosing, he said, as well as the respiratory therapist to ensure respiratory care data are accurately delivered on rounds, allowing for the formation of an appropriate daily respiratory care plan.
Radu Postelnicu, MD, Assistant Professor at NYU Grossman School of Medicine, discussed the importance of integrating patients’ family members into ICU rounds. As the one constant across the continuum of care, families are key to the shared decision-making process, and they want to be included in rounds if able to join, he said.
Family engagement can help to decrease patients’ fear and anxiety and lead to improved relationships, communication, and trust in the medical team. And rather than creating an additional burden on ICU staff, the presence of families can actually speed up rounds when integrated in a structured manner, Dr. Postelnicu said.
Tools for improving rounds
Kerry M. Hena, MD, Assistant Professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at the NYU School of Medicine, discussed the efficacy of various methods and tools for studying and improving ICU rounds.
The ABCDEF bundle is an evidence-based guide for clinicians to coordinate multidisciplinary patient care in the ICU, but its utilization has yielded variable results in the literature, Dr. Hena said.
Additionally, she said that studies assessing the use of checklists or clinician-prompting tools have yielded contradictory results.
Despite a strong conceptual rationale, the evidence demonstrating that checklists actually improve clinical outcomes is limited. Some studies suggest that checklists improve the use of evidence-based practice and aid in error avoidance. However, other studies show persistent quality gaps despite the use of rounding checklists, Dr. Hena said.
There is growing evidence, she said, that emerging artificial intelligence systems have the potential to provide efficient organization of information in the ICU that could improve important patient outcomes and provide helpful rounding support.
Teaching across disciplines
Maryam Kaous, MD, Assistant Professor of Medicine and Medical Director of the Cardiac Critical Care Unit at the University of Texas Health Science Center in Houston, concluded the session with a discussion of the challenge of teaching across multiple disciplines while rounding in the ICU.
The high stress of the ICU environment, combined with unstable patients, time constraints to not only finish rounds but also to address family members and any ICU-related issues, interactions with other consultants, and the varying educational backgrounds of team members all pose unique challenges to becoming an effective teacher in the ICU, Dr. Kaous said.
It is important that clinicians leading rounds create an optimal learning environment that promotes learner engagement, encourages input, and provides opportunity for feedback.
Success in the ICU is truly dependent on many team members working together, and interprofessional bedside rounds have been shown to lead to improvement in communication, increased input from the entire team, and clarity on task assignments and roles, Dr. Kaous said.