A Time-Motion Study of Multidisciplinary Bedside Rounds in ... · A Time-Motion Study of...

A Time-Motion Study of Multidisciplinary Bedside Rounds in Pediatric Critical Care

by

Carly Marie Warren

A thesis submitted in conformity with the requirements for the degree of Master of Health Science, Clinical Engineering

Institute of Biomaterials and Biomedical Engineering University of Toronto

© Copyright by Carly Marie Warren 2018

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A Time-Motion Study of Multidisciplinary Bedside Rounds in Pediatric Critical Care

Carly Marie Warren

Master of Health Science, Clinical Engineering

Institute of Biomaterials and Biomedical Engineering

University of Toronto

2018

Abstract

The objective of this study was to characterize workflow during multidisciplinary bedside rounds

in a pediatric critical care unit. Time-motion data and attendance were collected through

observation, and healthcare provider (HCP) perceptions were gathered through surveys. Over 65

hours of time-motion data was collected during 57 rounds. High patient acuity was related to

longer encounter durations and high unit census was related to shorter encounter durations.

Family interaction and a high level of multidisciplinary contribution was found to increase the

encounter duration. HCP satisfaction with the current process was low; most clinicians reported

often not being able to hear the discussion and not feeling free to share their opinion. The unit

should determine which factors (e.g., efficiency, patient-centredness) are most valuable to the

rounding process at what time, to inform the design of a system that is suited to the needs of the

HCPs and the constraints of the environment.

iii

Acknowledgments

This thesis is the result of hard work combined with an overwhelming level of support from

people around me. I would like to sincerely thank and acknowledge the following people:

My supervisors Dr. Patricia Trbovich and Dr. Mark Chignell for their non-stop encouragement,

wisdom and guidance. Thank you Patricia for pushing me to make it through when I thought I

couldn’t, and thank you Mark for adding humour to every situation.

My committee members Dr. Anne-Marie Guerguerian, Dr. Peter Laussen and Dr. Anthony Easty

for their time, guidance, thoughtful insights and feedback.

All members of the HumanEra lab. Thank you Karli for making data collection more fun than I

ever would have expected. Thank you Jessica for your extensive knowledge of the SickKids

CCU and constant moral support. Thank you Sonia, Mark and Lauren for your guidance and

encouragement throughout the project.

Teryl, Kathy, Jeanette, and all of the staff in the SickKids CCU for not only accommodating our

presence, but going out of their way to help us become familiar with the unit and find who/what

we were looking for.

My friends Kaitlyn, Sarah, Michelle, Danny, Taimoor, Dustin, Steph, Sarah, Ravell and Steven

for their support when I needed support, and distraction when I needed distraction. I don’t think

you realize how much you helped me.

And finally, my family for their non-stop support and unwavering confidence in me. Mom, Dad,

Marcus, Maria, Dan, Gerhard and Lynn, I could not have done it without you.

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Table of Contents Acknowledgments.......................................................................................................................... iii

Table of Contents ........................................................................................................................... iv

List of Figures ................................................................................................................................ vi

List of Tables ............................................................................................................................... viii

List of Abbreviations ..................................................................................................................... ix

Introduction ..................................................................................................................................... 1

Multidisciplinary Rounds and Patient Safety ................................................................................. 1

Methods Used to Study Rounds ...................................................................................................... 4

Study Framework ............................................................................................................................ 7

Summary ......................................................................................................................................... 9

Research Objectives ........................................................................................................................ 9

Methods......................................................................................................................................... 10

Setting ........................................................................................................................................... 10

Data Collection Methods .............................................................................................................. 10

Observation ............................................................................................................................... 10

Time-Motion ............................................................................................................................. 12

Attendance ................................................................................................................................ 13

Survey ....................................................................................................................................... 13

Departmental Metrics................................................................................................................ 14

Data Analysis Methods ................................................................................................................. 14

Time-Motion ............................................................................................................................. 14

Survey ....................................................................................................................................... 15

Results ........................................................................................................................................... 16

Summary of Data Collection ........................................................................................................ 16

Best Practice: Implement multidisciplinary rounds (including at least a medical doctor,

registered nurse, and pharmacist) ............................................................................................. 17

Best Practice: Standardize location, time and team composition ............................................. 19

v

Best Practice: Reduce nonessential time wasting activities ...................................................... 24

Best Practice: Focus discussions on development of daily goals and document all discussed

goals in health record ................................................................................................................ 25

Best Practice: Conduct discussions at bedside to promote patient-centeredness ..................... 32

Best Practice: Conduct discussions in conference room to promote efficiency and

communication .......................................................................................................................... 37

Best Practices: Establish open collaborative discussion environment/Empower HCP to

promote team-based approach to discussions ........................................................................... 39

Discussion ..................................................................................................................................... 52

Best Practice: Implement multidisciplinary rounds (including at least a medical doctor,

registered nurse, and pharmacist) ............................................................................................. 52

Best Practice: Standardize location, time and team composition ............................................. 54

Best Practice: Reduce nonessential time wasting activities ...................................................... 55

Best Practice: Focus discussions on development of daily goals and document all discussed

goals in health record ................................................................................................................ 56

Best Practice: Conduct discussions at bedside to promote patient-centeredness ..................... 58

Best Practice: Conduct discussions in conference room to promote efficiency and

communication .......................................................................................................................... 61

Best Practice: Establish open collaborative discussion environment/Empower HCP to promote

team-based approach to discussions ......................................................................................... 63

Summary ................................................................................................................................... 65

Contributions Made .................................................................................................................. 66

Limitations ................................................................................................................................ 67

Generalizability of Results ........................................................................................................ 67

Future Research ........................................................................................................................ 68

Conclusions ............................................................................................................................... 68

References ..................................................................................................................................... 69

Appendix A - Survey .................................................................................................................... 73

vi

List of Figures

Figure 1: Patient acuity as a function of RT attendance in the CCCU ......................................... 19

Figure 2: Patient acuity as a function of pharmacist attendance in the CCCU ............................. 19

Figure 3: Total rounding duration as a function of unit and time of day ...................................... 20

Figure 4: Minutes PICU rounds starts late as a function of time of day ....................................... 21

Figure 5: Minutes CCCU rounds starts late as a function of time of day ..................................... 21

Figure 6: PICU Morning - Encounter duration as a function of unit census and patient acuity ... 22

Figure 7: CCCU Morning - Encounter duration as a function of unit census .............................. 23

Figure 8: CCCU Morning - Encounter duration as a function of patient acuity........................... 23

Figure 9: CCCU Afternoon - Encounter duration as a function of patient acuity ........................ 24

Figure 10: PICU - Discussion topic duration as a function of time of day ................................... 26

Figure 11: PICU - Discussion topic duration as a function of unit census ................................... 27

Figure 12: PICU - Discussion topic as a function of patient LOS ................................................ 28

Figure 13: CCCU - Discussion topic duration as a function of time of day ................................. 29

Figure 14: CCCU - Discussion topic as a function of unit census................................................ 30

Figure 15: CCCU - Discussion topic as a function of patient LOS .............................................. 31

Figure 16: Mean score by clinician type of survey question "Are you confident in your

understanding of the patient's care plan after rounds are finished?" ..................................... 32

Figure 17: Percentage of patient encounters attended by family by unit and time of day ............ 33

Figure 18: PICU Afternoon - Encounter duration as a function of family interaction and unit

census..................................................................................................................................... 34

Figure 19: PICU Afternoon - Encounter duration as a function of family interaction and patient

LOS ........................................................................................................................................ 35

Figure 20: PICU Afternoon - Encounter duration as a function of family interaction and patient

acuity ..................................................................................................................................... 35

Figure 21: CCCU Afternoon - Encounter duration as a function of family interaction ............... 36

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Figure 22: Encounter duration as a function of location (conference room vs bedside) .............. 37

Figure 23: Mean score by clinician type of the survey question "Is the current rounding system

efficient?" .............................................................................................................................. 38

Figure 24: Mean score by clinician type of the survey question "Can you clearly hear what is

being said during rounds?" .................................................................................................... 39

Figure 25: Average speaking duration during PICU patient encounter by clinician type ............ 41

Figure 26: Average speaking duration during CCCU patient encounter by clinician type .......... 43

Figure 27: PICU Morning - Encounter duration as a function of multidisciplinary contribution

level ....................................................................................................................................... 45

Figure 28: PICU Afternoon - Encounter duration as a function of multidisciplinary contribution

level ....................................................................................................................................... 46

Figure 29: CCCU Morning - Encounter duration as a function of multidisciplinary contribution

level ....................................................................................................................................... 47

Figure 30: CCCU Afternoon - Encounter duration as a function of multidisciplinary contribution

level ....................................................................................................................................... 48

Figure 31: Mean score by clinician type to the survey question "Are you satisfied with your level

of involvement in rounds?" ................................................................................................... 49

Figure 32: Mean score by clinician type of the survey question "Do you feel free to share your

opinion and/or ask questions during rounds?"....................................................................... 50

Figure 33: Mean score by clinician type of the survey question "Do you think that others feel free

to share their opinion and/or ask questions during rounds?" ................................................. 51

viii

List of Tables

Table 1: Lane's Evidence-Informed Practices for Patient Care Rounds in the ICU (5) ................. 3

Table 2: Examples of previous studies of clinical information exchange ...................................... 4

Table 3: Select best practices that comprise the study framework ................................................. 7

Table 4: DELTA interface configuration ...................................................................................... 12

Table 5: Select DELTA variables with definitions ....................................................................... 12

Table 6: Number of rounds and patient encounters observed by unit and time of day ................ 16

Table 7: Number of survey responses by clinician type ............................................................... 16

Table 8: Characteristics of rounds by unit and time of day .......................................................... 17

Table 9: Percentage of patient encounters attended by clinician type .......................................... 18

Table 10: Results of post-hoc tests on PICU average speaking duration, comparison of clinician

type ........................................................................................................................................ 41

Table 11: Results of post-hoc tests on PICU average speaking duration, comparison of time of

day ......................................................................................................................................... 42

Table 12: Results of post-hoc tests on CCCU average speaking duration, comparison of clinician

type ........................................................................................................................................ 43

Table 13: Results of post-hoc tests on CCCU average speaking duration, comparison of time of

day ......................................................................................................................................... 44

Table 14: Average speaking duration in seconds by clinician type - breakdown of "Other"

category ................................................................................................................................. 44

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List of Abbreviations

CCCU Cardiac Critical Care Unit

CCU Critical Care Unit (Department of Critical Care Medicine)

CSN Clinical support nurse

CNS Clinical nurse specialist

HCP Health care provider

ICU Intensive Care Unit

LOS Length of stay

MD Medical Doctor

NP Nurse Practitioner

PACS Picture archiving and communication system

PELOD Pediatric Logistic Organ Dysfunction

PICU Pediatric Intensive Care Unit

RN Registered Nurse

RT Respiratory Therapist

SickKids The Hospital for Sick Children

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Chapter 1 Introduction

Multidisciplinary Rounds and Patient Safety

In the Intensive Care Unit (ICU), the delivery of safe, high-quality patient care relies on strong

collaboration between the clinicians comprising the multidisciplinary care team (1-3). Effective

communication is essential to this endeavor, and the most important opportunity for

multidisciplinary communication occurs during patient care rounds (4). This regularly scheduled

verbal exchange of information provides a forum for providers to review the patient’s status,

discuss treatment, and make crucial patient care decisions. Ensuring the quality of this exchange

is particularly crucial in the ICU setting (3, 4), as communication failures can have a profoundly

negative impact on critically-ill patients with limited physiological capacity to tolerate errors (2,

5).

“Rounds” is an all-encompassing term that may include any regularly scheduled meeting during

which clinical problems encountered are discussed (6, 7). Rounds can be classified by location,

content or attendees; bedside rounds focus on patient care and take place in the patient’s

presence, while teaching rounds (e.g., grand rounds) usually take place off the ward and are

delivered in a lecture format (8). Interdisciplinary rounds involve all members of the care team

and provide an opportunity to discuss and coordinate care between physicians, nurses,

pharmacists and others (9).

The exchange of clinical information is an essential element to providing safe and effective care.

Communication errors are one of the most common causes of adverse medical events, having

been found to lead to adverse drug reactions, hospital-acquired infections, sepsis, unplanned

returns to the operating theatre, and more (10-13). A frequently reported communication error is

the omission of important handover content such as medication changes or pending tests (14,

15). However, failures of communication may be much more nuanced and complex, resulting

from social factors such as the hierarchical differences of providers, ambiguity in roles, and

interpersonal conflict (13).

2

In a study examining the impact of structure and care processes in the ICU on patient outcomes,

Pronovost et al. found that when daily rounding by an ICU physician did not take place, there

was a significant increase in in-hospital mortality, and an increased risk of cardiac arrest, acute

renal failure, septicemia, platelet transfusion and reintubation (16). Similarly, O’Leary et al.

found a significant decrease in the incidence of preventable adverse events (e.g., drug-related

complications, symptoms of poor glycemic control, hospital-acquired infection) in their

controlled trial of structured interdisciplinary rounds in a medical teaching unit of an academic

tertiary-care hospital (9). Other studies have found that rounding processes may have a negative

effect on some patents, as those admitted to the ICU during morning rounds have higher rates of

mortality (17, 18).

The process of rounds can also have an impact on other factors related to the quality of patient

care, such as unit workflow and patient, family, and provider satisfaction (19, 20). Following the

implementation of a lean rounding process in a pediatric ICU, Vats et al. observed a significant

increase in family satisfaction with their child’s physician, and decrease in time spent on non-

essential activities (i.e., travel time, teaching) (21). Ham et al. introduced an electronic “rounds

report” consisting of relevant patient data automatically extracted from the electronic medical

record displayed in tables and diagrams (22). Following the introduction of this visual summary

of patient information, Ham et al. were able to decrease the time required to gather data for

rounds by 62%, increase the relative percentage of work hours spent on direct patient care by

20%, increase the time available for educational activities by 55%, and decrease resident duty

hour violations by nearly 60% (22).

It is clear that the exchange of clinical information, through structured daily rounds and

handover, is essential to providing safe and effective care. As shown in previous studies, when

done right, rounds can improve patient safety, health care provider (HCP) and patient

satisfaction, and unit efficiency. With the goal of aggregating all of this data, Lane et al.

conducted a systematic review of evidence-informed practices for patient care rounds in the ICU

(5). They identified 13 facilitators of and 9 barriers to conducting high-quality rounds. Based on

their results, Lane, et al. compiled an itemized list of recommended best practices to improve

rounds, ranked by strength of recommendation (Table 1).

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Table 1: Lane's Evidence-Informed Practices for Patient Care Rounds in the ICU (5)

Best Practice Strength of

Recommendation

Implement multidisciplinary rounds (including at least a medical doctor, registered

nurse, and pharmacist)

Strong

Standardize location, time and team composition Strong

Define explicit roles for each HCP participating in rounds Strong

Develop and implement structured tool (best practices checklist) Strong

Reduce nonessential time wasting activities Strong

Minimize unnecessary interruptions Strong

Focus discussions on development of daily goals and document all discussed goals in

health record

Strong

Conduct discussions at bedside to promote patient-centeredness Weak

Conduct discussions in conference room to promote efficiency and communication Weak

Establish open collaborative discussion environment Weak

Ensure clear visibility between all HCP Weak

Empower HCP to promote team-based approach to discussions Weak

Produce visual presentation of patient information No Specific

Recommendation

Tripathi, et al. incorporated the strategies proposed by Lane et al. to promote open, honest, and

unbiased communication between patients, their families, and all HCPs in their pediatric ICU

(23). They evaluated their intervention via survey and found an increase in family participation

and HCP satisfaction with the rounding process (23). In 2015, Holodinsky, et al. conducted a

cross-sectional survey of Canadian adult medical/surgical ICUs with follow-up interviews to

describe the structure, process, and outcomes of rounds and explore whether or not Lane et al.’s

best practices are used in daily patient care (4). They discovered differential adoption of

recommended practices and identified the following areas for improvement in addition to those

listed by Lane et al.: identifying and ensuring the engagement of essential participants,

determining the role of patients and families in rounds, modifying the role of teaching, and

developing a metric for measuring rounding quality. Despite literature reporting the value of

4

following evidence informed rounding practices, there is variability in the success of their

implementation, likely due to variation in environments in which they are implemented. This

highlights a need to fully understand and characterize the rounding process prior to introducing

an intervention to evaluate its applicability and potential benefits in the unit of interest.

Methods Used to Study Rounds

A variety of methods have been used to study rounds in the past, including observation, survey,

interview and chart review. Table 2 provides an overview of how these methods have been

employed in previous studies to gain a better understanding of the transfer of information or to

evaluate the impact of interventions.

Table 2: Examples of previous studies of clinical information exchange

First Author Aim of Study Methods Used Results

Abbas, P. I.

(24)

To assess the impact of

a new dedicated

rounding surgeon role

Chart Review

- Safety reports

- Billing data

- Decreased in patient safety

complaints

- Increase in work relative value units

- Increase in non-operative billing

Survey

- Nursing

satisfaction

- Increased satisfaction with nursing

to physician communication

- Increased perception of parental

satisfaction

Baysari, M. T.

(25)

To assess the impact of

clinicians using an iPad

during rounds on

patient engagement and

experience

Observation

- Field notes

- 77.3 hours

- 525 patient

encounters

- Physicians did not use the iPad to

share information with patients

Interview

- Physicians

- 15 min semi-

structured

- Verbal information sharing was

preferred to the iPad

Survey

- Patients

- Likert scale

- Patient engagement not effected by

use of the iPad

Bhansali, P.

(26)

To describe time use

and discrete events

during pediatric

inpatient family-centered rounds

Observation

- Time-motion

- 159 patient

encounters

- Rounds lasted an average of 7.9 min

per patient

- Parent participation, location, most

teaching, and interruptions not

associated with increased rounding

time

Butcher, B. W.

(27)

To examine the effect

of rounding by a rapid

response team

Chart Review

- ICU readmission

rate

- ICU average

length of stay

- No change in ICU readmission rate,

length of stay or in-hospital

mortality

5

- In-hospital

mortality of

patients

discharged from

the ICU

Ham, P. B.

(22)

To create an electronic

rounds report and

evaluate its effect on

surgical residents

Survey

- 23 surgical

residents

- Time spent preparing for rounds

decreased

- Work day spent in direct patient

care increased (45% to 54%)

- Educational activity time increased

(35% to 55%)

- Reported duty hour violations

decreased 58%

- Estimated department savings from

$66000-$273000

Levin, A. B.

(28)

To identify areas for

improvement in family

centred rounds

Observation

- Field notes

- 232 patient

encounters

- Rounds averaged 10.5 min per

patient

- Presence of family associated with

longer rounding times, even though

family members only spoke for an

average of 25 seconds

Survey

- HCPs and family

- Open and closed

ended questions

- Families attend rounds “to be

informed”

- Most families and providers thought

positively of family centered rounds

- PICU fellows did not think families

provided useful information during

rounds

- Nurses thought the presence of

family limited discussion

O'Leary, K. J.

(9)

To assess the effect of

structured

interdisciplinary

rounds on collaboration

and adverse events

Chart Review

- Medical records

- Decreased rate of adverse events

- Decreased rate of preventable

adverse events

Paradis, E.

(7)

To better understand

how the "operational

realities of care

delivery" in the ICU

impact the success of

interdisciplinary

morning rounds

Observation

- Field notes

- 576 hours

- Rounds are limited due to time

constraints, struggles over space,

and conflict between medical

education vs. collaborative care plan

development

Interview

- Clinicians

Pronovost, P.

(29)

To evaluate and

improve the

effectiveness of

communication during

patient care rounds in

the ICU using a daily

goals form

Survey

- Residents and

nurses

- Likert scale

- Increase in percent of residents and

nurses who understood goals of care

for the day (10% to 95%)

- Decreased ICU LOS (2.2 days to

1.1 days) Chart Review

- Patient LOS

Vats, A. Observation - Total rounding time decreased

6

(21) To evaluate the impact

of a lean rounding

process on rounding

efficiency, physician

resource, stakeholder

satisfaction,

throughput, and

communication

- Field notes

- 110 patient

encounters

- Reduction in time spent on non-

essential activities

Survey

- HCPs and family

- Likert scale

- Increase in provider and family

satisfaction

Chart Review

- Admission and

discharge data

- PICU patients discharged an average of

58 min sooner

As shown in Table 2, the process of rounds has been previously studied using objective and

subjective measures. Observation or chart review data is often complemented by surveys or

interviews with HCPs or families. Observations hours range from approximately 40 to 576, with

a similarly wide range of patient encounters (7, 21, 25, 26, 28, 30). Observation field notes are

used to collect information on the duration of rounds as well as a variety of descriptive text-

based data including information on the rounding environment, attendees, and use of technology

(25, 26). Chart review is commonly leveraged in intervention-based studies and includes data

such as medical records and safety reports (9, 24, 27). Surveys appear to be the most common

method used for understanding HCP, patient or family perceptions of information exchange,

encompassing topics such as family engagement and satisfaction with communication practices

(21, 25, 28). Interviews have also been used to capture similar information (7, 25).

Although a variety of methods have been used to study rounds in the past, many of the methods

are retrospective and subjective (i.e., surveys and interviews), relying on the recollection of

participations. When observations have been used, qualitative field notes are the most common

data collected; this method is also highly subjective and reliant on the observer. With very little

research into what HCPs actually do during rounds and how much time they spend on various

rounding activities, we do not know what influences HCPs behaviours during rounds.

Consequently, it is unclear whether rounding behaviours are particularly entrenched, or what

interventions might be implemented to influence them. The lack of such insight is a critical gap

in the literature. A time-motion study collecting quantitative duration data could prove

beneficial to objectively characterize workflow and communication patterns during rounds.

7

A time-motion study is an observation technique in which an external observer methodically

tracks the time and actions required of a worker to complete a specific task (31). This method is

often used to inform improvements to efficiency and workflow. Continuous observation is a type

of time-motion study in which the observation is triggered by an action of the subject (e.g., the

commencement of rounds), and is considered the gold standard time-motion method in

healthcare (31). The resultant time-motion data consists of a comprehensive list of timestamped

events that occurred during the observed task, and provides insight into exactly how time is spent

and potential areas for improvement.

A limited number of time-motion studies have been performed in the critical care environment

(26, 32, 33). Ballermann et al. used the Work Observation Method by Activity Timing

(WOMBAT) software to quantify the time ICU HCPs spend on tasks and interruptions, but with

a focus on validating the time-motion software (33). Hefter et al. used the same software to

evaluate the impact of strain on physician workflow in the ICU (32). Although these studies

collected incidental data on communication in the ICU, this was not their focus. Bhansali et al.

performed a time-motion study on rounds in hospitalist and neurology services, collecting

information on location, attendees, interruptions, and the duration of specific tasks (26).

However, the focus of the research was on family-centered rounds and the data was collected and

interpreted through this lens. Previous time-motion studies have not been focused on information

exchange in the ICU, nor have been used to evaluate or inform interventions to the rounding

process.

Study Framework

This study will use time-motion data collected during naturalistic observation to evaluate Lane’s

Best Practices. As not all thirteen of Lane’s recommendations are amenable to this methodology,

eight have been selected to comprise the framework of this study. The selected recommendations

are presented in Table 3, along with evidence for their implementation.

Table 3: Select best practices that comprise the study framework

Best Practice Evidence

8

Implement multidisciplinary rounds

(including at least a medical doctor,

registered nurse, and pharmacist)

● Lower mortality in medical ICU patients when rounds done

by multidisciplinary team (34)

● Reductions in ICU and hospital lengths of stay, reduction in

charges and costs with multidisciplinary approach to

ventilator dependent patients (35)

● Higher RN satisfaction with multidisciplinary rounds (36)

● Shared understanding of goals and expectation among

multidisciplinary professionals when rounds done as a team

(37)

● Reduced hospital length of stay, readmission rate, and

pharmacy cost when pharmacist present (38)

● Cost savings and decrease in drug-related complications

when pharmacist present (39)

● Decreased in adverse drug events drug interactions with

pharmacist present (40)

● RT participation in interdisciplinary rounds improved

communication and teamwork (41)

Standardize location, time and team

composition

● Improved attendance and participation from nurses when

timing is standardized (42)

● Shorter encounter duration per patient, improved use of

daily goals form and increased nursing engagement with

standardized and audited rounds (43)

● Decreased total rounding time and increased HCP

understanding of patient problems with standardized

discussion and team composition (44)

Reduce nonessential time wasting

activities

● Reallocating nonessential activities could reduce rounding

duration and increase timeliness of the completion of plan

of care (45)

● Lean rounding process increased timeliness and efficiency

of rounds, improved HCP and patient satisfaction, improved

throughput, and reduced attending physician man-hours

(21)

Focus discussions on development of

daily goals and document all discussed

goals in health record

● Prompting to use a checklist during rounds was related to

decrease mortality and decreased LOS (46)

● Improvement in percent of HCPs who understood the goals

for the day and a reduction in ICU LOS (29)

● Increased HCP agreement with staff physicians stated

patient goals when daily goals are documented (47)

Conduct discussions at bedside to

promote patient-centeredness

● Increased family satisfaction with rounds at the bedside (48)

● Increased nursing attendance and participation when rounds

take place at bedside (42, 49)

● Increased rounding time with bedside rounds (50)

Conduct discussions in conference room

to promote efficiency and communication

● Better communication (greater clinical content

completeness score) and shorter handover time away from

the bedside (50)

● Less interruptions in private space than at bedside (49, 50)

9

Establish open collaborative discussion

environment/Empower HCP to promote

team-based approach to discussions

● Hierarchical structure of HCP relationships restrict

information exchange (51-53)

● Nurse satisfaction and participation in discussions increased

when they felt their presence was valued (42, 49)

Summary

Multidisciplinary bedside rounds have a positive impact on patient safety when implemented

based on evidence informed recommendations. In 2013 a systematic review of evidence-

informed practices for patient care rounds was conducted and the results were compiled into an

itemized list of recommended best practices to improve rounds. These best practices have yet to

be evaluated through observation, as well as in a pediatric environment. A time-motion study can

be used to evaluate how well rounds are following these best practices and provide insight into

areas of improvement; both for rounds and for the best practices. Eight best practices

recommended by Lane et al. were selected to comprise the framework of this study.

Research Objectives

The overarching goal of this study was to gain a comprehensive understanding of the transfer of

information in The Department of Critical Care Medicine (CCU) at The Hospital for Sick

Children (SickKids) to inform the development of safety enhancing interventions. The specific

objectives for this thesis were:

1. To characterize workflow and communication patterns during multidisciplinary bedside

rounds (i.e., morning and afternoon rounds)

2. To compare the current practices to those recommended by Lane, et al.:

a. Determine which of the best practices are currently applied, and with what

success,

b. For those which are not applied, determine what is done instead, or what reasons

there are for the lack of compliance, and

c. Identify any additional effective practices and opportunities for improvement.

10

Chapter 2 Methods

Data collection for this project took place alongside a larger study examining all aspects of

information exchange in the SickKids CCU. The focus of this thesis was specifically on

workflow and communication patterns during multidisciplinary rounds.

Setting

This study was conducted at The Hospital for Sick Children, a pediatric academic and teaching

hospital located in Toronto, Canada. The study had institutional research ethics board approval

(SK REB #1000059173). Data was collected in The Department of Critical Care Medicine

(CCU), which consists of 42 beds divided between two units; the Pediatric Intensive Care Unit

(PICU) and Cardiac Critical Care Unit (CCCU). The department admits approximately 2200

patients per year (54). Multidisciplinary bedside rounds are conducted twice daily (7:30, 16:00)

in each unit.

Data Collection Methods

Observation

Two researchers observed multidisciplinary bedside rounds (i.e., morning and afternoon rounds)

in both the PICU and CCCU. Observations took place over a period of 10 weeks and occurred on

all days of the week, including weekends. Observations were conducted 3 days per week,

alternating between the PICU and CCCU. Observations lasted for the entire length of rounds,

starting with the review of patient images at the picture archiving and communication system

(PACS) station to the end of the last patient encounter. Time-motion data and attendance were

collected in parallel.

The observation schedule was designed to maximize the number of staff physicians observed in

the study, as there was a limited study period and staff physicians may be off service for weeks

at a time. We aimed to observe each staff physician 4 times; twice during morning rounds and

twice during afternoon rounds. During the study period, 16 staff physicians were divided

11

between the two units, and the on-service physician for each unit rotated on a weekly basis. Ten

weeks of observations were expected to elicit a representative observation data sample for this

population while allowing for an equal number of observations in both units. Staff physicians

were assigned a random identification code at the start of the study and their attendance was

tracked during observations. Twenty-two fellows, approximately 300 RNs, 62 RTs, 7

pharmacists and 2 dietitians also staffed the unit during the study period. Based on staffing

estimates, advance scheduling, and discussion with clinical program managers, it was ensured

ahead of time that a representative sample of nursing and RT staff would be observed over the

10-week period.

An opt-out consent model was used for observations; HCPs, parents, patients (if able), and

parents on behalf of patients were given the opportunity to indicate if they wished to opt-out, as

opposed to explicitly opting in. Easily accessible information about the nature of the study and

the option and process to opt-out were provided to all HCPs, parents and patients through

posters, emails, and presentations. Multiple options for opting out were provided including

email, phone call or in-person discussion.

The study was designed such that SickKids staff would not be made aware of who opted out.

Observation scheduling took place ahead of time in consultation with staff schedules; when

possible, days when opted-out staff were working were not included. The researchers reviewed

the attending physician, medical trainee, RN and RT schedules prior to each observation to check

if anyone who had opted out would be on shift, and if so, observation of the patient encounters

involving that staff member did not take place. If incoming staff had opted out of observations,

observation stopped for the remainder of the relevant encounters. Staff who had opted out were

asked to ensure that they displayed their badges prominently so that they were readily

identifiable. Rounds on patients whose families had opted out were not observed.

12

Time-Motion

One observer performed a continuous time-motion study using an iPad running the application

DELTA (55). DELTA was developed to guide observational studies by allowing users to capture

time-stamped event data across multiple dimensions, to capture workflow and communication

patterns (56). The application has previously been used to characterize patterns of work in ICU

settings (56). Table 4 depicts the interface configuration of the tool. The data points collected for

each event were start time, end time, time elapsed, and the variables selected from each column.

Table 4: DELTA interface configuration

Speaker Discussion Topic Discussion Content Body System

Staff physician

Fellow (presenting)

Fellow (other)

Bedside nurse

Resident

Pharmacist

Clinical nurse specialist

Charge nurse/support nurse

Respiratory therapist

Nurse practitioner

Family

Dietitian

Other

Patient encounter

Introduction/history

Acute status update

Care plan

Pre-rounds

Post-rounds

Request info

Correct info

Teaching

Interruption

Logistics

Discussion with family

Non-patient related discussion

CNS

CVS

Access

Respiratory

GI

GU

Skin

Labs

ID

Social

The “Discussion Topic” variables primarily focused on in this study are described in Table 5.

Table 5: Select DELTA variables with definitions

Patient encounter ● The time spent discussing one patient during rounds

● Start time: beginning of patient presentation

● End time: end of discussion, team starts moving on to next patient

Introduction/history ● Patient age, weight, diagnosis

● Explanation of why they were admitted to the unit

● Relevant clinical history

Acute status update ● Summary of what occurred overnight (during morning rounds) or during the day

(during afternoon rounds) regarding the patient

● Usually reported by body system (e.g., cardiovascular system, respiratory

system)

Care plan ● Discussion and decision-making regarding plan for the day (during morning

rounds) or overnight (during afternoon rounds)

13

Prior to the start of the formal data collection phase, 14 days of pilot observations were

completed in the unit, including 4 days observing alongside an experienced SickKids clinician.

The pilot period served to familiarize the researchers with the data collection tools as well as the

SickKids CCU. Sixty-five patient encounters were observed with the SickKids clinician, who

then reviewed all collected data to ensure the researchers developed an appropriate sensitivity to

clinical details. When the configuration of the DELTA interface was finalized, two researchers

collected time-motion data in parallel. Collected duration of staff physician, fellow, resident and

bedside nurse input per patient encounter was calculated for each observer, as was duration of

the introduction/history, acute status update and care plan. An intra-class correlation coefficient

of >0.95 was achieved prior to official observations.

Attendance

The number of rounding participants was tracked at all patient encounters by the following

categories: staff physician, fellow, resident, pharmacist, nurse practitioner, charge nurse/CSN,

CSN, dietitian, surgeon, CVS fellow, bedside nurse, family, RT, ECMO and other. In the

analysis, the category MD refers to a staff physician, fellow or resident. An RN refers to a

bedside nurse, charge nurse/CSN, CNS or nurse practitioner.

Survey

Surveys were distributed to critical care healthcare providers (HCPs) including physicians

(fellows, residents and staff), RNs, RTs, pharmacists and dietitians to assess perceptions of

rounds as they are currently implemented in the unit. The survey (Appendix A) was derived from

Holodinsky’s National Survey of ICU Patient Care Rounds (4) and Vats’ Rounding Process Staff

Satisfaction Survey (21), with additional questions added to complement the objective data that

was captured by the time-motion method.

The survey contained closed and open-ended questions, although only the closed-ended

questions were included in this thesis. Most responses were collected on a 5-point frequency-

based Likert scale: never, rarely, sometimes, usually, always. Responses to the question “Is the

14

amount of teaching done during rounds appropriate” was collected on a 3-point scale: not

enough, appropriate amount, too much.

Departmental Metrics

The unit census was recorded before each observation (morning and afternoon). The length of

stay (LOS) and acuity of each patient was also collected. Patient acuity was measured by the

Pediatric Logistic Organ Dysfunction (PELOD) score collected once per day.

For analysis, unit census was considered high when it was above the mean for the unit during the

observation period, and low when it was below the mean. Based on discussion with unit

clinicians, a LOS of 3 or less days was considered low, and greater than 3 days was considered

high. Patient acuity was considered high when it was above the mean for the data collection

period (PELOD score of 10 of greater), and low when it was below the mean (PELOD score less

than 10).

Data Analysis Methods

Time-Motion

Time-motion data was downloaded from the DELTA tool to Microsoft Excel. The raw data was

divided into patient encounters, and for each patient encounter the total duration, duration of

discussion topic (i.e., introduction/history, acute status update, care plan) and duration of

participant input (e.g., staff physician, bedside nurse, etc.) as calculated. The main dependent

variables used in the analyses were total rounding duration, patient encounter duration and

discussion topic duration, and it was assessed to see if these varied as a function of unit census,

patient LOS, patient acuity, family participation and level of multidisciplinary contribution.

Various ANOVAs were conducted and are described individually in the results. All analyses

were conducted using IBM SPSS Statistics GradPack Version 1.0.0-2366.

15

Interpretation of the results reported below was facilitated by a consideration of Lane’s best

practices. Each best practice implies patterns to be expected in the observed time-motion data

and insights relating to some of the practices may be gleaned from the survey data that was

collected. Only significant results (p < .05) are described unless otherwise stated. All pairwise

comparisons use the Bonferroni adjustment for the number of comparisons made (in order not to

inflate familywise alpha (57), unless otherwise stated. The Greenhouse Geisser correction was

used when Mauchly’s test was significant. Where used in figures, the error bars show standard

error. The horizontal lines above the bars indicate pairs of bars where the data points (e.g.,

means) are significantly different from each other (p < 0.05). In cases where a horizontal line

connects not to a bar but to another horizontal line above a group of bars, one side of the

horizontal line (e.g., a single bar or a group of bars) differs significantly (p < 0.05) from the other

side of the horizontal line (which can also be either a bar or a line representing a group of bars).

Survey

Survey data was entered manually into an Excel spreadsheet following the completion of the

study. The 5-point Likert scale responses were converted into scores of 1 (never) to 5 (always).

Responses to the question regarding teaching were converted into scores of 1 (not enough) to 3

(too much). Likert scale results were treated as interval scale and subject to parametric analysis

of variance. A between subjects ANOVA was conducted for each question to examine

differences in mean response by clinician type (described in Table 7).

16

Chapter 3 Results

Summary of Data Collection

Approximately 65 hours of time-motion data was collected on 32 different days between the

dates of February 20th, 2018 and April 26th, 2018. A total of 57 rounds and 792 patient

encounters were observed (see Table 6 for breakdown by unit and time of day). All 16 CCU staff

physicians at the site were observed leading rounds at least twice. No HCPs, patients or family

members opted out of the observations. 126 surveys were collected (see Table 7 for breakdown

by clinician type).

Table 6: Number of rounds and patient encounters observed by unit and time of day

PICU

Morning

PICU

Afternoon

CCCU

Morning

CCCU

Afternoon

Total

Rounds Observed 16 12 16 13 57

Patient Encounters Observed 248 170 223 151 792

Table 7: Number of survey responses by clinician type

Clinician Type Number of Survey Participants Percentage of Unit Population

Staff Physician 8 50%

Fellow/Resident/Nurse Practitioner 18 ~41%

Nurse (Bedside, Charge, Clinical

Support, Clinical Specialist)

66 ~22%

Respiratory Therapist 25 40%

Other (Pharmacist, Dietitian, Did

Not Specify, etc.)

8 Unknown

As can be seen in Table 8, the total duration of rounds ranged from 1 hour 10 min to 1 hour 39

min, depending on unit and time of day. The average patient encounter duration ranged from 4

min 9 sec to 5 min 48 sec. The average percentage of rounding time spent per patient was around

5-6% during all rounds.

17

Table 8: Characteristics of rounds by unit and time of day

PICU Morning PICU Afternoon CCCU Morning CCCU

Afternoon

Average Total Duration

(hh:mm:ss)

01:27:48 01:32:37 01:10:14 01:39:38

Standard Deviation of Total

Duration (hh:mm:ss)

00:15:25

00:21:50

00:15:38 00:23:39

Average Patient Encounter

Duration (hh:mm:ss)

00:04:23 00:04:52 00:04:09 00:05:48

Standard Deviation of Patient

Encounter Duration

(hh:mm:ss)

00:02:46 00:03:12 00:02:36 00:03:12

Average Percent of Time

Spent on 1 Patient Encounter

(%)

5.0% 5.3% 5.9% 5.8%

During the study period the average unit census was 16.1 patients in the PICU and 13.9 patients

in the CCCU. The average PELOD score was 9.0 in the PICU and 9.57 in the CCCU.

Best Practice: Implement multidisciplinary rounds (including at least a medical doctor, registered nurse, and pharmacist)

As can be seen in Table 9, an MD (i.e., staff physician, fellow or resident), RN (i.e., bedside

nurse, charge nurse, clinical support nurse, clinical nurse specialist, nurse practitioner), and

pharmacist was present for 62.4% of patient encounters during PICU morning rounds, but only

48.2% of those encounters during PICU afternoon rounds. While multidisciplinary attendance

was similar (at 47.6%) to that of the PICU setting in the case of CCCU afternoon rounds, the

corresponding proportion of patient encounters during CCCU morning rounds was much lower

than was the case for the PICU setting (14.4% vs. 62.4%).

18

As respiratory therapists (RTs) also play an important role in the unit, the percentage of patient

encounters an MD, RN, pharmacist and RT were present for was calculated. The four roles

attended 45.4% of PICU morning patient encounters, 25.3% of PICU afternoon encounters, 2.9%

of CCCU morning encounters and 17.2% of CCCU afternoon encounters.

From Table 9, it can be seen that MDs and RNs are typically always present, and that

pharmacists and RTs are the cause of the drop in percentage of multidisciplinary attendance.

Table 9: Percentage of patient encounters attended by clinician type

Percentage of Patient Encounters Attended by Clinician Type, %

MD RN Pharmacist RT MD, RN and

Pharmacist

MD, RN, Pharmacist

and RT

PICU Morning 100 100 62.4 68.8 62.4 45.4

PICU Afternoon 100 91.8 51.8 48.2 48.2 25.3

CCCU Morning 100 100 14.4 35.1 14.4 2.9

CCCU Afternoon 100 99.3 47.6 38.6 47.6 17.2

For each unit (PICU and CCCU), between subjects ANOVAs were carried out separately with

patient acuity (as measured by PELOD score) and LOS as dependent variables. The analyses

were two-way ANOVAs with clinician type (RT vs. pharmacist) and attendance (present or

absent) as the factors.

19

As can be seen in Figure 1, in the CCCU, the patient encounters attended by an RT had a

significantly higher acuity level (average PELOD score 11) than those encounters where an RT

was not present (average PELOD score = 6.8 , F(1, 227) = 16.56, p < 0.01). The same trend was

found for pharmacists, F(1, 227) = 4.99, p < 0.05, as can be seen in Figure 2. No significant

differences were found in the PICU.

Best Practice: Standardize location, time and team composition

In the PICU, both morning and afternoon rounds started at the picture archiving and

communication system (PACS) station 100% of the time. In the CCCU, both morning and

afternoon rounds started in the cardiac hub 100% of the time.

With respect to the standardization of timing, total rounding duration was assessed using a 2

(unit type: PICU vs. CCCU) X 2 (census: low vs. high) x 2 (time of day: morning vs. afternoon)

mixed factors ANOVA with repeated measures on the last factor. There was a statistically

significant interaction between unit and time of day, F(1,17) = 6.59, p < 0.05. Specifically, post

hoc tests (using Bonferroni adjustment) revealed that total rounding duration was significantly

shorter for CCCU morning rounds than PICU morning rounds. CCCU morning rounds was also

Figure 1: Patient acuity as a function of RT attendance in the

CCCU

Figure 2: Patient acuity as a function of pharmacist

attendance in the CCCU

20

significantly shorter than CCCU afternoon rounds. As can be seen in Figure 3, CCCU morning

rounds lasted for an average duration of 1hr 10min while the other three types of rounds ranged

from 1hr 27min to 1hr 39min. Unit census did not have an effect on total rounding duration.

Figure 3: Total rounding duration as a function of unit and time of day

21

For each unit (PICU and CCCU) separate one-way repeated measures ANOVAs were conducted

that examined the effect of time of day (i.e., morning versus afternoon rounds) on the number of

minutes late that rounds began. It was found that PICU afternoon rounds began significantly later

than scheduled compared to morning rounds, F(1,24) = 24.15, p < 0.01, as can be seen in Figure

4. PICU morning rounds began an average of 1.7 minutes late, while PICU afternoon rounds

began an average of 9.0 minutes late. Similarly, as can be seen in Figure 5, CCCU afternoon

rounds began significantly later than morning rounds, F(1,24) = 27.50, p < 0.01. CCCU morning

rounds began an average of 1.1 minutes late, while CCCU afternoon rounds began an average of

6.2 minutes late.

Figure 4: Minutes PICU rounds starts late as a function of

time of day

Figure 5: Minutes CCCU rounds starts late as a function of

time of day

Given that the duration of rounds varied as a function of the unit and time of day the following

results in this section were analyzed separately, broken into PICU morning, PICU afternoon,

CCCU morning and CCCU afternoon rounds. A three-way between subjects ANOVA was

conducted that examined the effect of unit census, patient acuity and patient LOS on encounter

duration. Note that between subjects analysis was used because the research protocol didn’t

allow easy matching of different instances of the same patient at different times, and the widely

varying number of observations per patient would have undermined estimates of individual

differences effects.

22

PICU Morning

Figure 6: PICU Morning - Encounter duration as a function of unit census and patient acuity

As can be seen in Figure 6, for PICU morning rounds there was a significant interaction between

unit census and patient acuity on encounter duration, F(2, 158) = 4.98, p < 0.01. Specifically,

post hoc tests revealed that patient encounters were significantly longer for both high and low

acuity patients when the unit had a low census compared to a high census. When the unit had a

high census, patient encounters were significantly longer for high acuity patients.

PICU Afternoon

No significant effects were found.

23

CCCU Morning

It was found that encounter durations were significantly longer when the unit had a low census

compared to a high census, F(1,152) = 4.76, p < 0.05, as seen in Figure 7. In addition, encounter

durations were significantly longer for high acuity patients compared to low acuity patients,

F(1,152) = 10.05, p < 0.001, as seen in Figure 8.

Figure 7: CCCU Morning - Encounter duration as a function

of unit census

Figure 8: CCCU Morning - Encounter duration as a function

of patient acuity

24

CCCU Afternoon

It was found that encounter durations were significantly longer for high acuity patients compared

to low acuity patients, F(1,142) = 3.13, p < 0.05, as seen in Figure 9.

Figure 9: CCCU Afternoon - Encounter duration as a function of patient acuity

Best Practice: Reduce nonessential time wasting activities

As this best practice did not specify what activities may be considered nonessential, literature on

this topic was reviewed. Previous studies, including articles cited by Lane, suggest retrieval of

patient data (58), teaching (45) and transit time (26, 45) to be nonessential. Tracking the retrieval

of data was out of scope for this study, but transit time was tracked in the time-motion data and

satisfaction with the level of teaching was assessed through survey.

Time spent in transit (i.e., moving from bedspot to bedspot) was tracked for all types of rounds in

the unit. During PICU morning and afternoon rounds, 14.4% and 15.7% of the total rounding

duration was spent in transit, respectively. In the CCCU, 16.0% of the total rounding duration

was spent in transit during morning rounds and 15.0% in the afternoon.

25

A researcher walked the typical rounding path for both sets of rounds, stopping at 16 PICU

patient beds and 14 CCCU patient beds (the average unit census for the duration of the study).

Using the time this took as the necessary transit time for bedside rounds (i.e., time required to

physically move from bed to bed), it can be said that only about 5% of the total rounding time

needs to be spent in transit, and the remaining 10% found in the study was potentially

nonessential time spent waiting for participants, maneuvering around the bedside, or setting up

the computer-on-wheels.

To assess whether teaching should be considered a potential nonessential activity, we analyzed

the survey question “Is the amount of teaching done during rounds appropriate?”. The mean

score was 1.8, falling between the categories “Not Enough” (1) and “Appropriate Amount” (2).

The mean score did not vary by clinician type. Although previous studies suggest teaching could

be considered a nonessential rounding activity, it appears clinicians in the SickKids CCU value

this aspect of rounds and even tend towards wanting more teaching.

Best Practice: Focus discussions on development of daily goals and document all discussed goals in health record

The time-motion data for patient encounters was divided into three main categories: patient

introduction/history, acute status update and care plan (described in Table 5). We examined the

duration and variability of time spent on these three discussion topics as they represent the

elements of discussion where the development and documentation of daily goals occurs.

PICU

Duration of discussion was analyzed using a 2 (time of day: morning vs. afternoon) X 2 (unit

census: low vs. high) X 2 (patient LOS: low vs. high) X 2 (patient acuity: low vs. high) X 3

(discussion topics: introduction/history vs. acute status update vs. care plan) mixed factors

ANOVA with repeated measures on the last factor.

26

Figure 10: PICU - Discussion topic duration as a function of time of day

As seen in Figure 10, there was a significant interaction between discussion topic and time of

day, F(1.7, 582.2) = 5.19, p < 0.01. Post hoc tests revealed that the duration of time spent on the

acute status update was higher in the afternoon compared to the morning.

27

Figure 11: PICU - Discussion topic duration as a function of unit census

As seen in Figure 11, there was a significant interaction between discussion topic and unit

census, F(1.7, 582.2) = 2.91, p < 0.01. Post hoc tests revealed that a significantly longer amount

of time was spent on the acute status update when the census was low compared to high, as well

as the care plan when the census was low compared to high.

28

Figure 12: PICU - Discussion topic as a function of patient LOS

As seen in Figure 12, there was a significant interaction between discussion topic and patient

LOS, F(1.7, 582.2) = 8.42, p < 0.01. Post hoc tests revealed that a significantly longer amount of

time was spent on the patient introduction when the patient’s LOS was low compared to high. In

addition, significantly longer time was spent on the acute status update and care plan when the

LOS was high compared to low.

29

CCCU

As earlier reported for the PICU data, duration of discussion was analyzed using a 2 (time of

day: morning vs. afternoon) X 2 (unit census: low vs. high) X 2 (patient LOS: low vs. high) X 2

(patient acuity: low vs high) X 3 (discussion topics: introduction/history vs. acute status update

vs. care plan) mixed factors ANOVA with repeated measures on the last factor.

Figure 13: CCCU - Discussion topic duration as a function of time of day

As seen in Figure 13, there was a significant interaction between discussion topic and time of

day, F(1.5, 467.0) = 11.28, p < 0.001. Post hoc tests revealed that a significantly longer amount

of time was spent on the acute status update during afternoon rounds compared to morning

rounds, as well as the care plan during afternoon rounds compared to morning rounds.

30

Figure 14: CCCU - Discussion topic as a function of unit census

As seen in Figure 14, there was a significant interaction between discussion topic and unit

census, F(1.5, 467.0) = 11.06, p < 0.001. Post hoc tests revealed that a significantly longer

amount of time was spent on the acute status update when the census was low compared to high,

as well as the care plan when the census was low compared to high.

31

Figure 15: CCCU - Discussion topic as a function of patient LOS

As seen in Figure 15, there was a significant interaction between discussion topic and patient

LOS, F(1.4,440.4) = 6.95, p < 0.01. Post hoc tests revealed that a significantly longer amount of

time was spent on the introduction/history when the patient had a low LOS compared to a high

LOS.

A between subjects ANOVA determined that the mean score to the question “Are you confident

in your understanding of the patient’s care plan after rounds are finished?” differed significantly

between clinician types, F(4,124) = 7.79, p < 0.001, as seen in Figure 16. Post hoc tests using the

Bonferroni correction revealed the mean score reported by staff physicians to be significantly

higher than all the other clinician groups. In addition, RNs reported a significantly higher mean

score than RTs.

32

Figure 16: Mean score by clinician type of survey question "Are you confident in your understanding of the patient's care plan

after rounds are finished?"

Best Practice: Conduct discussions at bedside to promote patient-centeredness

A chi-square test of independence was performed to examine the relation between family

attendance and type of rounds. As seen in Figure 17, family members were more often present

for CCCU afternoon rounds (52.4%) compared to PICU afternoon rounds (38.6%), χ2 (1, N =

298) = 5.76, p < 0.05. As well, family members were more often present for CCCU afternoon

rounds compared to CCCU morning rounds (21.3%), χ2 (1, N = 319) = 33.55, p < 0.001.

33

Figure 17: Percentage of patient encounters attended by family by unit and time of day

When present, a family member actively participated in the rounding discussion during 57.1% of

patient encounters during PICU morning rounds and 61.9% during PICU afternoon rounds. In

the CCCU, a family member participated during 43.6% of encounters when present during

morning rounds, and 58.2% of encounters when present during afternoon rounds. There was no

significance difference between family participation and type of rounds.

Next, for each type of rounds, differences in encounter duration were analyzed in a 2 (family

interaction: no interaction vs. interaction) X 2 (unit census: low vs. high) X 2 (patient LOS: low

vs. high) X 2 (patient acuity: low vs. high) between subjects ANOVA.

PICU Morning

There were no significant effects.

34

PICU Afternoon

As seen in Figure 18, there was a significant interaction between family interaction and unit

census on encounter duration, F(1, 153) = 4.14, p < 0.05. Post hoc tests revealed that the average

patient encounter duration was significantly longer when the unit census was low and the team

interacted with the patient’s family, compared to when the census was high and the team

interacted with the patient’s family. When the unit census was low, the average patient encounter

duration was significantly longer when the team interacted with the family compared to when the

team did not interact with the family.

Figure 18: PICU Afternoon - Encounter duration as a function of family interaction and unit census

As seen in Figure 19, there was a significant interaction between family interaction and patient

LOS on encounter duration, F(1, 153) = 4.56, p < 0.05. The average encounter duration was

significantly longer when the team interacted with the family of a patient who had a high LOS

compared to when they interacted with the family of a patient who had a low LOS or when they

did not interact with the family.

35

Figure 19: PICU Afternoon - Encounter duration as a function of family interaction and patient LOS

Figure 20: PICU Afternoon - Encounter duration as a function of family interaction and patient acuity

36

As seen in Figure 20, there was a significant interaction between family interaction and patient

acuity on encounter duration, F(1, 153) = 5.16, p < 0.01. Post hoc tests revealed that for low

acuity patients, the encounter duration was significantly longer when the team interacted with the

family. When there was no interaction with the patient’s family, the average encounter duration

was significantly longer for high acuity patients than low acuity patients.

CCCU Morning

There were no significant effects.

CCCU Afternoon

As seen in Figure 21, encounter durations were significantly longer when the rounding team

interacted with the patient’s family, F(1,145) = 5.46, p < 0.05.

Figure 21: CCCU Afternoon - Encounter duration as a function of family interaction

37

Best Practice: Conduct discussions in conference room to promote efficiency and communication

Differences in encounter duration were analyzed using a 2 (location: conference room vs.

bedside) X 2 (unit: PICU vs. CCCU) between subjects ANOVA. It was found that patient

encounters that took place on Tuesday afternoons in a seated office area (comparable to a

conference room) were significantly shorter than those that took place at the bedside, F(1,69) =

5.47, p < 0.05, as seen in Figure 22. Note that the effect of unit (i.e., PICU vs CCCU) was not

significant.

Figure 22: Encounter duration as a function of location (conference room vs bedside)

38

For the survey question “Is the current rounding system efficient?”, a between subjects one-way

ANOVA determined that the mean score on a 5-point Likert scale differed statistically

significantly between clinician types, F(4,123) = 5.79, p < 0.001 (as seen in Figure 23). Post hoc

tests using the Bonferroni correction revealed the mean score reported by the “other” category

(which includes interdisciplinary professionals such as pharmacists and dietitians) to be

significantly lower than staff physicians, fellows/residents/NPs, RNs and RTs.

Figure 23: Mean score by clinician type of the survey question "Is the current rounding system efficient?"

39

Figure 24: Mean score by clinician type of the survey question "Can you clearly hear what is being said during rounds?"

For the survey question “Can you clearly hear what is being said during rounds?”, a between

subjects one-way ANOVA determined that the mean score on a 5-point Likert scale differed

statistically significantly between clinician types, F(4,124) = 5.99, p < 0.001 (as seen in Figure

24). Post hoc tests using the Bonferroni correction revealed the mean score reported by staff

physicians to be significantly higher than RTs and other. In addition, the mean score reported by

fellows/residents/NPs was significantly higher than that of other, as was the mean score reported

by RNs.

Best Practices: Establish open collaborative discussion environment/Empower HCP to promote team-based approach to discussions

The openness of the discussion environment in the SickKids CCU was evaluated based on the

duration of time that each profession spoke during patient encounters, and responses to surveys

questions “Are you satisfied with your level of involvement in rounds?”, “Do you feel free to

share your opinion/ask questions during rounds?” and “Do you think others feel free to share

40

their opinion/ask questions during rounds?”. In addition, the effect of multidisciplinary

contribution on the duration of patient encounters was examined.

The average duration each clinician type spoke during a patient encounter can be seen in Figure

25 and Figure 26. Two separate (time of day: morning vs. afternoon) X 5 (clinician type: staff vs.

fellow vs. resident/NP vs. bedside nurse vs. other) between subjects ANOVA were conducted for

each unit (PICU and CCCU) to examine differences in speaking duration. In the PICU, a

significant interaction was found between time of day and clinician type, F(1794,4) = 15.28, p <

0.001. A significant interaction between time of day and clinician type was also found in the

CCCU, F(1614, 4) = 44.31, p < 0.001. Post hoc tests revealed differences between specific

clinician types and time of day. Results of the post hoc tests are shown in Table 10 and Table 11

for the PICU, and Table 12 and Table 13 for the CCCU.

During both PICU morning and afternoon rounds a fellow spoke for the largest duration of the

time during patient encounters (126 and 102 seconds respectively). Speaking time during PICU

morning rounds was dominated by physicians (staff, fellow and resident), with a bedside nurse

speaking on average about 10 seconds per encounter, and all other professions combined an

average of 7 seconds (see Table 14 for breakdown of other professions). During PICU afternoon

rounds a bedside nurse spoke for the second highest duration of time at 65 seconds, followed by

a staff physician and a resident. The other interdisciplinary professions spoke for a combination

of 15 seconds on average per patient encounter.

41

Figure 25: Average speaking duration during PICU patient encounter by clinician type

Table 10: Results of post-hoc tests on PICU average speaking duration, comparison of clinician type

Comparison

Clinician Type

1

Clinician Type

1 Speaking

Duration (sec)

Comparison

Clinician Type

2

Clinician Type

2 Speaking

Duration (sec)

Time of Day p < 0.05

Staff 66.9 Fellow 126.5 Morning *

Staff 66.9 Resident 37.2 Morning *

Staff 66.9 Bedside Nurse 10.6 Morning *

Staff 66.9 Other 7.0 Morning *

Fellow 126.5 Resident 37.2 Morning *

Fellow 126.5 Bedside Nurse 10.6 Morning *

Fellow 126.5 Other 7.0 Morning *

Resident 37.2 Bedside Nurse 10.6 Morning *

Resident 37.2 Other 7.0 Morning *

Bedside Nurse 10.6 Other 7.0 Morning

Staff 58.9 Fellow 102.1 Afternoon *

Staff 58.9 Resident 28.0 Afternoon *

Staff 58.9 Bedside Nurse 64.7 Afternoon

Staff 58.9 Other 15.9 Afternoon *

Fellow 102.1 Resident 28.0 Afternoon *

Fellow 102.1 Bedside Nurse 64.7 Afternoon *

42

Fellow 102.1 Other 15.9 Afternoon *

Resident 28.0 Bedside Nurse 64.7 Afternoon *

Resident 28.0 Other 15.9 Afternoon

Bedside Nurse 64.7 Other 15.9 Afternoon *

Table 11: Results of post-hoc tests on PICU average speaking duration, comparison of time of day

Clinician Type Comparison

Time of Day 1

Time of Day 1

Speaking

Duration (sec)

Comparison

Time of Day 2

Time of Day 2

Speaking

Duration (sec)

p < 0.05

Staff Physician Morning 66.9 Afternoon 58.9

Fellow Morning 126.5 Afternoon 102.1 *

Resident Morning 37.2 Afternoon 28.0

Bedside Nurse Morning 10.6 Afternoon 64.7 *

Other Morning 7.0 Afternoon 15.9

Similarly, a fellow spoke for the largest percentage of time during patient encounters during

CCCU morning and afternoon rounds, at 173 and 122 seconds, respectively. Speaking time

duration CCCU morning rounds was dominated by physicians (staff and fellows). A bedside

nurse spoke for an average of 4 seconds per encounter, and all other professions spoke for an

average of 6 seconds combined (see Table 14 for breakdown of other professions). CCCU

afternoon rounds were more multidisciplinary. A bedside nurse spoke for an average of 83, a

nurse practitioner for 42 seconds, and all other professions for 11 seconds.

43

Figure 26: Average speaking duration during CCCU patient encounter by clinician type

Table 12: Results of post-hoc tests on CCCU average speaking duration, comparison of clinician type

Comparison

Clinician Type

1

Clinician Type

1 Speaking

Duration (sec)

Comparison

Clinician Type

2

Clinician Type

2 Speaking

Duration (sec)

Time of Day p < 0.05

Staff 48.8 Fellow 173.4 Morning *

Staff 48.8 NP 0.9 Morning *

Staff 48.8 Bedside Nurse 3.9 Morning *

Staff 48.8 Other 5.7 Morning *

Fellow 173.4 NP 0.9 Morning *

Fellow 173.4 Bedside Nurse 3.9 Morning *

Fellow 173.4 Other 5.7 Morning *

NP 0.9 Bedside Nurse 3.9 Morning

NP 0.9 Other 5.7 Morning

Bedside Nurse 3.9 Other 5.7 Morning

Staff 60.6 Fellow 122.3 Afternoon *

Staff 60.6 NP 42.1 Afternoon *

Staff 60.6 Bedside Nurse 83.2 Afternoon *

Staff 60.6 Other 11.8 Afternoon *

Fellow 122.3 NP 42.1 Afternoon *

Fellow 122.3 Bedside Nurse 83.2 Afternoon *

Fellow 122.3 Other 11.8 Afternoon *

44

NP 42.1 Bedside Nurse 83.2 Afternoon *

NP 42.1 Other 11.8 Afternoon *

Bedside Nurse 83.2 Other 11.8 Afternoon *

Table 13: Results of post-hoc tests on CCCU average speaking duration, comparison of time of day

Clinician Type Comparison

Time of Day 1

Time of Day 1

Speaking

Duration (sec)

Comparison

Time of Day 2

Time of Day 2

Speaking

Duration (sec)

p < 0.05

Staff Physician Morning 48.8 Afternoon 60.6

Fellow Morning 173.4 Afternoon 122.3 *

NP Morning 0.9 Afternoon 42.1 *

Bedside Nurse Morning 3.9 Afternoon 83.2 *

Other Morning 5.7 Afternoon 11.8

Table 14: Average speaking duration in seconds by clinician type - breakdown of "Other" category

PICU Morning PICU Afternoon CCCU Morning CCCU Afternoon

Family 1.9 4.6 1.1 5.2

RT 1.3 5.2 0.1 3.0

Pharmacist 0.9 3.2 0.0 1.0

Dietitian 1.0 0.0 0.1 0.0

Charge Nurse/CSN 0.5 0.3 0.8 0.5

CNS 0.2 0.0 0.0 0.0

ECMO 0.4 2.3 0.9 2.2

Surgeon/Surgical Fellow 0.8 0.0 2.7 0.0

Other 0.2 0.3 0.0 0.0

Next, one-way between subject ANOVAs were used to determine whether the encounter

duration varied as a function of the level of multidisciplinary contribution. The level of

multidisciplinary contribution was divided into 3 categories: low (only physicians contributed to

the discussion), medium (physicians + one other role contributed to the discussion) and high

(physicians + 2 or more other roles contributed to the discussion). The results are presented by

unit and time of day.

45

PICU Morning

Figure 27: PICU Morning - Encounter duration as a function of multidisciplinary contribution level

As seen in Figure 27, encounter duration varied as a function of the level of multidisciplinary

contribution, F(2,205) = 14.27, p < 0.001. Post hoc tests revealed that encounter duration was

significantly longer when there was a high or medium level of multidisciplinary contribution

compared to a low level.

46

PICU Afternoon



significantly longer when there was a high level of multidisciplinary contribution compared to a

medium or low level.

Figure 28: PICU Afternoon - Encounter duration as a function of multidisciplinary contribution level

47

CCCU Morning



significantly longer when there was a high level of multidisciplinary contribution compared to a

medium or low level, as well as a medium level compared to low level.

Figure 29: CCCU Morning - Encounter duration as a function of multidisciplinary contribution level

48

CCCU Afternoon



significantly longer when there was a high or medium level of multidisciplinary contribution

compared to a low level.

Figure 30: CCCU Afternoon - Encounter duration as a function of multidisciplinary contribution level

49

Figure 31: Mean score by clinician type to the survey question "Are you satisfied with your level of involvement in rounds?"

For the survey question “Are you satisfied with you level of involvement in rounds”, a one-way

between subjects ANOVA determined that the mean score on a 5-point Likert scale differed

statistically significantly between clinician types, F(4,124) = 12.69, p < 0.001, as seen in Figure

31. Post hoc tests using the Bonferroni correction revealed the mean score reported by staff

physicians to be significantly higher than fellows/residents/NPs, RTs and other. The mean score

reported by fellows/residents/NPs was significantly higher than RTs. The mean score of RNs

was significantly higher than RTs and other.

50

Figure 32: Mean score by clinician type of the survey question "Do you feel free to share your opinion and/or ask questions

during rounds?"

For the survey question “Do you feel free to share your opinion and/or ask questions during

rounds”, a between subjects one-way ANOVA determined that the mean score on a 5-point

Likert scale differed statistically significantly between clinician types, F(4,124) = 8.57, p < 0.001

(as seen in Figure 32). Post hoc tests using the Bonferroni correction revealed the mean score

reported by staff physicians to be significantly higher than fellows/residents/NPs, RNs, RTs and

other. The mean score of RNs was significantly higher than RTs.

51

Figure 33: Mean score by clinician type of the survey question "Do you think that others feel free to share their opinion and/or

ask questions during rounds?"

For the survey question “Do you think that others feel free to share their opinion and/or ask

questions during rounds”, a between subjects one-way ANOVA determined that the mean score

on a 5-point Likert scale differed statistically significantly between clinician types, F(4,123) =

2.57, p < 0.05 (as seen in Figure 33) . Post hoc tests using the Bonferroni correction revealed the

mean score reported by staff physicians to be significantly higher than RTs.

52

Chapter 4 Discussion

The discussion is organized by Lane’s best practices. The adherence and applicability of each

best practice was evaluated in the context of the current rounding system of the SickKids CCU.

Adherence to Lane’s best practices was variable, and when appropriate, suggestions were made

for their improvement.

Best Practice: Implement multidisciplinary rounds (including at least a medical doctor, registered nurse, and pharmacist)

Rounds in the SickKids CCU adhered to Lane’s definition of being multidisciplinary (attended

by a doctor, nurse and pharmacist) about 50% of the time, except for CCCU morning rounds,

during which the three roles were only present for 14.4% of patient encounters. Although not

mentioned in Lane’s recommendation, RTs play an important role in the SickKids CCU. There

are 62 RTs on staff in the unit, and the majority of patients are on some form of ventilatory

support. There is evidence that RT participation in interdisciplinary rounds improves

communication and teamwork (41). As such, the percentage of patient encounters attended by a

doctor, nurse, pharmacist and RT was also calculated. The results were variable depending on

the type of rounds, ranging from 2.9% during CCCU morning rounds to 45.4% during PICU

morning rounds.

Although the interdisciplinary professions (e.g., pharmacists and RTs) are invited to morning and

afternoon rounds in both the PICU and CCCU, the unit is not set up to allow them to attend all

patient encounters. Pharmacists and RTs are assigned to patients from both units, and as rounds

in the two units take place at the same time, they have to decide which to attend.

The level of multidisciplinary attendance is likely so much lower during CCCU morning rounds

because twice a week the timing of these rounds changes; on Mondays and Fridays they take

place from 6:45am-7:30am, followed by an hour break as the team attends either surgical

conference or performance rounds, and then resume around 8:45am. The 6:45am start time is

before the pharmacist and RT day shift begins, making it impossible for them to attend all

53

encounters. Additionally, when rounds resume after the surgical conference/performance rounds

it is often unclear exactly where and when the interdisciplinary professionals should meet the rest

of the team, once again making it difficult for them to be present at all encounters.

Although multiple papers recommend implementing multidisciplinary rounds (34, 37, 59), none

describe the exact levels of attendance to expect by patient encounter. Our results show that

implementing multidisciplinary rounds (i.e., inviting the multidisciplinary care team to attend

rounds) does not necessarily mean that a multidisciplinary group of clinicians will be present for

all patient encounters. Based on our findings, we can say that even when multidisciplinary

rounds are in place in a unit, only around 50% of patient encounters are truly multidisciplinary

according to Lane’s definition, and the percentage is even lower when RTs are also taken into

account.

Knowing that pharmacists and RTs were unable to attend all patient encounters, we examined

whether their attendance varied as a function of patient acuity or patient LOS. Although LOS had

no impact, in the CCCU both RTs and pharmacists were more often present at the encounters of

higher acuity patients. This shows that the multidisciplinary clinicians adapt within their

constraints, prioritizing the more acute patients who likely require the most discussion and

interdisciplinary decision-making.

In sum, although multidisciplinary professionals such as RTs and pharmacists are invited to

rounds in the SickKids CCU, the current rounding process is not designed to allow them to

attend all encounters. However, it is possible that it is not necessary for them to attend all patient

encounters; Lane’s best practice does not specify the exact percentage of the time that

multidisciplinary professionals should be present. Further work should be done to evaluate

whether it is necessary for them to be present for all patient encounters, or if they should be

invited to all but have the flexibility to choose which encounters to attend (e.g., high acuity

patients). If it is shown to be necessary for a pharmacist and RT to be present for all patient

encounters, the structure of the unit and rounding system should be redesigned to allow this.

Otherwise, Lane’s best practice should be updated with a clearly defined expected level of

attendance.

54

Best Practice: Standardize location, time and team composition

As attendance and team composition was the focus of the previous best practice, this section

focuses on the standardization of rounding location and timing.

The starting location of rounds in both the PICU and CCCU was very standardized. The start

time of morning rounds in both units was also highly standardized, averaging only ~1 minute late

in both units. The start time of afternoon rounds was more variable, averaging 9.0 minutes late in

the PICU and 6.2 minutes late in the CCCU. Morning rounds take place at the start of the day

shift for doctors, nurses, and RTs, so it is easier for participants to arrive on time. Afternoon

rounds take place at the end of the day shift, when participants are immersed in patient care and

busy wrapping up any issues before they round and then go home for the day. There is some

room for improvement to the standardization of the start time of afternoon rounds, but for the

most part the SickKids CCU adheres to Lane’s recommendation.

From the perspective of timing, we also examined whether the total duration of rounds varied by

unit, time of day and census. CCCU morning rounds were found to be significantly shorter than

CCCU afternoon rounds and PICU morning rounds. As mentioned previously, on Mondays and

Fridays these rounds take place at a different time than usual to accommodate surgical

conference/performance rounds. They start at 6:45am, are paused at 7:30am, resume around

8:45am and must finish by 9:30am. The rounding team is aware of these time constraints and

likely speeds up the rounding process to ensure they finish on time. The results suggest that if

rounds has a clear end time, the clinicians will adhere to it.

Although unit census did not have an impact on the total duration, it did have an impact on the

average encounter duration. PICU morning rounds has a cut-off time of 9:00am or 9:30am

(depending on the day of week) regardless of how many patients are in the unit. When the unit

census is low, the rounding team is able to spend more time per patient. When the unit census is

high, the rounding team adapts to the constraints placed on them and spends more time on high

acuity patients, as these patients likely require the most discussion and decision-making. Similar

trends were found during CCCU morning and afternoon rounds; more time spent on patient

55

encounters when the unit census was low, and more time spent on high acuity than low acuity

patients.

The fact that the overall duration of rounds does not vary as a function of unit census, but the

individual patient encounters do, shows that there is a certain level of structure and

standardization in the rounding process, but that there is also flexibility within that structure.

Although it makes sense for some aspects of rounds to be standardized (i.e., start time, start

location, overall duration), not all patients necessarily require the same rounding time, and

flexibility during the rounding process with respect to individual encounter duration allows the

clinicians to adapt to the current constraints of the unit and needs of the patient. If this flexibility

is encouraged, units may be able to reduce the total time spent on rounds when appropriate to do

so. With this is mind, Lane’s best practice should be updated to provide more detail as to what

level of standardization to implement.

Best Practice: Reduce nonessential time wasting activities

It was difficult to evaluate adherence to this best practice as it does not specify what activities

should be considered nonessential. However, previous studies, including articles cited by Lane,

suggest retrieval of patient data (58), teaching (45) and transit time (26, 45) to be nonessential.

Tracking the retrieval of data was out of scope for this study, but transit time was tracked in the

time-motion data and satisfaction with the level of teaching was assessed through survey.

Although it is necessary to spend some time in transit during bedside rounds, it was determined

that it took one person only 5% of the average rounding duration to walk the typical rounding

path in both the PICU and CCCU, while the time-motion data showed that approximately 15% of

the total rounding duration was spent in transit. The remaining 10% of the total rounding

duration was likely wasted on the large number of rounding participants maneuvering around

each bedside, waiting for participants who stayed behind at the previous bedside, waiting for

participants pulling along the computer-on-wheels, or waiting for family members of other

patients to leave the room. Reducing the amount of time spent on these activities could increase

the amount of time spent on patient encounters and improve the overall efficiency of rounds.

56

The mean response to the survey question “Is the amount of teaching done during rounds

appropriate?” was 1.8, falling between the categories “Not Enough” (1) and “Appropriate

Amount” (2). Although Vats et al. classified teaching as a nonessential activity, HCPs in the

SickKids CCU appear to value the educational aspect of rounds, with responses even tending

towards a desire for more teaching to take place. However, it should be further evaluated

whether there is a need for more teaching specifically during rounds, or more teaching on the

unit in general.

Lane’s recommendation to reduce nonessential time wasting activities could be improved by

providing specific examples of activities that may be nonessential. The SickKids CCU could

reduce time wasted in transit by adapting the rounding location to the number of participants on

rounds (i.e., when too many people are present to fit around a cramped bedside the discussion

could take place in the hallway or the centre of the room), using a smaller and more portable

computer for order entry, or ensuring that family members are prepared ahead of time to either

leave the room or put on headphones when their patient is not being discussed.

Best Practice: Focus discussions on development of daily goals and document all discussed goals in health record

The collected time-motion data for each patient encounter was divided into three main

categories: patient introduction/history, acute status update and care plan. We examined the

duration and variability of time spent on these three discussion topics as they represent the

elements of discussion where the development and documentation of daily goals occurs. To

evaluate the level of focus on daily goals, we analyzed results from the survey question “Are you

confident in your understanding of the patients’ care plan after rounds are finished?” Tracking

documentation of goals was beyond the scope of the study.

Staff physicians reported feeling significantly more confident of their understanding of the

patient’s care plan after rounds were finished than all other clinician types. On a 5-point Likert

scale the mean for staff physicians was 3.7, landing between the categories “sometimes” and

“usually”. The mean score for the other clinician types ranged from 2.3-2.8, falling between the

categories “rarely” and “sometimes”. As rounds is meant to be a time for effective

57

multidisciplinary communication regarding patient issues, the fact that most HCP’s report

“rarely” to “sometimes” feeling confident in their understanding of the care plan is clearly an

issue with the current rounding system and an area for improvement.

It makes sense that staff physicians have the highest confidence in their understanding on the

care plan as they are the ones who have the final say in the plan. The current structure of the

presentation of the care plan is that the fellow/resident/NP assigned to the patient presents their

suggested plan to the rounding team, and when necessary the staff physician corrects it or

suggests changes. Although this is an effective mechanism for teaching, having multiple versions

of the plan presented, coupled with the fact that being able to hear what is being said during

rounds is an issue reported by all participants, the current structure of the presentation of the care

plan may not be the most effective way to transfer information. Although the mean is quite low,

it is comparable to results from other studies (some of which were cited by Lane) prior to the

implementation of an intervention (e.g., a checklist) that forced the team to focus on the

development of daily goals (29, 47, 60).

Although a longer duration is spent discussing the care plan than other aspects of the discussion,

the rounding team reports a low confidence in their understanding of the patients’ care plan after

rounds are finished. This suggests that the current process of presenting the care plan is

ineffective. It has been shown in the literature that using a daily goals checklist while rounding

can improve HCPs understanding and agreement of patient care goals as it forces the team to

decide on and explicitly document the goals; this could be something to consider for the

SickKids CCU (29, 46, 47, 60).

Next, the duration of each discussion topic (i.e., introduction/history, acute status update, care

plan) and if it varied as a function of time of day, unit census, patient LOS and patient acuity was

evaluated. It was found that more time was spent on the acute status update during afternoon

rounds than morning rounds in both the PICU and CCCU. Morning rounds has stricter time

constraints than afternoon rounds. In addition, in the morning the fellow or resident who was on

shift all night does the presentation for all patients; since they are thinking about the perspective

of the entire unit they likely focus only on necessary information. In the afternoon each patient’s

58

bedside nurse does the acute status update for their patient; conversely, as they are only assigned

to one patient that they have spent all day with, more information may feel necessary to pass on.

More time was spent on the acute status update (PICU) and care plan (PICU and CCCU) when

the unit census was low compared to high. When there is a high census the team has less time to

spend per patient. As the patient introduction/history is the shortest part of the rounding

discussion, there is little room to cut anything. The acute status update and care plan can be

shortened to adapt to time constraints. More time is spent on the patient introduction/history

when patient has a low LOS likely because the team is less familiar with the patient. More time

is spent on the acute status update (PICU) and care plan (PICU and CCCU) when the patient has

a high LOS, likely because the patient has been in the unit longer so there is more to update on

and possibly a more developed or complicated care plan.

Although each patient presentation can consistently be broken into three main discussion topics,

the length of time spent on the topics vary as a function of the time of day, unit census and

patient LOS. The rounding team adapts to the patient and the constraints of the unit; there is an

overarching structure in place, but there is flexibility within that structure. This suggests that it

may be too rigid to recommend that the discussion should focus primarily on daily goals;

depending on the patient and the environment it could be beneficial to focus on other elements

(e.g., the introduction/history when the patient is first admitted). Lane’s Best Practice should be

expanded to account for contextual factors and allow for flexibility within the structure of the

patient discussion.

Best Practice: Conduct discussions at bedside to promote patient-centeredness

While Lane’s systematic review focused on rounds in the ICU, our study focused specifically on

rounds in a pediatric ICU. In this environment the focus was on family-centredness rather than

patient-centredness; the age and condition of the patients rendered most incapable of

participating in discussion and decision-making.

59

The SickKids CCU conducts bedside rounds each morning and afternoon, and the family is

invited to attend both sets of rounds. In this sense, the unit has met Lane’s recommendation,

however, we were interested in looking further at the family’s presence and participation, and

how it affects the duration of patient encounters.

Although the family is invited to attend both morning and afternoon rounds, they are more often

present during afternoon rounds in both units, likely because of time they take place (i.e., 4:00pm

vs 7:30am). A family member was most often present during CCCU afternoon rounds, attending

52.4% of encounters, and least often present at CCCU morning rounds, attending 21.3% of

encounters. When present, a family member actively participated in the discussion (e.g., asked a

question or added information) around 50% of the time.

Family attendance in the SickKids CCU is slightly higher than the 23% average reported by

Selena et al, who studied family participation in ICU rounds across 7 hospitals in 3 Canadian

cities (61). Family participation when present was similar to results from other studies (62, 63).

As the level of family attendance and participation matches or exceeds that of family-centred

rounds in other institutions, we can say that the SickKids CCU has successfully implemented

family-centred rounds as defined by Lane’s best practice. However, Lane’s recommendation

could be improved by expanding on ways to promote patient centredness other than conducting

rounds at the bedside.

Previous studies have conflicting results as to whether family participation in rounds is related to

longer rounding times (26, 61). We found that family participation is related to longer average

encounter durations, and that this also varies by unit census, patient LOS and patient acuity.

During PICU afternoon rounds when the unit census was high the average encounter duration

was the same whether the team interacted with the family or not. When the unit census was low,

the average encounter duration became significantly longer when the team interacted with the

patient’s family. This shows how the HCPs adapt their rounding practices to the time available to

them. The general cut-off time for afternoon rounds is 6:00pm, meaning that the team has 2

hours to round regardless of how many patients are in the unit. When the unit census is low there

is more potential time per patient, and so more time can be spent in discussion with the family

60

members. When the unit census is high, the team knows there is less time available per patient,

and so they do not allow interaction with the family to increase the encounter duration.

The average encounter duration was significantly longer when the team interacted with the

family of a patient who had a high LOS compared to a low LOS. The families of patients who

have been in the unit longer are likely more familiar with the environment and the HCPs, and

may feel more comfortable asking questions during rounds. Additionally, as the patient has been

in the unit longer, there may be more to discuss with the family regarding the care plan from the

perspective of the HCPs.

When the team does not interact with the patient’s family, significantly more time is spent on

high acuity patients than low acuity patients. For low acuity patients, significantly more time is

spent on the encounter duration when the team interacts with the family compared to when they

do not. The HCPs generally spend more time on high acuity patients than low acuity patients, but

interacting with the family increases the average duration of a low acuity patient encounter to

that of a high acuity patient encounter. During CCCU afternoon rounds the average duration of a

patient encounter was significantly higher when the team interacted with the patient’s family

compared to when they did not.

Family interaction had no effect on the duration of patient encounters during morning rounds.

Morning rounds has tighter time constraints as the team has to finish before 9:00am or 9:30am.

Due to this, if the family asks a question during rounds it is more likely it will be suggested that

someone comes back to talk to them after rounds, instead of including the discussion in the

patient encounter.

In summary, family-centred rounds (as defined by Lane’s best practice) have been implemented

in the SickKids CCU and family members attend and participate at a level similar to other

institutions. However, family participation in rounds is related to longer encounter durations; as

reported by Lane, there is a trade-off between family-centredness and efficiency. This suggests a

need for the unit to decide which is most valuable to the rounding process; if efficiency is a

requirement then it could be looked into whether a different time outside of rounds could be

61

allocated to updating the family. This is also further evidence of the emerging theme of

flexibility within the rounding structure; the rounding team adapts the level of family-

centredness to unit census and patient requirements.

Best Practice: Conduct discussions in conference room to promote efficiency and communication

Lane’s best practices present the option of either bedside rounds or rounds held in a conference

room, depending whether the unit chooses to promote patient-centredness or efficiency and

communication. As discussed above, the SickKids CCU holds daily bedside rounds that promote

family-centredness, and as such cannot also meet the best practice of conducting rounds in a

conference room to promote efficiency and communication. However, we can still evaluate

whether efficiency and communication are issues with the current rounding process and if this

could be improved by conducting rounds away from the bedside.

While most rounds in the unit take place at the bedside, Tuesday afternoon rounds are held in a

seated office area comparable to a conference room. It was found that the duration of encounters

that took place in this environment were significantly shorter than those that took place at the

bedside, validating Lane’s suggestion of conducting rounds in a conference room to promote

efficiency. However, Tuesday afternoon rounds also take place ~3.5 hours earlier in the day than

usual afternoon rounds, and attendance (both number of people and number of professions) is

lower, which likely also have an effect on encounter duration.

When asked to rank “Is the current rounding system efficient” on a 5-point Likert scale, the

mean score for all clinician types was below 3 (i.e., “sometimes”). The mean score for staff

physicians, fellow/residents/NPs, RNs and RTs fell between the categories “rarely” and

“sometimes”, while the mean score for “Other” (including interdisciplinary clinicians such as

pharmacists and dietitians) fell between “never” and “rarely”. There was a significant difference

between Other and all other clinician types. There is clearly room for improvement in the domain

of efficiency as all clinician types gave a mean ranking on the low end of the scale. The Other

category reported the lowest mean scores, which is understandable as rounds is not optimized for

their participation or attendance, as discussed earlier.

62

When asked to rank “Can you clearly hear what is being said during rounds” on a 5-point Likert

scale, the mean score for all clinician types was below 3 (i.e., “sometimes”). The mean score for

staff physicians, fellows/residents/NPs and RNs fell between “rarely” and “sometimes”, while

the mean score for RTs and Other fell between “never” and “rarely”. The means were

significantly different between staff physicians and RTs and Other, fellows/residents/NPs and

Other, and RNs and Other. As staff physicians are generally the main participants being spoken

to it makes sense that they report the highest score of being able to hear. RTs and other

interdisciplinary professionals are not the main contributors and often stand at the back of the

group where it is harder to hear.

It is clear that communication and efficiency are issues with the current rounding process, and

the fact that patient encounters are significantly shorter at the one time when rounds do not take

place at the bedside suggests that Lane’s best practice is valid and applicable to the SickKids

CCU. However, as mentioned by Lane, there is a trade-off between family-centredness and

efficiency. In addition, there are positive aspects of bedside rounds not mentioned by Lane, such

as increased multidisciplinary participation (42, 64), increased educational value (65, 66),

improved relationship building (both within HCP team, and between HCP team and

patient/family (67), and perceived improved patient care delivery (65, 67).

Although moving rounds away from the bedside would likely improve efficiency and ease of

communication, other valuable aspects of rounds would be lost in this environment. In addition

to patient- and family-centredness, Lane’s first best practice is to implement multidisciplinary

rounds; many professions (e.g., RNs, RTs) would be unable to attend rounds away from the

bedside. As Lane reports the strength of the recommendation to be “strong” for implementing

multidisciplinary rounds, and “weak” for conducting rounds in a conference room, it seems more

valuable to keep rounds at the bedside. However, multidisciplinary bedside rounds currently take

place twice a day, and something that could be considered is whether one could take place at the

bedside and one in a conference room.

63

Best Practice: Establish open collaborative discussion environment/Empower HCP to promote team-based approach to discussions

The openness of the discussion environment in the SickKids CCU was evaluated based on the

duration of time that each profession spoke during patient encounters, and responses to surveys

questions “Are you satisfied with your level of involvement in rounds?”, “Do you feel free to

share your opinion/ask questions during rounds?” and “Do you think others feel free to share

their opinion/ask questions during rounds?”. In addition, the effect of multidisciplinary

contribution on the duration of patient encounters was examined.

Speaking time during patient encounters was dominated by physicians (e.g., staff, fellows,

residents) during morning rounds in the both units, while afternoon rounds becomes more

multidisciplinary. This is how the current rounding system has been designed; in the afternoon

the bedside nurses provide the acute status update as they have been with the patient all day,

while in the morning the overnight fellow or resident provides a quick update of the patient.

Additionally, morning rounds has a clear cut-off time of 9:00am or 9:30am, while the ending

time for afternoon rounds is less strict. When there is less time pressure on the rounding team

they likely allow more time for multidisciplinary contribution.

The multidisciplinary contribution that does occur is mostly from RNs. Bedside nurses speak for

just over a minute per encounter on average during afternoon rounds in both units, and nurse

practitioners contribute during CCCU afternoon rounds (there are no NPs on staff in the PICU).

All other HCPs (including RTs and pharmacists) speak for a range of 5.7 to 15.9 seconds

depending on the time of day and unit. The exact duration of input from the members of the

multidisciplinary rounding team has not been described in previous literature, so it is difficult to

evaluate whether these durations represent an open collaborative discussion environment or not.

To assess this further we analyzed HCP perceptions of the discussion environment collected by

survey.

Staff physicians were most satisfied with their level of involvement in rounds, and feel most free

to share their opinion and ask questions. This is unsurprising as the staff lead rounds; they are in

64

control and can contribute without hesitation. RTs and other interdisciplinary professionals were

the least satisfied with their involvement (mean score between categories “never” and “rarely”),

and feel the least free to share opinions and ask questions (mean score between “rarely” and

“sometimes”). This is likely due to the fact that in addition to not being able to attend all

encounters, there is no designated time for them to contribute to the discussion during rounds, so

if they want to speak they often have to interrupt. The scores reported by fellows/residents/NPs

and nurses for both questions fell between that of staff physicians and RTs/other (mean score

between categories “rarely” and “sometimes”). Although these roles speak for a high duration of

time during patient encounters, on the individual level there is only a designated time to

contribute when rounding on patients that they are assigned to. The mean for all clinician types

fell between “rarely” and “sometimes” for the question “Do you think that others feel free to

share their opinion and/or ask questions during rounds?”.

Clearly work could be done to help participants feel more comfortable contributing to the

discussion during rounds, especially interdisciplinary clinicians such as RTs and pharmacists.

Even fellows and residents, who speak for the longest durations during rounds, reported a low

level of satisfaction with their involvement in rounds and a low level of feeling free to share

opinions and ask questions. Given that rounds has a standardized total duration, allocating more

time for multidisciplinary clinicians to speak would cut into the time the fellows have to speak,

who are already dissatisfied with their level of input. There is a trade-off between rounding

efficiency and HCP satisfaction with levels of involvement.

This could also be seen through our analysis of whether the level of multidisciplinary

contribution (i.e., number of roles that contributed to the discussion) had an impact on encounter

duration. It was found that for all rounds in the unit, as the level of multidisciplinary contribution

increased, the encounter duration also increased. As it does not seem possible to have both

efficient and highly multidisciplinary rounds, it needs to be decided if/when the unit requires

efficient rounds and if/when the unit most requires multidisciplinary rounds, and a balance

between the two could be reached. Lane’s Best Practice should be updated to reflect this.

65

Summary

The SickKids CCU has implemented multidisciplinary rounds, although a doctor, nurse and

pharmacist are only present for around 50% of patient encounters. The location and timing of

certain aspects of rounds were standardized (i.e., starting location, start time), while other aspects

showed variability; encounter durations were longer for high acuity patients and shorter when the

unit census was high. The unit could work to reduce time spent on nonessential activities, such as

in transit time. Although the longest duration of time during patient encounters is spent

discussing the care plan, HCPs have a low confidence in their understanding of the care plan

when rounds are done; implementing a tool to focus the discussion on daily goals could improve

this. Rounds in the unit take place at the bedside and promote family-centredness, although

interaction with the family was found to increase encounter durations. Efficiency and ease of

communication were confirmed to be issues with the rounding process taking place at the

bedside. Most HCPs reported low satisfaction with their level of involvement in the rounding

process, and do not feel comfortable sharing their opinion or asking questions. High levels of

multidisciplinary input was found to be associated with longer encounter durations.

Lane’s best practices should be modified to specify the expected level of multidisciplinary

attendance by patient encounter, as well as which rounding activities could be considered

nonessential. The recommended level of standardization in timing and discussion focus should

be studied further; we found evidence to suggest that flexibility allows the HCPs to adapt to the

needs of the patients. Lane’s recommendation of rounding location should include evidence from

the literature for bedside rounds other than to promote patient-centredness, and the expected

level of patient-centredness and multidisciplinary input should be more clearly defined.

When the consequences of each of the best practices were examined further, many ended up

conflicting with each other: promoting family-centredness increased the duration of encounters,

conducting rounds away from the bedside prevented collaboration and multidisciplinary

attendance, promoting a team-based approach to discussions decreased the efficiency of the

rounding process. It appears impossible to have efficient, multidisciplinary, patient-centred

rounds, and as such it is not feasible to implement all of Lane’s best practices. As opposed to

66

trying to follow the list of recommendations, the focus should be on evaluating which of the

recommendations are most important to the unit at what time. Two sets of multidisciplinary

bedside rounds currently take place on the unit per day; perhaps one could be optimized for

efficiency and the other for multidisciplinary collaboration and family-centredness.

Another theme that emerged was structure versus flexibility; we found that rounds was

standardized at a high level, but at a lower level there was room to adapt to contextual factors

such as unit census, patient LOS and patient acuity. This flexibility often tended towards

prioritizing more acute patients, suggesting a benefit to allowing the HCPs to tailor the rounding

process to the needs of the patients. Although Lane recommends structure and standardization,

our results show that this should be specified to standardization of the overarching structure of

rounds (e.g., topics discussed), but flexibility with the duration of patient encounters and

duration of each topic discussed.

Contributions Made

The following contributions are made to the study of rounds in the ICU in this research:

1. First study to report time-motion data from an ICU environment at the level of detail of

rounding discussion topic and specific HCP speaking duration

2. Evaluated Lane’s Best Practices through observation, expanding on their

recommendations and informing when contextual factors should be considered

3. Related time-motion data to patient characteristics such as acuity and LOS, showing that

these variables should be incorporated into future studies as they were highly influential

4. Provided specific attendance rate and speaking duration of HCPs during multidisciplinary

rounds which can be benchmarked against in future studies

5. Updated review of literature as it supports or refutes Lane’s Best Practices

The following are our contributions made to understanding rounds in the SickKids CCU:

1. Characterized workflow during multidisciplinary rounds that can be used to inform

interventions to improve the rounding process

67

2. Elucidated perceptions from the multidisciplinary care team about the current rounding

process that can be used to inform interventions to improve the rounding process

Limitations

A potential limitation of the observation method is that participants may have altered their

behavior due to the presence of observers, or due to advance notice of the study taking place.

However, rounds was conducted in a large group and having observers present during rounds is

not uncommon in the unit, so the presence of two additional members did not stand out. The

researchers did not interact with participants during observations. Due to the methodology and

the number of observers it was not feasible for some aspects of round to be captured, such as

documentation, order entry, and conversations outside of the main rounding discussion. Other

limitations lie with the ability of the observers. It is possible that some communication events

were not captured, due to the fast-paced ICU environment, and/or a lack of medical knowledge

of the observers. To reduce the likelihood of these occurrences, observers went through a

training period to become familiar with the ICU environment and data collection tools, and did

not begin observation until an interrater reliability was achieved between two observers.

Generalizability of Results

While this study was based specifically on the information exchange processes at SickKids,

findings from this study may be generalizable to other units and institutions given that the

effective exchange of clinical information, through structured daily rounds and handover, is

essential to providing safe and effective care in all hospital settings. The general principles

behind the findings can be applied to any setting. Furthermore, the developed data collection

tools and analytical framework may be adapted for use by other sites to embrace and understand

the complexity of their own systems. Other hospital units can use a similar time-motion method

to evaluate different components of their existing information exchange processes, to inform

necessary areas of improvement.

68

Future Research

Further research should be completed to evaluate the remaining best practices summarized by

Lane, including assessing the adherence and value of defining explicit roles for each HCP,

implementing a structured tool such as a best practices checklist, ensuring clear visibility and

producing a visual presentation of patient information. Interviews or focus groups should be

completed with all stakeholders of rounds in the SickKids CCU to determine which

characteristics of rounds the unit values most (e.g., efficiency versus the level of

multidisciplinary attendance or contribution). Based on this feedback, a user-centred design

methodology should be followed to develop an intervention to improve the rounding process in

the unit.

Conclusions

This study provides a comprehensive understanding of the current work system state surrounding

information exchange practices in the SickKids critical care unit, and expands on

recommendations compiled by a systematic review of evidence informed practices to improve

rounds. While this study was based specifically on the information exchange processes at

SickKids, findings from this study may be generalizable to other units and institutions given that

the effective exchange of clinical information, through structured daily rounds and handover, is

essential to providing safe and effective care in all hospital settings. Finally, findings from this

study can be used to generate evidence to support process improvements tailored to the unique

and dynamic challenges present in a particular setting.

69

References

1. Centofanti JE, Duan EH, Hoad NC, Swinton ME, Perri D, Waugh L, et al. Use of a daily

goals checklist for morning ICU rounds: A mixed-methods study. Critical Care Medicine. 2014;42(8):1797-803.

2. Alameddine M, Dainty KN, Deber R, Sibbald WJ. The intensive care unit work environment:

Current challenges and recommendations for the future. Journal of Critical Care. 2009;24(2):243-8.

3. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky MRNB, Sprung CL, et al. A look into the

nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995;23(2):294-

300.

4. Holodinsky JK, Hebert M, A., Zygun D, A., Rigal R, Berthelot S, J. Cook D, et al. A Survey

of Rounding Practices in Canadian Adult Intensive Care Units: e0145408. PLoS One. 2015;10(12).

5. Lane D, Ferri M, Lemaire J, McLaughlin K, Stelfox HT. A Systematic Review of Evidence-

Informed Practices for Patient Care Rounds in the ICU. Critical Care Medicine. 2013;41(8):2015-29. 6. Mosby's Medical Dictionary. 8th edition ed2009. Rounds.

7. Paradis E, Leslie M, Gropper MA. Interprofessional rhetoric and operational realities: an

ethnographic study of rounds in four intensive care units. Advances in Health Sciences Education.

2016;21(4):735-48.

8. Sandal S, Iannuzzi MC, Knohl SJ. Can we make grand rounds "grand" again? Journal of

graduate medical education. 2013;5(4):560.

9. O'Leary KJ, Buck R, Fligiel HM, Haviley C, Slade ME, Landler MP, et al. Structured

Interdisciplinary Rounds in a Medical Teaching Unit Improving Patient Safety. Archives of Internal

Medicine. 2011;171(7):678-84. 10. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality

in Australian Health Care Study. The Medical journal of Australia. 1995;163(9):458.

11. Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Risk reduction for

adverse drug events through sequential implementation of patient safety initiatives in a children's

hospital. Pediatrics. 2006;118(4):e1124-9.

12. Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study.

BMJ. 1998;316(7132):673-6.

13. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to

medical mishaps. Academic medicine : journal of the Association of American Medical Colleges.

2004;79(2):186-94. 14. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in

patient sign-out and suggestions for improvement: a critical incident analysis. Quality & safety in

health care. 2005;14(6):401-7.

15. Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information

transferred at resident sign-out (in-hospital handover of care): a prospective survey. Quality & safety

in health care. 2008;17(1):6-10.

16. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving

communication in the ICU using daily goals. Journal of critical care. 2003;18(2):71-5.

17. Afessa B. Association between ICU admission during morning rounds and mortality. Chest.

2009;136(6):1489-95. 18. de Souza IAO, Karvellas CJ, Gibney RTN, Bagshaw SM. Impact of intensive care unit

admission during morning bedside rounds and mortality: a multi-center retrospective cohort study.

Critical care (London, England). 2012;16(3):R72-R.

70

19. Rathert C, May DR. Health care work environments, employee satisfaction, and patient

safety: Care provider perspectives. Health care management review. 2007;32(1):2.

20. Mosadeghrad AM. Factors influencing healthcare service quality. International journal of

health policy and management. 2014;3(2):77-89. 21. Vats A, Goin KH, Villarreal MC, Yilmaz T, Fortenberry JD, Keskinocak P. The impact of a

lean rounding process in a pediatric intensive care unit. Critical Care Medicine. 2012;40(2):608-17.

22. Ham PB, Anderton T, Gallaher R, Hyrman M, Simmerman E, Ramanathan A, et al.

Development of Electronic Medical Record-Based "Rounds Report" Results in Improved Resident

Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour

Violations. The American surgeon. 2016;82(9):853.

23. Tripathi S, Arteaga G, Rohlik G, Boynton B, Graner K, Ouellette Y. Implementation of

Patient-Centered Bedside Rounds in the Pediatric Intensive Care Unit. Journal of Nursing Care

Quality. 2015;30(2):160-6.

24. Abbas PI, Zamora IJ, Elder SC, Lee TC, Nuchtern JG. Impact of the surgeon of the week system in an academic pediatric surgery practice. Journal of Pediatric Surgery. 2016;51(4):634-8.

25. Baysari MT, Adams K, Lehnbom EC, Westbrook JI, Day RO. iPad use at the bedside: a tool

for engaging patients in care processes during ward rounds? Internal Medicine Journal.

2014;44(10):986-90.

26. Bhansali P, Birch S, Campbell JK, Agrawal D, Hoffner W, Manicone P, et al. A time-motion

study of inpatient rounds using a family-centered rounds model. Hospital pediatrics. 2013;3(1):31.

27. Butcher BW, Vittinghoff E, Maselli J, Auerbach AD. Impact of proactive rounding by a rapid

response team on patient outcomes at an academic medical center. Journal of Hospital Medicine.

2013;8(1):7-12. 28. Levin AB, Fisher KR, Cato KD, Zurca AD, October TW. An Evaluation of Family-Centered

Rounds in the PICU: Room for Improvement Suggested by Families and Providers. Pediatric critical

care medicine : a journal of the Society of Critical Care Medicine and the World Federation of

Pediatric Intensive and Critical Care Societies. 2015;16(9):801.

29. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving

communication in the ICU using daily goals. Journal of Critical Care. 2003;18(2):71-5.

30. Deitrick LM, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with

implementation of an evidence-based process. Journal of nursing care quality. 2012;27(1):13-9.

31. Lopetegui M, Yen P-Y, Lai A, Jeffries J, Embi P, Payne P. Time motion studies in

healthcare: what are we talking about? Journal of biomedical informatics. 2014;49:292-9. 32. Hefter Y, Madahar P, Eisen LA, Gong MN. A Time-Motion Study of ICU Workflow and the

Impact of Strain. Critical Care Medicine. 2016;44(8):1482-9.

33. Ballermann MA, Shaw NT, Mayes DC, Gibney RTN, Westbrook JI. Validation of the Work

Observation Method By Activity Timing (WOMBAT) method of conducting time-motion

observations in critical care settings: an observational study. BMC medical informatics and decision

making. 2011;11(1):32-.

34. Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. The Effect of Multidisciplinary

Care Teams on Intensive Care Unit Mortality. Archives of Internal Medicine. 2010;170(4):369-76.

35. Young MP, Gooder VJ, Oltermann MH, Bohman CB, French TK, James BC. The impact of

a multidisciplinary approach on caring for ventilator- dependent patients. International Journal for Quality in Health Care. 1998;10(1):15-26.

71

36. Ventura Ribal MR, Portillo Jáurena E, Verdaguer Cot M, Carrasco Gómez G, Cabré Pericas

L, Balaguer Blasco R, et al. Joint clinical rounds in the ICU and satisfaction of the professionals.

Enfermeria intensiva. 2002;13(2):68.

37. Miller A, Scheinkestel C, Limpus A, Joseph M, Karnik A, Venkatesh B. Uni- and Interdisciplinary Effects on Round and Handover Content in Intensive Care Units. Human Factors:

The Journal of the Human Factors and Ergonomics Society. 2009;51(3):339-53.

38. Weant KA, Armitstead JA, Ladha AM, Sasaki-Adams D, Hadar EJ, Ewend MG. Cost

effectiveness of a clinical pharmacist on a neurosurgical team. Neurosurgery. 2009;65(5):946-50.

39. Patel NP, Brandt CP, Yowler CJ. A prospective study of the impact of a critical care

pharmacist assigned as a member of the multidisciplinary burn care team. Journal of Burn Care and

Research. 2006;27(3):310-3.

40. Al-Jazairi AS, Al-Agil AA, Asiri YA, Al-Kholi TA, Akhras NS, Horanieh BK. The impact of

clinical pharmacist in a cardiac-surgery intensive care unit. Saudi Medical Journal. 2008;29(2):277-

81. 41. Genet IC, Firestone KS, Volsko TA. Neonatal respiratory therapist-led rounds can improve

staff satisfaction and timeliness of respiratory interventions. Respiratory Care. 2015;60(3):321-7.

42. Walden M, Elliott EC, Gregurich MA. Delphi Survey of Barriers and Organizational Factors

Influencing Nurses' Participation in Patient Care Rounds. Newborn and Infant Nursing Reviews.

2009;9(3):169-74.

43. Hagg D, Adrienne M, Kelsey P, McCully N, Willis M. Patient rounding audits: Volunteers as

members of the MICU quality improvement team. Critical Care Medicine. 2014;42(12 SUPPL.

1):A1563.

44. Seigel J, Whalen L, Burgess E, Joyner BL, Purdy A, Saunders R, et al. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric

ICU. Joint Commission Journal on Quality and Patient Safety. 2014;40(2):83-90.

45. Vats A, Goin KH, Fortenberry JD. Lean analysis of a pediatric intensive care unit physician

group rounding process to identify inefficiencies and opportunities for improvement. Pediatric

Critical Care Medicine. 2011;12(4):415-21.

46. Weiss CH, Moazed F, McEvoy CA, Singer BD, Szleifer I, Amaral LAN, et al. Prompting

physicians to address a daily checklist and process of care and clinical outcomes: A single-site study.

American Journal of Respiratory and Critical Care Medicine. 2011;184(6):680-6.

47. Rehder KJ, Uhl TL, Meliones JN, Turner DA, Smith PB, Mistry KP. Targeted interventions

improve shared agreement of daily goals in the pediatric intensive care unit. Pediatric Critical Care Medicine. 2012;13(1):6-10.

48. Landry M-A, Lafrenaye S, Roy M-C, Cyr C. A Randomized, Controlled Trial of Bedside

Versus Conference-Room Case Presentation in a Pediatric Intensive Care Unit. Pediatrics.

2007;120(2):275-80.

49. Manias E, Street A. Nurse–doctor interactions during critical care ward rounds. Journal of

Clinical Nursing. 2001;10(4):442-50.

50. Lyons MN, Standley TDA, Gupta AK. Quality improvement of doctors' shift-change

handover in neuro-critical care. Quality and Safety in Health Care. 2010;19(6):e62-7.

51. Knoll M, Lendner I. Nurses' perspective on interprofessional communication on an intensive

care unit. PFLEGE. 2008;21(5):339-51. 52. Coombs M. Power and conflict in intensive care clinical decision making. Intensive &

Critical Care Nursing. 2003;19(3):125-35.

72

53. Hill K. The sound of silence – nurses’ non‐verbal interaction within the ward round. Nursing

in Critical Care. 2003;8(6):231-9.

54. Laussen PC, Hubbert J. Critical Care Medicine [Available from:

http://www.sickkids.ca/Critical-Care/index.html.]

55. Sasangohar F. DELTA-ACELAB. 2018. Mobile application software. Available from:

https://itunes.apple.com/CA/app/id1375847192?mt=8]

56. Sasangohar F, Donmez B, Easty AC, Trbovich PL. Mitigating nonurgent interruptions during high-severity intensive care unit tasks using a task-severity awareness tool: A quasi-controlled

observational study. Journal of critical care. 2015;30(5):1150.e1-.e6.

57. Field A, Miles J, Field Z. Discovering Statistics Using R: SAGE Publications; 2012.

58. Cummings A, Parker CD, Kwapniowski LA, Reynolds G. Using mobility technology to

improve pharmacist workflow in the PICU rounding process. Journal of healthcare information

management : JHIM. 2008;22(4):39-43.

59. Wright S, Bowkett J, Bray K. The communication gap in the ICU--a possible solution.

Nursing in critical care. 1996;1(5):241-4.

60. Narasimhan M, Eisen LA, Mahoney CD, Acerra FL, Rosen MJ. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. American

journal of critical care : an official publication, American Association of Critical-Care Nurses.

2006;15(2):217-22.

61. Au SS, des Ordons ALR, Leigh JP, Soo A, Guienguere S, Bagshaw SM, et al. A Multicenter

Observational Study of Family Participation in ICU Rounds. CRITICAL CARE MEDICINE.

2018;46(8):1255-62.

62. Henneman B, Bellamy P. AN EVALUATION OF FAMILY MEMBER PARTICIPATION

IN MULTI-DISCIPLINARY BEDSIDE ROUNDS. Critical Care Medicine.

1995;23(Supplement):A40.

63. Kelly ER, Priyanka R, Elizabeth H, Kate MS, Melissa KC. Families’ Experiences With Pediatric Family-Centered Rounds: A Systematic Review. Pediatrics. 2018;141:1.

64. Watson N, Gibson C, Nowatzke R, Monsma N. 1175: BEDSIDE ROUNDS OR TABLE

ROUNDS IN THE ICU? Critical Care Medicine. 2018;46(1 Suppl 1):571-.

65. Gonzalo JD, Chuang CH, Huang G, Smith C. The Return of Bedside Rounds: An

Educational Intervention. Journal of General Internal Medicine. 2010;25(8):792-8.

66. Mookherjee S, Cabrera D, McKinney CM, Kaplan E, Robins L. Observing bedside rounds

for faculty development. The Clinical Teacher. 2017;14(6):446-50.

67. Gonzalo JD, Heist BS, Duffy BL, Dyrbye L, Fagan MJ, Ferenchick GS, et al. The value of

bedside rounds: a multicenter qualitative study. Teaching and learning in medicine. 2013;25(4):326-33.

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Appendix A - Survey Your profession:

Bedside nurse Charge nurse CSN CNS NP Dietician

Attending Fellow Resident RT Pharmacist Other: ______

Current unit:

CCCU PICU

Years of experience in current role: Years of experience in SickKids CCU:

< 1 1-3 4-10 > 10 < 1 1-3 4-10 > 10

Have you ever received training on how to perform rounds?

Formal training Informal training (e.g., mentorship) No training

Rate the overall quality of the current rounding system in the SickKids CCU:

Very poor Poor Acceptable Good Very good

Approximately how many times are you paged during rounds?

<3 3-5 >5 N/A

How much does it add to your workload to prepare for and participate in rounds?

None/very little Appropriate amount Too much

How much cognitive effort does it take for you to prepare for and participate in rounds?

None/very little Appropriate amount Too much

Is the amount of teaching done on rounds appropriate?

Not enough Appropriate amount Too much

Do you use a structured tool/worksheet to prepare for or take notes during/after rounds?

Yes No

If yes, please describe. If no, would you like one?

☐ Census

☐ i-PASS

☐ Other ________________

https://www.emojibase.com/emoji/2610/ballotbox



74

Nev

er

Rar

ely

Som

etim

es

Usu

ally

Alw

ays

Is the current rounding system efficient?

Is technology used effectively during rounds?

Do you find each patient summary useful?

Are you confident in your understanding of the patient’s care plan after rounds are finished?

Are orders effectively reviewed and updated during rounds?

Is the patient’s family effectively involved in the rounding process?

Are you satisfied with your level of involvement in rounds?

Do you feel free to share your opinion and/or ask questions during rounds?

Do you think that others feel free to share their opinion and/or ask questions during rounds?

Can you clearly hear and understand what is being said during rounds?

Do you have a clear understanding of your role in rounds? What is it?

What should be accomplished during rounds?

75

What challenges or barriers do you come across to attending and participating in rounds?

In your opinion, does the current rounding system promote patient and family centeredness? Should it?

In your opinion, what are the best aspects of the current rounding system?

In your opinion, what are the worst aspects of the current rounding system?

If you could change one thing about the current rounding system, what would it be?

Additional comments?

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