A Time-Motion Study of Multidisciplinary Bedside Rounds in ... · A Time-Motion Study of Multidisciplinary Bedside Rounds in Pediatric Critical Care Carly Marie Warren Master of Health
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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
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.
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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
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.
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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
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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.
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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
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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
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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.
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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
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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
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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.
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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.
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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
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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.
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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
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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
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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
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