Effective Critical Care Rounding

Rounding on a large number of complex trauma patients can present serious problems for a busy trauma service, especially with resident work hour restrictions.  Detailed multi-disciplinary rounding is crucial to providing optimal patient care, but how can a team cover all the necessary details without spending hours upon hours rounding?   There have been a number of changes to our trauma rounding teams over the 5 years that I have been involved in Cook County Trauma,  and every year we are getting better and better at effective critical care rounding.

Here are our TOP THREE RULES for effective critical care rounding, which we strive to implement on a daily basis.

1- Use a checklist

Having a routine checklist which is reviewed for each patient decreases preventable errors and enhances patient care.  One assigned team member (a junior resident on our team, but elsewhere an RN may take this role) is assigned to listen to each patient presentation and make sure that every point on the check list is covered.  Many ICU's have developed their own quality checklist, specific to their teams strengths and weaknesses.  We use a trauma-specific checklist called "TRAUMA LIFE".  It is an acronym which stands for:

Thromboembolic/VTE Prophylaxis

Restraints

Analgesia/Sedation

Ulcer prophylaxis

Metabolic support/nutrition

Activity

Lines/tubes/drains

Integrity (skin)

Family message/plan

Exit strategy

2- Don't interrupt

Most patient presentations are interrupted by other team members within one minute.  Presentations that are interrupted are 30% longer than those which are uninterrupted; which really adds up over the course of 20 or 30 patients.  Often times, other team members jump in with additional information or plans fearing that the presenter has forgotten or does not know the information.  However,  by creating a NO INTERRUPTIONS rule the presenter can give all of the information in the order which is most appropriate and create a cohesive plan.  Other team members can comment at the end, if their question is still unanswered or they disagree with the plan.  Eliminating interruptions reduces presentation time, repetition of information, team frustration and improves the quality of plans developed by the presenting resident.

3- Know who is in charge

We have assigned a "Fellow of the Week" and "Attending of the Week" whose primary responsibility is being present for and leading daily rounds.  Previously, various on-call and post-call fellows and attendings were sporadically involved on different days of the week, often being pulled away by OR cases or administrative duties.  By assigning a fellow and attending to prioritize rounds every day for one week straight, we can develop longer term patient plans which will not be frequently revised by new physicians with alternative ideas.  Stabilizing the rounding team has decreased the amount of information repetition and frustrating changes to key patient plans.  Additionally, on days when multiple fellows or attendings are present for rounds, having a defined LEADER is crucial for directing rounds and making final decisions on patient care.

There is still lots of room for improvement, but these TOP THREE RULES have made our rounding smoother and our patient care better.

from Laura Grimmer MD PGY5