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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
© 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.
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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
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
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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
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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
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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).
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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
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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
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- 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
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(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
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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
As seen in Figure 28, encounter duration varied as a function of the level of multidisciplinary
contribution, F(2,153) = 26.81, p < 0.001. Post hoc tests revealed that encounter duration was
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
As seen in Figure 29, encounter duration varied as a function of the level of multidisciplinary
contribution, F(2,173) = 21.12, p < 0.001. Post hoc tests revealed that encounter duration was
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
As seen in Figure 30, encounter duration varied as a function of the level of multidisciplinary
contribution, F(2,145) = 9.55, 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.
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
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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 ________________
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?