#13 ICU Rounds: Focusing on the Patient
In critical care, it's easy to get distracted. Patients are dynamic, learners are hungry, and families eagerly await updates on their loved ones. As important as all of these elements are - it's the patient that we need to focus on, and sometimes patient care can take a backseat when clinicians lean on the rounding conventions of old. On this episode of Critical Care Time, Nick & Cyrus discuss their opinions on rounding in the ICU and present strategies from their own practice which may enable you to be a more effective - and efficient - educator, communicator, mentor and ICU clinician!
Key Points:
Pre-round and prepare. The purpose of rounds is not to be spoon fed information but to devise a shared mental model. You should review all the EHR data and see all the patients before rounds.
Keep rounds short. Start on time, move efficiently, avoid interrupting. Consider the opportunity cost: every minute that rounds drags on costs time that could be spent caring for patients, communicating with families, or learning.
Respect everyone’s time. Don’t have people stand around watching you auscultate. (If it’s important, do it during pre-rounds or after rounding).
Use Micro-teaching & Nano-teaching to add educational value without wasting time.
Invite consultants to round together in the ICU. If you have several patients together this is often the most efficient way to formulate a shared plan.
Avoid perfunctory rounding rituals (e.g. the intern reading data for 10 minutes). Having someone recite a note is anachronistic and inefficient. Assume everyone has come to rounds prepared. Focus on sharing just the essential information and communicating a plan.
Having families present on rounds is great, but it’s no substitute for having an actual conversation with them. Keep rounds short & go back afterwards to answer questions and explain without using jargon.
Show Notes:
Bedside rounds are an essential aspect of caring for people with critical illness, but many aspects of rounds - including its length & structure - likely harm patients and compromise team learning and effectiveness.
The history of ward rounds can - like much of contemporary medicine - be traced to Sir William Osler. In Osler’s era, the only way to understand a patient’s story was via the resident physician who assimilated their history and physical exam with data from disparate sources all over the hospital (labs, radiology, medical records, etc). In the 1890s, listening to the resident’s recitation of data on rounds was the only way one could get a complete understanding of a patients story.
In the 2020s, this is no longer true; most of the data is available via EHR and can be reviewed remotely and asynchronously. People can read almost twice as fast as they can listen, and potentially with greater accuracy. The volume of data has increased exponentially in the last century, yet at many institutions today, ICU rounds are conducted in the same manner as William Osler prescribed in the 1890s, with residents reciting dozens of data points.
Is it time for a change in how we round?
How long should we spend per patient on rounds?
Duration of ICU rounds varies widely.
A large German study demonstrated that it is possible to conduct efficient academic ICU rounds with a median of <5 minutes per patient.
A Canadian survey reported that ICU rounds typically lasted 168 minutes, with a median of 15 minutes per patient.
In a US study, ICU rounds averaged 16 - 22 minutes per patient.
In a 20-patient ICU, this translates to 5-7 hours rounding!
This 5-fold difference likely represents non-rational variation.
Longer rounds are associated with greater team fatigue and delay essential tasks such as admissions, discharges, and procedures.
Long rounds may be associated with worse patient-centered outcomes.
In a large database (MIMIC-III) of almost 50,000 patients, admissions that occured during ICU rounds were associated with increased mortality. Specifically, Round-time admission was an independent risk factor for hospital death (OR 1.32). Notably people admitted during rounds were sicker and had more comorbidities.
In another multi-center retrospective study, admission during morning rounds was associated with increased mortality. In multi-variable analysis, to correct for acuity of illness and comorbidities, round-time admission remained associated with increased ICU mortality (OR 1.19).
In contrast, admissions overnight or on weekends are not associated with increased mortality.
Thus, shorter rounds are both feasible (they do it in Germany) and may improve patient centered endpoints such as ICU mortality.
Adjusting teaching styles for efficient on-rounds teaching:
High-impact teaching can occur on rounds without significantly prolonging rounding time.
Observational studies suggest that the typical ICU team spends about 16.8 minutes per day on bedside teaching while on rounds. This constitutes just 12% of time spent on rounds.
Time spent on teaching should be carefully budgeted and used in ways the are maximally effective for learners.
Rounds teaching should be targeted to the care of specific patient (e.g. metabolic alkalosis due to vomiting); abstract high-level lectures (e.g. how to interpret a blood gas) should not occur on rounds.
We recommend two forms of time-efficient teaching for rounds:
Micro-teaching: 1-minute teaching session, goal 1-2 per rounds
E.g., “Take a look at this patient’s ventilator waveform. What do you notice that’s abnormal? What is this called? What physiology does it imply? What should we do about it?”
Nano-teaching: 15-30-second teaching session, goal 1 per patient
E.g., “This patient’s fever may be medication-induced. Which of the medications hanging here is most likely to cause fever?”
Pro-tip: keep a list of the micro- & nano-teaching discussed on rounds. Review at the end of the week with learners.
Family presence on rounds
Having families participate in daily ICU rounds has both advantages and disadvantages.
According to a review of 16 studies: Family presence was associated with increased family satisfaction, physician comfort, and improved physician-family relationship. Family presence was found to increase rounding time and was felt to negatively impact teaching and opportunities for academic discussions.
Remember that while family presence on rounds provides transparency, listening to the team discussing a patient with medical jargon is not an ideal way to communicate. Furthermore, the opportunities for families to ask questions is often quite limited.
Family presence on rounds is NOT a substitute for time spent communicating with them after rounds. Fast rounds give you more time to have these conversations.
Set expectations by telling families that they will have the opportunity to ask questions when you return after rounds.
Tips to round faster and more effectively
Lead by example. Be concise and efficient. Avoid interruptions. Write down non-crucial things that can be adjusted later.
Set expectations.
Nick: I tell residents/students to assume that I’ve read their note and personally reviewed the data (vitals, labs, imaging). I don’t want to hear a recitation of data, I want to hear an assessment of what it means & a specific plan for what to do about it.
Measure how long rounds takes in total and for each patient. Write down the time on your round sheet.
Make efficient rounds a shared goal. Set a goal for how long rounds should take each day. Ask your team “what can we do to make rounds better and faster tomorrow?”
Audio:
Video
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Afessa B, et al Association between ICU admission during morning rounds and mortality. Chest. 2009
de Souza et al Impact of intensive care unit admission during morning bedside rounds and mortality: a multi-center retrospective cohort study. Crit Care 2012
Hillmann B, et al Structure and concept of ICU rounds: the VIS-ITS survey. Med Klin Intensivmed Notfmed. 2022
Holodinsky JK, et al A Survey of Rounding Practices in Canadian Adult Intensive Care Units. PLoS One. 2015
Cao V, et al Patient-Centered Structured Interdisciplinary Bedside Rounds in the Medical ICU. Crit Care Med. 2018
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