Rounds cut LOS, improve patient satisfaction
Multidisciplinary team resolves discharge issues
After The Reading Hospital in Reading, PA, implemented multidisciplinary walking rounds, patient satisfaction increased and length of stay decreased at the 615-bed tertiary care hospital.
"We feel that the multidisciplinary rounds have broken down a lot of silos between departments and removed barriers to discharge by allowing us to address any issues while the team is together, rather than trying to track someone down. Each discipline has a better understanding of the roles the other disciplines play and how we are interdependent on each other. We're communicating more, even outside of rounds," says Terri Mueller, RN, BS, CCM, manager of the hospital's care management department.
Patient reaction to the walking rounds has been very positive, adds Joanna Lucas, RN, BSN, director of care management, utilization review, and social services.
"Often patients feel like nobody tells them what is going on. This gives patients and family members a chance to talk to the caregivers, to ask questions, and to understand the disease process better," she says.
Sometimes patients have a lot of questions that require an in-depth discussion. In that case, the appropriate clinician gets back to them after rounds.
During rounds, the team discusses patient progress and the anticipated discharge date in order to give the patients and family members time to arrange transportation home from the hospital and line up any other discharge needs.
The team is experimenting with putting the expected discharge date on a white board in patient rooms as a way to keep patients and family members informed and to remind them to prepare for discharge.
The nurse manager, the nurses caring for the patients, and the case manager on each unit participate in the teams. Each discipline that is providing care for a particular patient is expected to be represented and attend the rounds. On some of the units, hospitalists take part in the rounds.
For instance, the rounding team on the intensive care unit (ICU) always includes the nurse manager, the case manager, and the dietician, says Agnes Gentile, RN, BS CCRM, nurse manager in the medical ICU.
A representative from pastoral care rounds with the ICU team three days a week. Social workers attend rounds on that unit twice a week unless there is a patient with a lot of social issues.
The ICU team has rounds at the time that the physicians are on the unit so they can be included if needed.
"Each unit sets the time for the rounds based on what works best for that unit. Everybody knows to meet in a certain spot at the designated time, and we start at one end of the unit and go around," Mueller says.
The case manager on the unit is captain of the team, facilitates the process, and determines who will follow up on any issues identified during the rounds.
"When we walk into the room, the case manager tells the team where the patient is from, the diagnosis, what issues he or she is having, and if they have had contact with the family. We look at the long-term plan and the discharge plan and determine what needs to happen before the patient is ready for discharge," Gentile says.
All of the teams cover every patient on the unit during the rounds, but they do not necessarily see every patient in person, depending on what is going on with the patient.
For instance, if a patient is in isolation or off the unit for a test or a procedure, the team doesn't go into the room during the rounds.
However, the case manager appoints someone from the team to touch base with the patient and let him or her know what was happening that day.
The rounds help remove barriers to discharge by allowing the disciplines involved with patient care to collaborate and to address any issues in a timely manner, Lucas says.
For instance, if a patient is ready for discharge except for a physical therapy evaluation, the physical therapist on the team knows to make sure the evaluation takes place so there is no delay in the discharge.
"The rounds have brought to the forefront a lot of issues that had been there for a long time. As we look at the patient's length of stay and barriers to discharge, we are exploring a lot of different options," Gentile says.
For instance, the hospital is discharging more patients from the ICU to a long-term acute care hospital (LTACH) than in the past.
"The closest LTACH is 60 miles away and in our area; we hadn't really focused on LTACHs as a discharge option. After working closely with physicians during the rounds, I have been able to discharge appropriate patients to an LTACH sooner and get them to the best level of care much sooner," she says.
As a result of the rounds, the hospital has started a mobilization protocol to get patients out of bed and ambulating sooner.
"We saw that patients weren't getting out of bed as soon as they should be because the nurses were waiting for the doctor to write an order for a physical therapy consultation. The nursing director worked on an order set that allows the physician to order the protocol and nursing to mobilize it at the appropriate time," Mueller says.
The project began in 2008 when a multidisciplinary team led by the chief nursing officer and care management director began meeting weekly for three months, reviewing literature for evidence-based best practices and brainstorming on the best ways to implement the process at the hospital. Team members wrote a formal charter that outlined the goals, time line, and action plan for the initiative.
"Our goal was to decrease length of stay, affect patient and staff satisfaction, and improve clinical outcomes. We wanted the walking rounds to assist all of the disciplines in planning their day and to be valuable for the patients as well," says Lucas.
The team started by identifying all the disciplines that had direct contact with patients, including nursing, physical therapy, speech therapy, occupational therapy, nutrition, respiratory therapy, pastoral care, pharmacy, as well as case management and social work.
"We identified the core items that each discipline wanted to get out of rounding and structured the rounds around that. We wanted to keep the rounding short so it didn't take a lot of everybody's day. Our goal was to complete the walking rounds within 30 minutes," Lucas says.
The team developed a formal database of information each discipline wanted to gather for each patient.
For example, the case managers wanted to know about patients' living situations before hospitalization, what medications they would need after discharge, the support system, and if they would need an alternate plan of care after discharge.
Before rolling the process out on the unit, the team engaged in role-playing activities with one team member acting as a patient and the other members asking questions.
"This was a real eye-opener. We realized then that we needed to keep the rounds simpler and more patient-centered. It felt like everyone was firing off questions and overwhelming the patient," Mueller says.
The team revamped its plan and came up with three simple questions to ask the patients at the beginning of the round:
- "Do you know why you are in the hospital?"
- "Do you know what is going to happen today with your plan of care?"
- "Do you know your discharge planning needs?"
The team rolled out the walking rounds on one unit a week for 12 weeks, starting with the unit where heart failure patients were admitted.
"We held weekly meetings with all the nurse managers. The nurse managers on the units where we already were having rounds talked about how it was going with the other nurse managers so they would know what to expect," Mueller says.
Whenever a nursing unit began rounds, one of the planning team members was on the unit for a week to answer questions, make sure the process was flowing, and identify barriers.
A hospital vice president was assigned to each unit where the rounds were being rolled out and was expected to attend rounds in the beginning.
In early 2010, the teams started focusing on length of stay during the rounds.
"On some of the units, we weren't seeing the expected drop in length of stay. We came up with enhanced rounds and added a clinical documentation specialist who assigns a working DRG to the case," Lucas says.
Now, during rounds, the team looks at the expected length of stay for the patient's DRG and focuses on why the patient is still in the hospital and roadblocks to discharge.
On the heart failure unit, the length of stay dropped almost a full day in six months after the focus on length of stay began.
A hospitalwide steering team, which includes all operational vice presidents, the director of care management, and medical records oversees the process.
The administrative team reviews the rounds to determine what was going right, what was going wrong, and what patient issues were delaying timely treatment and discharge.
"Because the vice presidents are able to move ideas forward, we have made some changes to facilitate a timely discharge," Lucas says.
For instance, the hospital has added procedures that were not usually available on weekends so patients no longer have to stay in the hospital from Friday to Monday, she adds.
"We look at barriers that are identified during the rounds and look for opportunities to make changes. We were committed to making the patient experience better, improving outcomes and staff satisfaction. This has brought a lot of satisfaction to the staff while improving the patient experience and ensuring that patients get the care they need in a timely manner," she says.
[For more information, contact Terri Mueller, RN, BS, CCM, The Reading Hospital, manager of the care management department, e-mail: [email protected].]
After The Reading Hospital in Reading, PA, implemented multidisciplinary walking rounds, patient satisfaction increased and length of stay decreased at the 615-bed tertiary care hospital.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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