Multidisciplinary rounds

We started doing it several months ago. Same group plus the hospitalist (our hospitalist group works so that each dr is assigned to a unit for the week). So they only round on the pts the hospitalists are seeing, and not pts admitted by other physicians. Case mgmt, dietician, pharmacy, etc them goes and sees the other pts afterward as needed. It works good because all the pts needs can be addressed at once. The pharmacist is there to answer any questions if needed and I feel like little things are less likely to get missed.

As far as time management its not bad. They round at 1000 so at least most morning meds have already been given. plus i work icu so it's a lot easier to give updates on two pts as opposed to five or six on the floors.

We do something similar at my hospital, only the nurses don't usually go to rounds. We report to our Clinical Leader (Charge Nurse), who then takes any outstanding issues to rounds. Sometimes the nurses do go too, mainly if the issue is complex and/or difficult to explain.

"Rounds" here are also attended by Pharmacy, Dietary, SW, Case Management, the Hospitalists, Surgical and whoever else is anticipated to be needed.

Our multidisciplinary rounds consist of the critical care team with the attending physician, the fellow or resident, pharmacy, infectious diseases, nutrition, and respiratory therapy. Bedside nurses are expected to be present for rounds and you can spend anywhere from 5 minutes to half an hour discussing the patient's care (unless your patient is going to hell in a hand basket in which case you take care of your patient). You have to plan ahead for it, maybe you end up giving your medications at 9 o clock that are written on the computer at 10. Maybe you get the patient out of bed after they finish rounds at noon- it takes time but you'll find your own tricks.

Since our patient ratio is 1:1 or 1:2 its nice to be able to sit down and discuss things with everyone, and depending on the attending (ours rotate) it really makes us feel like we have an impact on the decision making process. We use a system based process and look at the patient from top to bottom to make sure everything is covered. The resident/fellow is responsible for reporting to the attending so they assess their patients quickly before rounds to get a general picture and anything lifesaving or necessary can be addressed with them then.

I also get report the same way rounds are delivered so it helps for a reference point if you're worried you're going to miss something. For example:

• Neuro: Is the patient receiving adequate sedation? Pain management? Are the neuro checks sufficient for your assessments? Do you need more or less? Are there any drains or output that need to be discussed like an IVC?
  
• Respiratory: What are the ventilator settings? Does the patient have thick secretions? Can they be extubated? What does their x-ray look like?
  
• Cardiovascular/IV lines: What does the patient's heart rate look like? Are there any ectopic beats? Do they need an EKG? Is the blood pressure adequate? Do they have enough IV access? What about their labs? Is their crit high enough or do they require any kind of products? What about electrolyte replacements?
  
• GI/GU: Can we feed the patient? What do we feed them? How do we feed them? Are their blood sugars okay? Do they have/need a Foley? Is their urine output adequate?
  
• Skin: Do they have any dressings? Is there any wound that we need to be concerned about? (Is there something infectious disease needs to look at because their white count is in the 40s and climbing?)
  
• Family/Social: Did you find something new about the patient's history? Did we give them blood and they're a Jehovah's witness? Did the wife recently bring in an advanced directive? Does the whole team need to address the family in a meeting?
  

You're not going to know absolutely everything there is to know about a patient in the limited amount of time you have to look them over. Obviously the questions I riffed off are just a small portion. If you have a recent set of labs, print them at the beginning of the shift along with your med list. Get bedside report in the same manner you deliver it on rounds, go down the patient from head to toe and when you're done discussing and assessing think to yourself before you go on rounds "what can I get done with them today?" (that last part becomes routine once you feel more comfortable)

Its a cool feeling when you find an issue with a patient that hasn't been addressed by anyone else, the docs at my hospital know we spend the most time with the patient so you wind up really having a say in your patient's treatment plan. Stick with it, it gets easier! And you wind up learning the most on day shift because once you come up with a treatment plan you're not 100% familiar with you can ask the people around you how things are done. Good luck! :)

This is a great idea. I'm sure this cuts down on miscommunication between the specialists. It's great they include the nurses as well since the nurses spend more time with the patients than anyone else.

Sounds like a great idea. I wish we did this!

Our rounds are more informal. We join in on rounds when the team of white coated docs gather in front of our patient's room. Respiratory therapy usually joins in and often a pharmacist. When the intern finishes giving their report, the rest of us bring up issues for the doctors. For example, here is where I would ask for an out of bed order, a laxative, or mention other things that don't warrant an immediate call.

When the docs move on to the next room, I have heard the plan for the day, gotten questions answered, and I am ready to start my day.

I work in the surgical department and find that the surgeons rounds are more focused and go faster. Unless interrupted, the docs might spend 5 minutes for an uncomplicated patient about to get transferred out to 15 for something more complex.

Error