Interprofessional Rounds in the ICU

Function

In an ICU setting, the interprofessional team may be composed of: physicians, advanced practice providers, bedside nurses, case managers, respiratory, physical, and occupational therapists, pharmacists, chaplains, and occasionally family members. Each member of the team offers a unique background of information, training, and technical skill, which can improve patient care and ICU outcome. 

There are two types of physicians involved in an interprofessional team the primary physician and the consulting physician. In an ICU, the primary physician is either the intensivist or the primary attending, depending on the staffing model at the specific hospital. The consulting physicians represent many specialties of both medical and surgical healthcare. In most models, the primary physician leads the interprofessional team and functions to determine a direction for therapy based on the team members' input. Specialists are present for the consultation, depending on the specific illnesses being treated and the organ systems involved. Advanced practice providers provide direct support to the decision processes of physicians, and oversight by the physician is based on state regulations.

The bedside nursing team is the frontline healthcare provider in an ICU setting. Depending on hospital staffing models and acuity, a nurse is assigned to work directly with 1 to 4 patients; whereas, physicians care for many more patients. This ratio of patients allows the nursing staff to develop a rapport with patients and learn important information that can significantly alter the goals of care. This insight is valuable due to the brief nature of a physician's encounter with patients. Furthermore, nurses frequently have in-depth knowledge of the humanistic concerns of patients and their families due to both increased contact time and training. Also, the bedside nurse is responsible for carrying out many of the elements of the daily plan. This can range from medication administration, dressing changes, feeding, hygiene, venipuncture, and protocol adherence. Consequently, effective communication and understanding of the treatment plan are crucial for successful implementation and completion.

Case managers and social service are trained to address the psychosocial aspects of a patient’s needs. They help facilitate the transition to the next level of care. They are critical for providing additional patient education on treatment options and helping to coordinate various service needs following discharge. This may include medical equipment and medications. Social workers and or chaplains also work to arrange support and grief counseling or other mental health services for patients and their families.

Many patients within an ICU setting require supportive pulmonary care. This may include mechanical ventilation or non-invasive respiratory support. While physicians may determine the type and setting of pulmonary support, it is the respiratory therapist’s role to constantly monitor and adjust settings based on endpoints provided by the physicians.

Pharmacists assist with pharmacotherapy decision-making and dosing. They help reduce medication errors by identifying correct dosing and duration, proper monitoring of drugs, and any possible medication-associated interactions. Furthermore, infection control management, anticoagulation therapy, and sedation/analgesia utilization in ICUs are improved significantly when a pharmacist is directly involved in the interprofessional rounding team.

Family members may also participate in daily rounds, and they are a tremendous resource. The family can give insight into the patient’s preferences, likes, and dislikes. They can point out nuances specific to the patient. Involving the family in daily rounds allows for information sharing with the team and with the family. The collaborative decision-making process can allow for better follow-through of medical care as well as decrease associated anxiety and confusion about illness and the recommended treatments.[2][3][4][5][6]

Clinical Significance

Patient length of stay is consistently demonstrated to decrease when an interprofessional team approach is used for rounding. On average, the length of stay is shown to decrease from 1.1 to 2.2 days per admission. Increased communication between providers and the inclusion of safety conversations in rounds leads to a reduction in adverse events and delays in the initiation of appropriate therapy, which translates into improved mortality rates. Other markers for morbidity, including weaning days, total days of mechanical ventilation, and prevention of complications such as stress ulcers, deep vein thrombosis, falls, skin breakdown, infection, and readmissions, also show significant improvement with the interprofessional approach. Staff satisfaction is also significantly improved with interprofessional rounds. This is based on satisfaction surveys, with one study showing satisfaction increasing from 86% to 95% among ICU staff. Furthermore, participants in interprofessional rounds have a greater understanding of patient care, more effective communication, and a better sense of teamwork than providers of traditional rounds.

The primary goal of healthcare providers within a hospital setting is to deliver standardized, evidence-based care and achieve maximum patient safety. Also, goals include decreased adverse events, increased patient satisfaction, decreased length of stay, and decreased mortality. This challenge has proven particularly difficult within intensive care units as many of the most severely ill patients with complex medical pathologies and the poorest prognoses are admitted to these wards. However, through the implementation of interprofessional rounds and by using a collaborative team-based approach, patient outcomes can be optimized.[7][8]

Enhancing Healthcare Team Outcomes

While there is no single optimal structure, the consolidation of all team members for interprofessional rounds that occur at a set time on a regular schedule is considered best practice. Standardization of start time improves rounding effectiveness by facilitating greater participation among team members as they know when they will be needed. Rounds should emphasize a systematic, coordinated approach to patient data presentation, the formation, and documentation of medical therapy plans, the order of team member input, and a summary of overall goals of care for the day. In many ICUs, rounds occur each morning to establish the daily plan of care and allow the providers, including nurses and pharmacists, to work as a team to provide patient and family education, coordinate care, and monitor the patient's progress. A coordinated interprofessional team effort will lead to the best outcomes. [Level 5]