Daily Collaborative Rounds Seek to Optimize Outcomes In Neurology Patients

In an effort to improve treatment strategies and outcomes for neurological patients, The Neuroscience Institute has embraced collaborative rounds as a new standard of care. During collaborative rounds, the entire neurological healthcare team meets each morning to discuss all aspects of a patient’s treatment.

Topics include the patient’s diagnosis, health status, diagnostic tests, changes that may have occurred during the night, discharge and follow-up treatment and rehabilitation.

The collaborative rounds team, which meets at a set time each day in a conference room on the neurology floor, comprises nurses, social workers, speech and occupational therapists, teaching physicians and young physicians in training (residents).

Brett Kissela, MD, an Associate Professor of Neurology who heads up the program, said neurology researchers are collecting data and will determine whether the collaborative rounds process improves quality indicators, including length of hospital stay and mortality.

In the meantime, University Hospital has quantified two important improvements: 1) morale has risen significantly among nurses, who have an opportunity to meet with physicians each morning to review their patients’ progress, needs and orders for tests and medications; and 2) patients, when surveyed, are more likely to say that nurses kept them informed.

“The Department of Neurology’s collaborative rounds serve as a model for our other clinical areas in the hospital,” said Lee Ann Liska, Vice President and Executive Operations Director at University Hospital. “Not only do they improve the interdisciplinary experience for the care team and patient, they also undoubtedly reduce cost and length of stay.”

Said James Kingsbury, Executive Director of University Hospital: “Collaborative rounding is one of many – and one of the most important — innovative cultural and operational improvements made at University Hospital during the last three years. Several of these initiatives, including collaborative rounds, have received national recognition; collectively, they have led to significant improvements in quality of care and service provided by University Hospital.”

Collaborative rounds were launched in 2006 in a handful of departments at University Hospital by Paul Uhlig, MD, a former vice president and associate chief of staff for clinical improvement. Uhlig has published several journal articles that demonstrate the benefits of collaborative rounds.

In addition to The Neuroscience Institute’s floor for neurology patients, collaborative rounds were established in the Thoracic Intensive Care Unit, Surgical Intensive Care Unit, Center for Emergency Care, and Medicine Clinics.

“Collaborative rounds improve communication and enable us to complete a lot of the work tasks in one sitting,” Dr. Kissela said. “With the old model, everyone involved in a patient’s care comes to the patient’s chart. Everyone wrote notes on the chart and, although no one was talking at the same time, the chart allowed communication to occur. This works in theory, but in the real world we can be interrupted while we’re studying a patient chart in a busy hallway or at the bedside; we may not see all the notes that other people have written. And taking time to page someone so that you can get a direct answer to a question can be time consuming.

“The theory of collaborative rounds is that it’s much more effective to communicate person to person and in real time. Having everyone come together for a few minutes to get on the same page does a lot of good. It can be more effective and efficient.”

It can rectify, for example, a classic miscommunication that occurs when a physician orders a test that requires fasting but forgets to make a notation in the patient’s chart. “When the nurse comes to collaborative rounds she or he will find out that this procedure has been scheduled,” Dr. Kissela said. “If the nurse is not aware of this, the breakfast tray shows up, the patient eats, and the test is delayed for an entire day.”

Collaborative rounding also allows physicians to know exactly when a patient last took his or her medication, enabling the physician to make a quick dose alteration if required.

John Hill, RN, a clinical manager, said that collaborative rounds had led to better relationships among nurses and doctors while improving the relationships of nurses with each other. Hill also noted that only one physician responded to a workplace satisfaction survey taken prior to collaborative rounds; 20 physicians, including nine residents, responded to a similar survey taken after the implementation of collaborative rounds.

A session of collaborative rounds, in addition to keeping doctors and nurses in sync, also provides a superior educational laboratory for residents.

“There is an element of teamwork in caring for the patient that is important for residents to learn,” Dr. Kissela said. “A hierarchical system in which the doctor is the captain of the ship and everyone takes their orders from the doctor is not as effective as a system of equality in which everyone works together as a team and pulls the oars to move the boat through the water.”

Once a week, Dr. Kissela and others hold a special meeting, dubbed “glitch rounds,” to assess the collaborative rounds system and trouble-shoot flaws that have emerged. “We have an open discussion about what has worked and hasn’t worked,” Dr. Kissela said. “It is a critical part of ensuring that the collaborative rounds system is sustained and continually improved.”

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