Published in the February 2009 issue of Today’s Hospitalist
WHEN SOFIA TEFERI, MD, talks about how family-centered rounds have changed the way pediatric hospitalists practice at Bon Secours Health System in Richmond, Va., she recalls the difficult conversations that have all but disappeared.
Before pediatric hospitalists at Bon Secours began including patients’ family members in rounds last September, parents would sometimes complain that a doctor had not seen their child that day. Or they would question new medication orders because they didn’t have a chance to talk to the doctor who had changed them.
Now that family-centered rounds bring family members and nurses into the loop, says Dr. Teferi, medical director of Bon Secours’ pediatric hospitalist program, parents end up with a better understanding of their child’s course of care because the entire medical team is there to answer questions.
And it’s not just parents who feel like they’re more up to speed. Hospitalists and other health care professionals also benefit from being able to answer the family’s questions ” and each other’s “at one time and avoid being bombarded with pages later in the day.
In the past, Dr. Teferi says, she and her colleagues spent a huge chunk of their afternoons catching up with patients and nurses to clarify treatment plans and review medications. But the constant paging has disappeared because that information is shared during rounds.
A question of logistics
The pediatric community began endorsing the idea of family-centered rounds as early as 2001, when the Institute of Medicine tagged family-centered care as one goal in its call for sweeping health care redesign. A policy statement from the American Academy of Pediatrics published in the September 2003 Pediatrics asserted that “conducting attending physician rounds in patients’ rooms with the family present should be standard practice.”
Hospitalists who have instituted family-centered rounds say they increase patient satisfaction, and can reduce medical errors and lead to more patients being discharged earlier in the day. But not everyone is sold on the concept. Critics contend that bringing family members into rounds takes more time. They also claim that such big-tent rounding is a logistical nightmare, shortens the teaching time available at the bedside, and makes doctors look unsure or indecisive in front of residents, patients and family members.
It’s true that these rounds can consume up to half of a hospitalist’s workday. Hospitalists say that family-centered rounding increases the amount of time spent with each patient by between two and 10 minutes.
Preparation for family-centered rounding begins at admission, when hospitalists explain the program and make sure that family members want to get involved. Once rounds begin, hospitalists need to introduce everyone in the room to family members and invite family members into the conversation by encouraging them to interrupt with any questions.
While all of that interaction definitely chews up more time than traditional rounds, physicians say that it pays off in terms of better and safer care, improved communication between the patient and medical personnel, more satisfied patients and shorter hospital stays.
“Most people believe it makes their work far more effective and efficient,” explains Jeffrey M. Simmons, MD, assistant professor of pediatrics at Cincinnati Children’s Hospital Medical Center, which has established a nationally recognized family-centered care program. “You get a good plan together faster, there are fewer communication breakdowns later in the day, and you spend less time clarifying things.”
Ruben J. Nazario, MD, assistant clinical professor of inpatient pediatrics at Kentucky Children’s Hospital in Lexington, says that many of the concerns about family- centered rounds melt away once physicians get involved. “Once they see how well it works and that they’re not doing things twice, they embrace it,” he says.
While Dr. Teferi agrees that family-centered rounds save hospitalists time, she says they also improve the overall quality of care. “Having a nutritionist and pharmacist at these rounds has been great,” she explains. “Sometimes they have ideas about medications or dosing that we aren’t aware of. If you’re a hospitalist, it’s easy to feel like you have to do everything yourself. Now, there’s a bit of backup and fewer chances of making mistakes.”
Physicians may worry that patients and family members will be uncomfortable sitting in on rounds and sharing personal information with large groups. But according to Dr. Simmons, the medical literature shows that the vast majority of families appreciate being included. He also notes that while families have the right to opt out of the rounds, only 5% to 7% of families at Cincinnati Children’s choose to do so.
While some physicians worry that concerns about privacy will be a barrier, hospitalists say it rarely comes up.
At Golisano Children’s Hospital at Strong University of Rochester Medical Center in New York, for example, patient rooms are small and shared, so privacy could easily have been a problem when family-centered rounds were introduced. But Ted D. Sigrest, MD, senior instructor of pediatric hospital medicine, says he was surprised by the lack of complaints. “We always ask everyone for permission to round,” he explains, “and only rarely do we encounter someone who does not want us to.”
During family-centered rounds at Kentucky Children’s Hospital in Lexington, Dr. Nazario goes through the patient’s history with the family and his 10-person team. The interns present, and then sometimes stop and ask the parents for permission to let the medical students practice a process like listening to a heart murmur.
“Most families are happy that you’re analyzing what’s going on,” Dr. Nazario says. “They know they’re in a teaching institution, so they understand that.”
There are times when hospitalists may need to take the discussion “about potential child abuse, for instance, or sexually transmitted diseases “to a more private area like a conference room. Likewise, there are times when parents may want to talk with the team without their child present.
While giving parents a frank assessment of their child’s condition can lead to some intense conversations, those dramatic moments serve as powerful teaching tools. Dr. Sigrest remembers one incident when a distraught mother was crying and shouting at the team. Her infant son had been brought to the hospital on suspicion of abuse, and she was upset that her husband had left the hospital and could not be found.
“The senior resident and I sat down beside her and talked her through it,” he recalls. “It was scary, but the teaching point was gained by the interns and nurses as we all worked as a team to resolve the situation. That’s the kind of teaching that you never forget.”
“Pulling back the curtain”
That raises another concern about family-centered rounds that’s unique to teaching hospitals: the impact on the learners in the room, typically residents and interns. Dr. Simmons says that residents tend to like the new style of rounding.
“Residents are actually empowered by it,” he explains. “They become more skilled because they practice it everyday and they see their peers and attendings doing it.” This new style of learning is also, he continues, a big improvement over years past when “doctors almost never got feedback on how to interact with the family. It’s important to learn how to have your own voice.”
Family-centered rounds can present a challenge for attending physicians, who must simultaneously meet the educational needs of housestaff and the informational needs of family members.
Dr. Simmons adds that family-centered rounds can be a little uncomfortable for some attendings for another reason: They have to relinquish control over communication. “It’s like the Wizard of Oz,” Dr. Simmons says. “You’re pulling back the curtain, and families get to see how it’s really done.”
He notes, however, that research from his hospital shows that the longer attendings participate in family-centered rounds, the more comfortable they become with the process.
Besides, he adds, what hospitalists give up in terms of control produces big rewards in quality and patient safety. Dr. Simmons says that family-centered rounding is the only way to know if you have the facts of the case correct. “Even if I’m hearing information from a great resident who I trust implicitly,” he says, “I’m not confident that a plan is correct until I can see the mom and a nurse nodding.”
Making it work One of the biggest challenges is creating a team that draws personnel from various parts of the hospital, and gets everyone in the right room at the right time with the right information.
When the hospitalists at Bon Secours first decided to implement family-centered rounds, Dr. Teferi says the questions about logistical issues were endless: Should we start at a specific room every day? If we start with one nurse, do we go to all her rooms first or do we go down the hallway and grab different nurses as we go?
Because two hospitalists round each day at the facility, but there’s only one nutritionist and one pharmacist, Dr. Teferi decided to stagger the two sets of rounds, with one team starting at 9:30 and another starting a half hour or hour later.
“Each day,” she says, “we work with the charge nurse and decide who’s going first.” She also decided to have teams round first with the nurse who has patients the farthest down the hall, so all the nurses will know where the team is on its rounding route.
It took some time for the nurses to get used to being pulled away from other tasks to do their patient rounds, but Dr. Teferi says everyone is now on board.
While scheduling is a big challenge of family-centered rounding, Dr. Simmons says that hospitalists have to know their limits when it comes to patient volume. He says that 30 patients, for example, is simply too much for one team to round on in a day. “Ten to 15 is the sweet spot,” he says. “You can do up to 20, but it’s a long day.”
Timing of the rounds is another issue. Golisano Children’s Hospital has three children’s floors, with one resident team caring for each floor of patients. The rounds are timed to fall right after the nurses’ morning report, between 8:30 a.m. and 11:00 a.m.
“We moved resident pre-rounding and morning conference up by half an hour so that residents and nurses who were finishing their reports could all get in there at the same time,” Dr. Sigrest says. The teams cover 10 to 18 patients in that time.
Twice a week, the teams check each patient’s medication list during rounds. The goal is to make sure not only that all medications are appropriate and properly dosed, but to give everyone a chance to review and agree on what’s been given and when.
“It ensures the safety of the patients,” Dr. Sigrest says. “It’s not all that infrequent that we find orders that were transcribed incorrectly.”
Whatever the approach, Dr. Sigrest cautions that any transition to family-centered rounds will produce a learning curve. “We tried to do too many interventions when we started,” he says. By the second year, however, family-centered rounds had been accepted as the standard of care.
“The residents cover an entire floor and they may have up to 10 different attendings,” he notes. “The rounds here are driven by the senior residents, but they may be driven by attendings in other institutions “and attendings are famous for not accepting new practices, like family-centered rounds.”
Early involvement and buy-in can create a groundswell of support that will remove many of the real and perceived barriers. “It’s a crusade,” Dr. Sigrest says. “It’s the way we need to treat people.”
Ingrid Palmer is a freelance health care writer based in West Chester, Ohio.
Trying to bring community pediatricians on board
Though family-centered rounds have been steadily increasing in academic children’s centers, applying the techniques to community-based hospitals poses a different set of problems.
A good example? In hospitals where many community physicians still follow their pediatric patients to the hospital, family-centered rounding introduces a whole new set of scheduling dilemmas.
To streamline its ability to hold family-centered rounds, Bon Secours Health System in Richmond, Va., tends to have its hospitalists take over once the child is hospitalized. The community doctors either don’t visit the patients at all or they come early in the morning for a social round.
“We had a child with an abdominal tumor and, in that case, we did ask the community pediatrician to round with us,” says Sofia Teferi, MD, director of the pediatric hospitalist program. “Sometimes it helps if the patient and the family see a familiar face.”
At St. John’s Mercy Children’s Hospital in St. Louis, Mo., the hospitalist program is planning to move to family-centered rounds on all units cared for by pediatric hospitalists. (Such rounds are already standard practice in both the neonatal and pediatric ICU.) But the variety of attendings will make the rounds difficult to implement hospital-wide. That’s because one group of patients is cared for by hospitalists, another is treated by community pediatricians and a third group is cared for by specialists.
Joseph Kahn, MD, chair of pediatrics, says that the biggest obstacle is convincing the community pediatricians to adopt family-centered rounding. “Community-based pediatricians who admit their own patients can round however they choose to do so,” Dr. Kahn says. He hopes that when those physicians observe how well the new rounds work and see the advantages, they’ll want to participate.