Grand Rounds: A Round Table Discussion - Collaborative Case Management Issue 71

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A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals I S S U E



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In This Issue:

Implications and Strategies to Proactively Prevent Burnout in Case Management Professionals




GRAND ROUNDS Going on Rounds – A Round Table Discussion Dani Hackner, MD, MBA, APLCM; Marc Adler, MD, MBA, FACP, CHCQM, APLCM President-Elect; Stephen Crouch, MD, FACEP, APLCM Board Member; Robert Grant, MD, MSc, FACS, APLCM President This article is a discussion regarding a case scenario on a topical issue involving care management, population health and physician advising. LEARNING OBJECTIVES 1 Identify ways in which multidisciplinary rounds can be organized efficiently based on your environment. 2 Identify what should not be negotiable for rounds. 3 Identify key elements in a strong progression of care rounds collaboration. PART I. PROGRESSION OF CARE ROUNDS Dr. Erin Smith, CMO for Progressions Hospital System (PHS), joins multidisciplinary rounds on the respiratory step-down unit (RCU) as an executive observer. PHS is attempting to improve length of stay and quality of care through enhanced progressions of care rounds. Intermediate level of care, the unit has telemetry, pulse oximetry, noninvasive positive pressure and tracheostomy care capabilities. Jim Vasquez is one of five rotating charge nurses for the area and runs multidisciplinary rounds one day a week. In the center of the 9

unit, PHS maintains a white board with observed length of stay (LOS), expected LOS, barriers and action items. At the board, hospitalists present their cases with occasional input from respiratory, therapy speech therapy and social work. Specialty services made up of doctors and advanced practitioners do not participate in rounds. Case management reports on “plans for the way” including skilled needs post discharge. For bedding status and level of care, utilization managers and CDI nurses electronically contact hospitalists through the health record inbox. Neither participate in multidisciplinary rounds. Bedside nurses sometimes participate as observers. Due to a standing meeting, the unit nurse manager is not typically present for rounds. She touches base with the rotating charge nurse later in the afternoon. WHAT IS YOUR PHILOSOPHY ON MULTIDISCIPLINARY ROUNDS AND LEVELS OF PARTICIPATION? Dani Hackner: My general philosophy is that rounds are for staff to hear from one another, to synthesize information efficiently, and to develop quality care plans and transitions plans. Multidisciplinary rounds require preparation, accountability, efficiency and empowerment.

Steve Crouch: Involvement by all members of the care team is optimal. Rounds should be multidisciplinary. Everyone should be there at the same time and provide whatever information they have and present their barriers to care, progression of care and ultimately to discharge. Participants should be encouraged to speak up. Having the conversations with all players is more efficient and the entire care team is aware of the responses, barriers and needs. Marc Adler: PHS may exemplify a risk of having rounds just for the sake of having rounds. They should be meaningful and task the right people at the right time to affect the right outcomes. I have found that trying to secure every clinical and administrative stakeholder at one rounding huddle ends up unsuccessful for all, especially the patient. Diffuse, overly large rounds may lead to misinformation and confusion leading to longer lengths of stay and possibly poor care. Dani Hackner: Clearly, there are different perspectives on rounds. We all agree that rounds per se are not the goal. However, multidisciplinary rounds organized efficiently can be an important tactic in progressing high-quality care.



Dani Hackner: Agreed. It is important to identify what is not negotiable for rounds— such as leader participation, the case management role, bedside nursing participation and an attending/hospitalist role. Then, customizing rounds based on unit/patient type may be needed. For instance, in the respiratory care unit described, regular attendance and participation of respiratory therapy may be essential. In the case of PHS, rather than the hospitalist alone speaking, asking for each role to contribute is optimal: we need to increase the voice of bedside nursing and respiratory therapy in this unit. WHAT ARE THE KEY ELEMENTS IN A STRONG PROGRESSION OF CARE ROUNDS COLLABORATION?


Dani Hackner: Keys to successful rounds are an organized process involving the right staff with clear accountabilities. Organized rounds may capture the prepared information such as expected LOS, barriers to progression and level of care needed in an electronic or visual board, and indeed, PHS has some of this information. Many organizations also carry over plans such as anticipated discharge date and therapies to boards in patient rooms for patient engagement. However, PHS does not involve bedside nursing staff regularly. Some organizations are able to consistently include bedside nursing on rounds either through a centralized unit-based rounds or a mobile, bedside rounds. Furthermore, the unit manager is not consistently present. Rotating charge nurses may not have continuity in the care of patients or in the supervision of rounds. Leadership presence is essential to assure clear accountability among participating staff. In summary, improvement opportunities include greater involvement of nurses, specialty providers and patients, as well as improved continuity of leadership. Marc Adler: This CMO should identify and communicate the goals of the process to rounding teams. Typically, hospital 10

administration wants to ensure progression of care (patient flow) and high-quality care with cost efficiency. Care management needs to ensure proper utilization and level of care decisions. Clinical staff seek appropriate care and outcomes through evidence-based medicine with patient satisfaction. Attending physicians want all to be streamlined and to personally have an efficient day. Finally, students want an educational experience. Communicating these goals will enhance the content of PHS multidisciplinary rounds. Then, negotiating an appropriate duration of rounds is important. HOW CAN WE BETTER STRUCTURE ROUNDS FOR THE DIFFERENT ROLES?

Marc Adler: Consider regularly scheduled brief rounds that are consistent in content, structure and attendees. Trainees may not realize part of their education is learning the art of formulating and using concise data. They may be frustrated if rounds are not presented in traditional didactic formats. Consider separating formal education from these rounds but emphasize the importance of regularly using concise communication in multidisciplinary rounds. The duration of these rounds should be limited so stakeholders can get to work on the necessary tasks.

Dani Hackner: In addition to goals for the stay (clinical endpoint), the day (testing and treatment) and way (transitions), there should an assessment of baseline functional status, a plan for mobility and an identification of patient-centered needs. A patient bedding classification should be identified. These data points enable effective planning. Any of these items could potentially trigger physician

If a member is unable to attend, they should provide their information to someone on the team before rounds. advising escalations for status, documentation or assistance with delays. Some organizations even involve physician advisors on multidisciplinary rounds in a rotating fashion. For each case, a working DRG helps the team establish a target date of discharge or documentation issues that can affect


planning and billing. An anticipated discharge date based on working DRG and potential barriers to discharge should also be identified, recorded and matched to action plans to hold staff accountable. Finally, we recommend a quality check during rounds on elements such as inappropriate use of telemetry, catheters, broad spectrum meds or central lines. WHAT IS APPROPRIATE ETIQUETTE FOR SUCCESSFUL ROUNDS?

Marc Adler: Stakeholders should be expected to attend rounds promptly, at the same time each day, with the up-to-date information specific to their profession. Clinical staff members need to pre-round and receive appropriate hand-offs from their overnight teammates. Owners of safety issues should have “run the list” before rounds. Care managers, PT, RT, etc. should be prepared with the latest information before the meeting. In short, everyone should be ready to speak up. Establish a rounds leader who takes the helm and runs the list. Each stakeholder provides relevant information about changes in status and any unanswered questions requested by team members. If a member is unable to attend, they should provide their information to someone on the team before rounds. Administrative leadership may need to clear schedules to allow managers to regularly attend at designated round times. WHAT IS YOUR KEY MESSAGE TO STAFF PARTICIPATING IN ROUNDS?

Marc Adler: We want to emphasize good communication. The key message to the team is that these rounds do not take the place of continuous updates and ongoing communication throughout the day; they serve as a connection point for all to communicate together to ensure efficiencies and clear understanding among team members. The rounds tee up action plans that will need follow-up and tracking. PART II. CASE ON ROUNDS—80 AND ALTERED On this particular day, a hospitalist presents an 80-year-old being observed with community acquired pneumonia and altered mental status. The patient has received antibiotics (piperacillin/


tazobactam and azithromycin). The hospitalist is reluctant to give fluids due to a history of mild heart failure. Fluid output is monitored with a urinary catheter. A consult is pending with the cardiologist who knows the patient from a prior visit. The charge nurse is concerned about the vitals, a respiratory rate of 20, a pulse of 135 and a blood pressure of 155/78. The pulse oximetry is 95% on 3L. Telemetry shows no arrhythmias. The chest x-ray shows an upper lobe pneumonia. Case management lacks an anticipated discharge date. Respiratory therapy is having difficulty obtaining a sputum for culture. The respiratory therapist indicates that the patient has had the cough for several months. The working diagnosis is simple pneumonia. The patient is in a double room. ARE THERE ANY RED FLAGS THAT MAY NEED TO BE ADDRESSED IN ROUNDS? ARE THERE ANY UTILIZATION, CLINICAL OR DOCUMENTATION ISSUES OF CONCERN?

Marc Adler: Multidisciplinary rounds may raise a broad set of issues needing to be addressed. If appropriately empowered, members of this rounds group would likely have addressed the indwelling urinary catheter. Clearly this patient’s clinical status and history raise concerns for himself, staff members and other patients. Active tuberculosis should be considered given complaints of chronic cough with an upper lobe infiltrate. Sometimes clinicians get sidetracked by alternate diagnoses and it is helpful for team members to raise a red flag. Mindfulness of patient and staff safety issues should be encouraged. Steve Crouch: I agree that this patient may need isolation until a communicable process has been ruled. Reactivation tuberculosis could be a possibility. Second, what is being done about the heart rate? Does the patient have a rhythm disturbance? Does the patient have an inflammatory response with fever or dehydration? This is another red flag. Third, is there a delay in the cardiologist consultation? Has anyone inquired as the need of fluids or addressed the hesitancy to give fluids by the attending? This is an opportunity to reach out to the attending or consultant. Lastly, this patient classification (observation) may be consistent with the low

severity and specificity documentation (generalized delirium, simple pneumonia) but not with the actual clinical condition of the patient. Both documentation and bedding order may need to be addressed. Marc Adler: Escalation due to clinical instability (tachycardia, tachypnea, hypoxia, etc.) and possible delays in consultation may be delayed in busy inpatient settings with many specialists and complex care plans. Multidisciplinary rounds may be an opportunity for several members of the care team to raise a red flag constructively. It is important to create a culture of safety where all hospital staff feel empowered to seek help and raise concerns without negative consequences. Dani Hackner: This case features several clinical red flags, quality opportunities or utilization concerns. Multidisciplinary rounds may help identify gaps in both care and planning. An escalation hierarchy within a Just Culture can leverage effective rounds to identify opportunities in real time. Regular multidisciplinary rounds can drive escalations before crises occur and tap on to support clinical teams. IN SUMMARY There are many opinions on progression of care rounds and multidisciplinary participation. Common themes include structured, brief rounds with leadership present and staff empowered to prepare, discuss and escalate when they encounter opportunities. ABOUT THE CONTRIBUTORS Dani Hackner, MD, MBA, APLCM Board Member, is pulmonary/critical care, chief clinical officer of Southcoast Health/SHG in Massachusetts. Marc Adler, MD, MBA, FACP, CHCQM, APLCM President-Elect, is a physician advisor in internal medicine, and medical director/physician advisor at NYU Langone Medical Center. Stephen Crouch, MD, FACEP, APLCM Board Member, is medical director of care management at Advocate Aurora Health System. Robert Grant, MD, MSc, FACS, APLCM President, is PA and Chairman Utilization Management Committee at New York Presbyterian. 11

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