Shortly after 8 o'clock one recent morning, UC Davis cardiothoracic surgeon J. Nilas Young arrived at UC Davis Medical Center's bustling intensive care unit for his early-morning rounds.
Beginning with patient Deborah Edwards, a woman who had surgery two days earlier to replace a diseased aortic valve, Young listened to a report from the person most intimately familiar with her status – her nurse.
As part of a pilot program yielding encouraging results, Young and his cardiothoracic surgery colleagues in the unit are actively integrating nurses into the periodic patient evaluations they conduct throughout the day. Young looks to nurses to lead bedside rounds by reporting the patient's vital signs, symptoms, lab test results and other information critical to an up-to-date assessment.
Known as "team rounding," the approach includes multiple members of the hospital health-care staff in daily assessments of patients.
"Team rounding has been implemented on many units and is anchored in the belief that close collaboration with all members of the patient-care team results in safe, effective care," says UC Davis Medical Center Chief Nursing Officer Carol Robinson. "We are working on an implementation plan for team rounding on all units, and we expect to see improved patient satisfaction with the teamwork and coordination of their care."
Continuity of care
"Basically, there is better continuity of care if the entire medical team is up to speed on all the issues involved with the patients," said Young, UC Davis School of Medicine professor and chief of the UC Davis Medical Center's Division of Cardiothoracic Surgery. "Because we are a teaching institution, there had been a tendency for nurses to defer interpretation of some aspects of the patient's clinical status to the medical residents. This current approach puts nurses in a more proactive role, resulting in better patient surveillance and coordination of care."
Young says giving nurses a prominent voice in rounding leads to more consistent and detailed patient assessments. Interns and residents frequently rotate in and out of the hospital's various units and have other demands during their day – classes, clinic service, stints in the operating room, to name a few. Nurses work 12-hour shifts and are permanently assigned to a given unit. More than anyone else on the care team, they have a continuous bedside view of the patient's clinical status.
Team rounding reflects the emergence of a new emphasis on collaboration in health-care training. In 2001, an Institute of Medicine report advocated reorienting healthprofessional education to emphasize teamwork, coordination and the integration of caregivers.
Training in teams
With the establishment of the proposed Betty Irene Moore School of Nursing, UC Davis will take that message to heart, offering a curriculum that stresses a multidisciplinary approach to care. Students from nursing, medical and other health professions will learn in classrooms together and train in teams.
The goals are more efficient and consistent patient care, improved communication and a reduction of errors.
Young believes the approach strengthens the monitoring of patients in the hospital's Surgical Intensive Care Unit II. On this fall morning, the eight-bed unit is abuzz with patient-care team members intent on ensuring patients' safe transition through the critical days between surgery and full recovery.
Young arrives for the first of several rounds the team will conduct throughout the day. Nurse Floricel Oliva-Dizon is positioned in front of a computer screen outside the room of patient Deborah Edwards. She gives the surgeon a rundown on Edwards' condition and progress overnight.
No acute events…Just got back from her walk and tolerated it well... GI – started on clear liquids...Chest tube on the left…
After a peek at Edwards' chest X-ray, Young and Oliva-Dizon discuss a care plan for the day, which includes a change in medication and a transfer to another ward. Then they step in to see Edwards, who is sitting up in a chair and enjoying a liquid breakfast.
Later, Young explains the value of collaborative rounds.
"By involving the nurses, we get a more nuanced interpretation and a very good feel not only of patients' medical needs, but of any psychosocial issues at play – family dynamics and other influences," Young said. "These patients are seriously ill and have a serious risk of mortality and complications. We need team work to ensure our surveillance is the best it can be."
Eunice Carlson, nurse manager for two hospital floors that have used team rounding, is among others applauding the concept.
"It's an awesome model, and I think it helps with patient satisfaction and their perception of coordination of care."
Edwards, a resident of Tracy, endorsed that perspective.
"I think it's great," she said between sips of broth. "It makes a lot of sense. The communication has been great between the nurses on different shifts, and between the nurses and my doctor."