Melanie Buba is a Hospital Pediatrician, Director of Quality Improvement for the Division of Pediatric Medicine at CHEO and an Assistant Professor in the Faculty of Medicine at the University of Ottawa.
Catherine Dulude is a Human Factors Specialist at the Children’s Hospital of Eastern Ontario.
Family-centered rounds have long been the cornerstone of pediatric hospital care. These rounds – defined as multidisciplinary rounds involving the medical team, patients and caregivers partnering in daily decision-making – have been shown to improve patient outcomes, satisfaction, communication, discharge planning, medical education and patient safety. Traditionally, family-centred rounds take place in the patient’s room. During the COVID-19 pandemic, however, congregating in patients’ rooms for rounds is no longer advisable as part of efforts to maintain physical distancing and preserve PPE. It soon became clear to us that a new standard process for our family-centred rounds was required to ensure their benefits could be maintained.
In March 2020, we worked quickly to develop the vision and scope for this work: appropriate hardware (laptops, iPads) and software (PHIPPA-compliant Zoom) were identified and a multidisciplinary team assembled to develop and implement a “virtual” workflow. Our pediatric residents do not have office space, so we identified large meeting rooms where the physician team could gather while still adhering to physical distancing requirements. We solicited administrative support to book virtual meetings and send out invitations. Nursing and clerical support became vital to creating the rounding schedule, setting up the iPads to join the right meeting, bringing devices to patients and families and ensuring devices are cleaned between participants.
On April 6th we launched our first virtual family-centered rounds. During our pilot, nurse auditors attended the rounds daily and met with our multidisciplinary project team to review their data and observations, and iteratively refine our process. Through this check-in and feedback approach, we quickly determined areas to optimize, including involvement of allied health care professionals, training and education, and processes of obtaining consent. The family partners who form part of our project leadership team brought forward suggestions on how to appropriately involve patients and families in virtual family-centered rounds, and for best practices to ensure they’re informed about the process. We also made small improvements, including changes to Zoom meeting IDs, sound optimization and start times for rounds.
Our goal was to develop a standard process that could be adhered to daily and picked up quickly by staff rotating through our unit. Here’s how it works:
First thing in the morning, unit clerks create and distribute a patient-by-patient rounding schedule, allotting 10 minutes per patient. Past research on family-centered rounds undertaken at our hospital revealed this is the time required to review essential medical information and make a plan for the day.
Meeting invitations with Zoom meeting details are sent out to the inpatient teams by Pediatric Medicine admins in advance of every new week of service. The meeting ID for each team is static to make it easy for everyone to keep track of the meetings.
Following this schedule, physicians, residents, pharmacists and nurses sign into the virtual meeting to discuss each patient in turn. The nurse is the only provider on the unit and they deliver an iPad to the bedside inviting patients and/or caregivers to partner in rounds with them. iPads are cleaned with disinfectant wipes between patients and between nurses.
- The entire care team meets “face-to-face”, safely physically-distanced from one another in a large meeting room.
Our preliminary data are encouraging: Physician and nursing feedback reports that 76% are satisfied or very satisfied with the process, while 90% report they feel they have a good understanding of their patient’s care plan after virtual family-centered rounds. 72% of patient rounds are 10 minutes or less, with an average transition time of <2 minutes between patients. Families report the virtual rounds to be more collaborative, less intimidating and more private than traditional rounds; in fact, many prefer it.
As with any technology-dependent process, challenges have arisen with our hardware and software, highlighting the need for the development of robust downtime processes. While adhering to a rounding schedule is vital to an efficient virtual rounding process, it is a new workflow and has been met with some resistance. Weekends are proving to be a challenge, given the lack of support staff and smaller medical teams. Providing iPads to patients and caregivers in isolation rooms was impossible prior to development of a system that allowed proper protection and cleaning processes to occur.
Ongoing data collection, time studies and feedback from participants will allow us to continue to improve our process as we plan for broad dissemination to all inpatient areas of our hospital. Future directions to explore include incorporating off-site caregivers, translators and subspecialists in the virtual rounding process. It may be possible to leverage closed captioning technology to support families. While the catalyst for this project was the COVID-19 pandemic, it is likely that virtual family-centered rounds will remain a necessity beyond the pandemic as we continue to look for safer ways to deliver care, particularly to our isolated patients.