•Interdisciplinary rounds (IDR) foster collaboration between provider types and establish a forum for patient care coordination.1

•The Centers for Medicare and Medicaid Services require hospitals to make a good-faith effort to conduct IDR on the majority of patients and that records are kept of the care coordination occurring through IDR.

•Tulane Medical Center (TMC) began weekday IDR in 2012.

•The majority of medical-surgical patients are discussed at morning IDR sessions; other units conduct similar care coordination rounds at different times of day.

•In 2015, TMC sought to streamline IDR as part of a hospital-wide throughput initiative. 1O'Mahony S, Mazur E, Charney P, Wang Y, Fine J. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med. 2007;22(8):1073-9.

IMPROVING THE QUALITY AND IMPACT OF INTERDISCIPLINARY ROUNDS AT

TULANE MEDICAL CENTER EM Clemens, BSPH1, BP Saccoccia, MPH2, C Waggaman, MS3, AL Wickerham, MPH2, D Bhatnagar, MD1

1Tulane University School of Medicine Department of Medicine, 2Tulane University School of Medicine, 3Tulane Medical Center Department of Infection Control & Prevention

Context

A Joint Chapter of the IHI Open School

Aim Primary: Improve the quality of communication in interdisciplinary rounds.

Secondary: Expand the IDR process house-wide at Tulane Medical Center.

Intervention •In March 2015 we standardized the content, schedule, and participants in IDR on two TMC medical-surgical units (5 Center and 5 East).

•We qualitatively and quantitatively tracked the content of IDR by “IDR saves” before and after the changes.

•We define an "IDR save” as a discordant communication corrected.

•IDR saves: 1.Occur during IDR. 2.Correct a potential error in management of a

patient, or clarify the best available plan of care.

3.Avoid errors typically related to transition of care, as opposed to medical care.

4.May coordinate outside resources, e.g. hospice discussions.

•We compared the saves-to-patients discussed ratio before and after March 2015.

•In Fall 2015, we conducted a participant satisfaction survey to assess staff perceptions of IDR and to solicit suggestions for further improvement as a house-wide expansion begins.

Results

Process Changes

Next Steps

T

•We found a large, statistically significant increase in the IDR saves-to-patients discussed ratio after the March 2015 process changes2:

Save Ratio Pre-March 2015: 6.8/100 Patients Save Ratio Post-March 2015: 35.1/100 Patients

p=2.2X10-6

• Fall 2015 survey data showed staff agrees that3: IDR facilitates safe inpatient care (19/20)

IDR facilitates safe discharges (16/20) IDR facilitates timely discharges (10/20)

2Wilcoxon Signed-rank Test. 320 regular IDR participants responding strongly agree or agree.

Conclusions •The process changes significantly increased the saves-to-patients discussed ratio, which demonstrates the value of focused care coordination such as the IDR process.

•We cannot identify specific drivers of this increase because of small numbers of save types; however, conversations are clearly more focused, efficient, and productive.

•IDR participants agree that our IDR process achieves certain goals, but the survey highlights areas for improvement.

•We plan to continue tracking the content of IDR with particular attention to fidelity to the script.

•Care teams will highlight target patients—those anticipated to have a greater number of care coordination needs—before daily IDR to triage patient panels and further improve discussion efficiency.

•We will expand IDR to units that do not currently have a procedure for daily care coordination rounds (SICU, 6 West).

Tulane Medical Center: Interdisciplinary Rounds, 5 Center & 5 East 2/3/14-3/7/14

IDR: Examples of Saves

CATEGORY: HOME HEALTH NEEDS Attending: His heart failure is really bad, so we might need follow-up for that. Case Management: So, is the patient homebound? Like would he qualify for home health? Attending: So he can walk about, less than a block at his baseline. Right now he is worse than that. So, I think he would be benefit yeah. Case Management: If you want to put the consult in for home health for a heart failure patient, education and mediation management. Attending: Ok we will do that then. CATEGORY: NURSING CONCERNS AND CLARIFICATIONS Nurse: She has a problem—we have to put a new IV in her every day. She really needs a PICC line. Attending: Yeah? What is she getting in this IV? Nurse: I’m not sure, but I know that every day it blows. Attending: Ok, I’ll walk over and see if we can determine what the medicine is and if she needs it, or if it would be better just to leave it out. I’ll see what we can do about that. Thank you for making me aware.

Category of Saves Number Occurred Dialysis - Dietary Changes 2 Dietary Education - Discharge- Home health needs 3 Discharge- Placement 2 Discharge appointments 2 Foley Catheter 1 Infections - Insurance - Medication Clarification and changes 1 Medication Education - Miscellaneous - Nursing Concerns and clarifications 2 Patient Safety 1 Patient Safety- DVT prophylaxis - Pharmacy Concerns and clarifications - Pressure Ulcer Risk - Proper Documentation 1 Psych Services 1 PT/OT needs - Telemetry - Vaccinations - Wound Care needs -

IDR Checklist New Admit

ROOM NUMBER PATIENT LAST NAME

OVERALL PLAN OF CARE MD

! Admitting Diagnosis ! Plan of care ! Tests/Procedures today ! Consulting services ! Goals of Care, Code Status ! PCP

CM ! Admit status" Inpatient v

observation ! Insurance status

Pharm ! Changes from home meds ! Med-Med interactions ! New medications anticipated at

discharge Dietary

! Diet ! Tube feeds or TPN

PATIENT SAFETY Nursing

! Vaccinations ! VTE prophylaxis ! Pressure ulcer risk ! Wound care needs (POA)

Nursing/MD

! Vascular access - Central line, PICC, POA

! Foley Catheter ! Telemetry

DISCHARGE PLANS MD/CM

! Anticipated date of discharge

PCC ! Discharge appointments

MD/Nursing

! Patient education needs (i.e. new diagnosis CHF)

Pharm ! Education on discharge

medications (i.e. Insulin, warfarin, enoxaparin)

! Bedside delivery of meds Therapy/Nursing

! Mobility assessment – Last out of bed/therapy, Fall risk

! Aspiration risk ! Therapy needs ! Medical equipment

MD/Social Work/Nursing

! Discharge Needs/Barriers ! Placement ! Home health needs ! Transportation ! Dialysis

Assessment Methods

2012-2015 Since 2015 Content

Schedule

Participants

Figure 4: Chart tracking saves by type, with examples.

Figure 5: Survey assessing attitudes of IDR participants.

Figure 2: Current physician script for IDR.

Figure 1: Checklist of topics to be addressed in IDR.

Time: 1:30 p.m. daily. Location: 7th Floor. Schedule: Post-call team presents first. Other teams presented depending on who was in the room.

Many of the same departments participated in IDR before March 2015 as currently participate; however, the overall number of participants decreased. We introduced a seating chart and a moderator to control the flow of conversation.

Figure 5 (left): Current IDR seating chart. MD 1&2: Physicians CRN: Nursing CM: Case Management SW: Social Work MOD: Moderator PCC: Patient care coordinator DCC: Discharge coordinator

We patterned the original IDR checklist after procedure checklists. We modified this concept into a daily script for IDR, focusing on standardized communication, so teams address all topics.

We introduced specific timeslots for rounding teams and the location of medical-surgical IDR was divided by unit.

Figure 4: Current daily IDR schedule. Figure 3: Old, loose schedule.

Identification: Role of all providers present – end with MD who identifies who patient will be handed off to, if post-call/leaving hospital

MD:

� ID – Name, Location, Admission Status – LOS � Assessment – Diagnoses (-es), Clinical Condition � Next steps – Goals of Care (Prioritized), Actions Needed

RN:

� Safety o Code – review if DNR o Access – Comment Box o VTE – Comment Box o FC – Comment Box o Telemetry – Comment Box o Restraints – Comment Box o Pressure Ulcer – Comment Box o Wound Care – Comment Box o Vaccinations – Comment Box o Other

CM/SW: � Admission Status � Living Condition

o Facility o Home o Homeless

� Disposition Need o Facility Displacement o Dialysis

� Discharge Needs o Equipment o Home Health o Home Therapy o Transport

PCC: � PCP � Appointments Needed