Trends and Successes in Implementing Family-­centered Rounding

Family/nursing-centered rounds are part of the process in your pediatric ICU. How does that work?

The foundation of what makes an ICU successful is a strong team — and not just any team, but a multidisciplinary one. Often in medicine, we, as physicians, tend to default into our decision-making “comfort zone,” either alone or with our focus team of peer and trainee physicians. We know that management decisions are stronger when we can approach them with an open mind and consider alternatives.

We also need to answer to the call of integrating each patient’s specific quality, safety, social, and operational metrics into the daily plan. By rounding with the patient’s nurse and family at each bedside, we not only continue to address the usual clinical status and formative medical plan, but we are hard-wired to address all quality and safety metrics.

The nurse now begins rounds with a quick summary of the patient’s ICU status: central line(s) status, intubation days, length of stay, hospital-acquired infection risks, drips, and, importantly, any of the patient’s concerns. The physician team then progresses with typical rounding presentation, forms plans collaboratively with the nurse, and integrates the family during and after the presentation.

There is a range of what a family member may engage on, from social and child life concerns, such as “Can my child hear me while intubated?” to clinical questions and contributions, such as “My child had a significant allergic reaction to Versed at the last hospital. Is there anything else you can choose instead?”

By and large, near-misses are avoided and missed opportunities are identified by integrating all members of the bedside ICU team to enhance our delivery of care.

What prompted the concept to introduce rounding with the families and how long has this protocol been in place?

Historically, it was commonplace to find a team rounding outside a patient room while the family member was sitting inside the room with their child. Family-centered rounding had been emerging as standard practice across centers nationally, and quickly became a core part of our mission and values.

The first step toward operationalizing the integration of families in our bedside rounds each day was a simple invitation: “We are about to round on your child, would you like to join us?” Suffice it say, at the beginning we were often met with bewilderment. Families had rarely been invited to rounds, let alone been given an opportunity to contribute and respond to their child’s care plan in real time.

Ten years later, this practice has become part of the standard expectation for ICU rounds, so much so that we will not round at a bedside if a family member wants to be part of rounds but is not present. We return later when they are available.

For families who want to be part of rounds but are not physically able to do so, we developed a telehealth rounding platform for families to videoconference into rounds on a display on wheels, brought into the rounding team circle just as though they were there in person.

How did the implementation for the program go?

As with all things that require us to hold a different lens to culture change, the implementation took some time. Anticipating that this would address not just culture, but years of practice and workflow processes, we initiated a step-wise approach to implementation.

While the physician and nurse collaboration was integral to buy-in, we were missing a key perspective on the design and implementation of introducing family-centered rounding into our ICU: the family.

We brought the concept to a board that consists solely of families of children who have been treated at our hospital. Their input into the design, introduction, and implementation was incredibly valuable.

This was the closest to human-centered design we could broach, and I am convinced it has been key to our success. As this was first introduced in the pediatric ICU, it has spread to other units and floors and has become the standard for rounding practice in our hospital.

What are some of the pros and cons of this program?

There are some perceived negatives when introducing anything new into an already well-established workflow, such as daily medical team rounding practice.

Initially, there was concern that bringing families into rounds would extend the duration of rounds. On average, this has not been a significant concern and, in fact, might have reduced the overall time spent by the medical team in family discussions, such as addressing concerns after rounds.

Additionally, there was debate on whether there would be over-exposure of the team’s medical decision-making to the family. To date, this has not been an issue. The literature clearly supports that transparency and timely disclosure may dissuade legal action, etc., and family-centered rounds position the team to address and discuss these related concerns with the family in real time.

Being an academic institution, we provide teaching during rounds, which we thought families would find time-consuming and not applicable. The reverse has proved to be true, as families have expressed interest, educational value, and even some enjoyment in being exposed to teaching.

Overall, it enhances our commitment to the team approach, and in an ICU where our priority is the health of the child, their family is just as integral a team member as anyone else.

What type of patient/parent feedback have you had and what would you tell other physician leaders who want to institute a similar process?

The feedback has been overwhelmingly positive and supportive. In fact, our bedside family-centered telehealth rounding initiative was born from requests by family to be present, as they felt they were missing out on their daily routine. We completely adapted our workflow to the parents’ morning schedules and time rounding to align with when they are present.

Of course, there are always some families who prefer to not join rounds and be updated separately. We always honor that request, acknowledging that their preferences take precedent.

The integration has been so successful that when families are finally transferred from the ICU to a general acute care floor, they request family-centered rounding in locations where it is not yet standard.

My recommendation to those wanting to explore implementing a similar process would be to not only garner buy-in from their medical teams, but also focus on nursing (the advocates who will encourage families to be present), and the families themselves. Their insight is unique and valuable, and will only help generate a smoother, more successful and impactful care paradigm for all.

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