Improving Communication During Cardiac Intensive Care Unit Multidisciplinary Rounds Through Visual Display of Patient Daily Goals

Abstract

BackgroundThe care of critically ill children in intensive care units (ICU) has become increasingly complex. Utilization of multidisciplinary care teams leads to reduction in mortality and length of stay, prevention of adverse events, and improvement in quality of care. However, as the number of care providers grows and patient demand increases, coordination of multidisciplinary care becomes more complicated.ObjectivesTo improve communication during cardiac ICU multidisciplinary rounds.MethodsQuality improvement methodology was utilized to evaluate implementation of a daily patient goal write-down/read-back process. The Rounds Effectiveness Assessment and Communication Tool (REACT) was developed, based on the previously validated Patient Knowledge Assessment Tool (PKAT), to evaluate comprehension of patient daily goals during multiple PDSAs (Plan, Do, Study, Act). Rounds were assessed for each patient by the bedside nurse, nurse practitioner or fellow, and attending physician, and answers were compared to determine percent agreement per day.ResultsBaseline percent agreement for patient goals was 62%. After intervention, percent agreement improved to 85%. Family satisfaction with rounds was assessed using a 1–6 Likert scale and improved from a mean of 4.6 to 5.7. Parent selection of the best possible score for each question was 19% at baseline and 75% after the intervention.ConclusionsVisual display of patient daily goals via a write-down/read-back process improves comprehension of goals by all team members and improves parent satisfaction. The daily goals whiteboard facilitates consistent development of a comprehensive plan of care for each patient, fosters goal-directed care, and provides a checklist for providers and parents to review throughout the day.Figure 1Rounds Effectiveness Assessment and Collaboration Tool.Figure 2Parent Satisfaction Survey.Figure 3REACT Results-Percent Matching Responses Per Day.Figure 4Figure 5Figure 6Family Survey Results-Family survey results improved for every question, and the overall mean score improved from 4.6 to 5.7 out of 6.Table 1Summary of PDSAs.#Plan/DoStudyAct1Goal write-down and read-back on RN bedside sheetUnclear if beneficial during small trial, bedside staff unsure what to write downAdapt2Full unit trial of goal-write-down and read-back on RN bedside sheet with prompts addedOnly visible to the bedside RNNo change in REACT scoresAdapt3Goal write-down and read-back using 1 whiteboardFavorable response from staff regarding improved visualization, but inconsistent useAdapt4Goal write-down and read-back using 5 whiteboardsFavorable response from staff and parents regarding improved visualization, but inconsistent useAdapt5Goal write-down and read-back using 5 whiteboards, extended x 3 months, with focused discussion about goals at the end of roundsImprovement in REACT scoresDifficulty with categories wiping off the boards or smudgingLarge goals whiteboards did not fit with the permanent CCHMC family communication boardsAdapt6Goal write-down and read-back on 1 legal size laminated sheetSmaller sheets are more mobile, no issues with categories wiping offCompatible with CCHMC family communication board.Concern was voiced regarding potentially reduced visibility of goalsAdapt7Goal write-down and read-back using 3 legal size laminated sheetsREACT scores maintainedADOPT

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Promoting Patient Preferences Through Nurse-prompted Elicitation of Daily Goals

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“…18,19,20 Recording daily goals on a whiteboard facilitates a consistent plan of care, goal directed care, and provides health care providers with a daily list of patient goals to review. 19 One quality improvement study focused on whether an educational intervention for nurses improved identification of patient daily goals. Overall, this study showed that the nurse educational intervention increased whiteboard documentation, articulation of goals, nurse collaboration concerning goals and patients felt more informed by nurses.…”