Keywords videoconferencing - telerounds - multidisciplinary rounds - social distancing - intensive
care units
Introduction
Bedside rounds in the intensive care units (ICUs) serve multiple purposes including
development of the patient care plan for the day, updating patient and/or their family,
performing safety checklists, teaching of trainees, and ensuring that all members
of the care team have the same mental model of the patient.[1 ] As critical care has evolved with more complex decisions, new equipment, pharmacologic
treatment and social dynamics, and determinants of health, the ICU rounding team in
many institutions has also expanded to include a respiratory therapist, pharmacist,
social worker, case manager, child life specialist, clinical nutritionist, as well
as the provider, and nursing teams. This multidisciplinary team can comprise of 15
to 20 people, when consultants are also involved. The use of a computer on wheels
to access the electronic health record further limits available space for bedside
rounds in hallways and outside of patient rooms.
The novel coronavirus disease 2019 (COVID-19) pandemic has led to guidelines on social
distancing by the World Health Organization and the Centers for Disease Control and
Prevention[2 ]
[3 ] that have been widely adopted. The implementation of these guidelines in the hospital
setting, especially during bedside rounds, makes the previous model of large group
rounds untenable.
In an effort to appropriately maintain distance and hence minimize the chances of
the spread of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) during
bedside rounds, we have started utilizing available videoconferencing technology.
This article describes the feasibility of the use of a mobile rounding cart to allow
members of the team to round from conference rooms while maintaining appropriate social
distance and have a small part of the team at the bedside.
Materials and Methods
Setting
The project was conducted in the Pediatric Intensive Care Unit (PICU) at the University
of Maryland Medical Center. The PICU is a 19-bed mixed medical/surgical and cardiac
surgery ICU.
Design
This was a pilot study to examine the use of videoconferencing to facilitate multidisciplinary
rounds following the initiation of strict isolation and social distancing policies
in the setting of a pandemic.
Equipment
In 2018, our unit purchased mobile workstations that were equipped with a high-resolution
camera, targeted microphone and speaker system, a monitor, and basic computer. Utilizing
secure ZOOM software platform (ZOOM Video Communications, Inc.; San Jose, CA), families
and consultants were enabled to use mobile devices to round at the bedside with the
team. With the onset of COVID-19 in 2020 and the need for social distancing during
rounds, we were able to repurpose this mobile workstation as the central hub for rounding
at the bedside by the attending physicians. Residents and nurse practitioners prerounded
on their patients prior to formal bedside rounds and then joined other members of
the multidisciplinary and multispecialty team from conference rooms and other locations
while maintaining appropriate social distancing using the same videoconferencing application
on tablets, phones, and personal computers.
Staff
There are two PICU rounding teams during weekdays and one on the weekends. Provider
teams consist of critical care attendings, fellows, nurse practitioners, and residents.
The cardiac provider team includes two cardiothoracic nurse practitioners, a critical
care attending, cardiothoracic surgeon, and cardiologist. The medical provider team
includes a critical care attending, fellow, nurse practitioner, and three residents.
The critical care attending, subspecialist (if necessary), nurse, and parent round
at the bedside with the use of a mobile workstation equipped with improved technology
([Fig. 1 ]). The attending physician and subspecialist examine the patient and then rounds
were conducted directly outside the patient's room during the pandemic. Other essential
team members (i.e., residents, fellow, nurse practitioners, and respiratory therapist)
participate in rounds from conference rooms and workstations ([Fig. 2 ]). Fellows, nurse practitioners, and residents examine patients prior to rounds unless
the patient is COVID-19 positive or under investigation. For these patients only senior
members of the team perform clinical assessments to minimize team exposure. Other
team members participate from home or office (i.e., nutritionist, case manager, and
pharmacist). Patients' families are always invited to participate on rounds with their
mobile device from inside the patient room or remotely. The medical and cardiac teams
round simultaneously and the presentation structure and flow remain unchanged. Workflow
duties are assigned at the beginning of rounds (i.e., displaying patient data, entering
orders, and reviewing safety checklists).
Fig. 1 ZOOM social distancing multidisciplinary rounds with a mobile cart at bedside.
Fig. 2 ZOOM social distancing multidisciplinary rounds with staff remotely.
Survey
We conducted a survey at the end of April 2020 to assess the feasibility and participant
attitudes regarding the use of a mobile cart as the central hub for multidisciplinary
rounding with other members of the team using mobile devices, 1 month after implementation.
The project was reviewed and approved as nonhuman subject research by the University
of Maryland institutional review board and exempted from further review.
Results
Overall Satisfaction/Feasibility Survey Results
Fifty-eight multidisciplinary staff members who participated in videoconferencing
rounds completed the survey. Respondents included intensivists, fellows, nurse practitioners,
residents, nurses, respiratory therapists, pharmacist, nutritionist, and multispecialty
team members ([Fig. 3 ]). All PICU providers (attending physicians, fellows, nurse practitioners, and residents)
who participated in multidisciplinary rounds during the study period completed the
survey. Thirty-seven percent of nurses (22 of 59) and 43% of respiratory therapists
(3 of 7) completed the survey. The results of the entire survey are presented in [Table 1 ]. Overall 88% of staff agreed that the use of videoconferencing to facilitate multidisciplinary
rounds was an effective strategy to maintain social distancing between team members
during the pandemic. Sixty-four percent of staff agreed that the use of videoconferencing
improved participation of the PICU team and consultants by increasing access to multidisciplinary
rounds. Fifty percent of staff agreed that the use of videoconferencing improved the
efficiency of multidisciplinary rounds including improved timeliness of order entry
and completion of standard practices (i.e., nurses summarizing plan of care and completion
of daily safety checklists). Only 3.5% of staff responded that videoconferencing increased
the duration of multidisciplinary rounds and 37% responded that it decreased resident
and team education. Only 46% of staff agreed that the team was able to adequately
maintain patient confidentiality at the bedside with the use of videoconferencing
during rounds. Based on respondent comments, staff satisfaction was higher on the
cardiac team with 70% of the respondents agreeing that workflow and team productivity
improved (i.e., presence of necessary team members and consultants, decreased distractions
for team members at the patient bedside, and early completion of daily notes). Fifty-five
percent of staff agreed that the use of videoconferencing to promote parental participation
during multidisciplinary rounds was encouraged during this pandemic month. Sample
staff survey comments are presented in [Table 2 ].
Table 1
Use of ZOOM to facilitate multidisciplinary rounds staff survey results (n = 58)
Survey questions
Responses n (%)
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
The use of ZOOM to facilitate multidisciplinary rounds has improved participation
of the multidisciplinary team and subspecialists by increasing access to care
12 (20)
25 (43)
15 (26)
4 (7)
2 (4)
The use of ZOOM to facilitate multidisciplinary rounds has improved the efficiency
of rounds by timeliness of order entry and completion of standard practices, i.e.,
nurse summarizing plan of care, daily safety checklist
7 (12)
21 (37)
18 (32)
9 (16)
2 (4)
The use of ZOOM to facilitate multidisciplinary rounds allows the team to maintain
patient confidentiality at the bedside
4 (7)
22 (39)
19 (33)
10 (18)
2 (4)
The use of ZOOM to facilitate multidisciplinary rounds Is disruptive to nurses by
decreasing time to perform tasks and respond to other patients
0 (0)
2 (4)
15 (26)
37 (65)
3 (5)
The use of ZOOM to facilitate multidisciplinary rounds has decreased time to educate
residents and other care team members
1 (2)
21 (36)
18 (32)
18 (32)
0 (0)
The use of ZOOM to facilitate multidisciplinary rounds has been an effective strategy
to maintain social distancing between team members
29 (51)
21 (37)
4 (7)
2 (3)
1 (2)
The use of ZOOM to facilitate multidisciplinary rounds has improved team participation
and engagement in rounds
7 (12)
12 (21)
26 (46)
10 (18)
2 (3)
The use of ZOOM to facilitate multidisciplinary rounds has been an effective method
to communicate clinical information and participate in shared decision making
7 (12)
39 (67)
7 (12)
3 (5)
2 (4)
The use of ZOOM to facilitate multidisciplinary rounds has not interfered with normal
workflow in the PICU
4 (7)
35 (60)
7 (12)
9 (16)
3 (5)
The use of ZOOM to facilitate multidisciplinary rounds has significantly increased
the duration of rounds
1 (2)
5 (9)
13 (22)
34 (59)
5 (9)
The use of ZOOM to facilitate multidisciplinary rounds is technically difficult, i.e.,
frequent visual or audio challenges
0 (0)
13 (22)
17 (29)
27 (47)
1 (2)
The use of ZOOM to facilitate multidisciplinary rounds has improved workflow, productivity,
i.e., presence of necessary team members, decreased distractions for team members
at the bedside, early completion of notes
5 (9)
26 (45)
15 (26)
10 (17)
2 (3)
The use of ZOOM to facilitate multidisciplinary rounds has provided additional opportunities
for team education, family education, and family communication and engagement
0 (0)
13 (23)
25 (43)
17 (29)
3 (5)
During this unfortunate time of visitation restrictions, parental participation by
ZOOM is encouraged to allow participation in multidisciplinary rounds or other opportunities
that are convenient for the parent
3 (5)
29 (50)
15 (26)
10 (17)
1 (2)
The use of ZOOM to facilitate multidisciplinary rounds is an effective rounding method
9 (16)
37 (64)
8 (14)
2 (3)
2 (3)
I would like multidisciplinary rounds via ZOOM to continue after social distancing
restrictions are removed
5 (9)
24 (41)
7 (12)
15 (26)
7 (12)
Abbreviation: PICU, pediatric intensive care unit.
Table 2
Use of ZOOM to facilitate multidisciplinary rounds staff survey comments
Representative statements
Rounds are much more efficient and allow providers to go to individual bedsides and
have one on one conversations with family.
It needs work but has the potential to favorably impact care after the pandemic. There
is no better option for social distancing during the times we are in.
This novel idea has helped patients and families stay connected to the team and was
welcomed for that purpose prior to COVID-19. I feel that presence of the residents
on rounds is vital to their learning and management/ownership of the patient and that
the primary resident for the patient should be allowed to be present at bedside (even
during pandemic distancing measures).
I think it has been a valuable tool during this unique time.
Use of ZOOM rounds has enabled social distancing; however, I believe it has also enhanced
the distancing between resident physicians and patients.
When rounding it may be helpful if all people in the PICU had situational awareness
of rounds going on and kept conversations quiet when rounds are going on. The audio
often catches side conversations.
Difficult to do bedside teaching. I felt like residents were disconnected from patients
and nursing staff.
ZOOM has been an adequate way to communicate while keeping team members at safe distances.
I have been able to complete notes by the end of cardiac rounds which has been very
helpful.
As the clinical pharmacist, It has been extremely helpful to be able to participate
in medical and cardiac team rounds simultaneously.
I think there is less teaching opportunities for residents with ZOOM rounds but if
the attending comes to the work room after rounds to make any further teaching points
then that would mitigate that discrepancy.
I would encourage the use of ZOOM rounds with the addition of bedside teaching and
education.
Sometimes sound has been challenging.
I feel there is a lack of communication between team members when orders are being
written. When rounding it may be helpful if all individuals in the PICU had situational
awareness that rounds are going on and keep conversations quiet.
Difficult to hear the provider on the computer if not standing directly next to it.
ZOOM rounds has improved the efficiency of rounds on the cardiac team and has allowed
additional time for other work activities, such as coordination of care and bedside
discussions, with families.
Abbreviations: COVID-19, novel coronavirus disease 2019; PICU, pediatric intensive
care unit.
Fig. 3 Breakdown of the multidisciplinary rounding and survey participants.
Discussion
This pilot study demonstrated the feasibility of treatment and participant attitudes
toward video-based multidisciplinary rounds to promote social distancing and enable
the team and family to participate on rounds during a pandemic. Multidisciplinary
rounds are a valued structural ICU process for the implementation of collaborative
decision making and evidenced-based management to achieve optimal patient outcomes.
Conducting rounds at the bedside has been shown to improve communication and trust
between the patient/family and multidisciplinary team and enhance shared understanding
and shared decision making regarding the patient plan of care.[4 ]
[5 ]
[6 ] In addition, multidisciplinary rounds can effectively identify safety risks and
prevent gaps and delays in care through the incorporation of care bundles, daily goals,
and safety/quality measure checklists.[6 ]
[7 ]
We used video teleconferencing since 2018 to enhance parental participation in PICU
rounds for parents who could not physically be present and thus allowed us to rapidly
incorporate videoconferencing into our new rounding process with social distancing.
The patient census during the implementation was lower than expected, and although
the addition of the donning and doffing strict isolation procedure for the majority
of patients added to the bedside workflow, it was not seen as a hindrance for bedside
rounding team members using the videoconferencing mobile cart. The staff education
required was minimal and there was little technical difficulty encountered, making
this a feasible solution for rounding while maintaining social distancing.
The staff survey results demonstrated that the use of videoconferencing for multidisciplinary
rounds did not disrupt nurses' normal bedside workflow processes or significantly
increase rounding time ([Table 1 ]). However, the respondent comments suggested differences in satisfaction between
the two rounding teams ([Table 2 ]). On the cardiac team, nurse practitioners are the sole direct care providers at
7 days/week and have a highly systematic daily workflow. The use of videoconferencing
allowed the nurse practitioners to more efficiently complete required work (i.e.,
writing daily notes) while maintaining consistent rounding processes and easily adapted
to this new workflow. The medical team members agreed that videoconferencing was effective
for social distancing during rounds and technically easy but were less satisfied with
the new process. For the residents rotating into the PICU, this novel approach to
rounds had not been adopted in other clinical areas and was perceived as having a
greater impact on the medical team dynamics. The respondent comments suggested less
resident and team teaching occurred and there was decreased resident engagement with
nurses and families ([Table 2 ]). The team work spaces are outside the PICU making it critical during huddles to
identify team members, responsibilities and roles and desired communication channels/devices
to readily access team member, as well as ensuring presence on the unit on a frequent
basis. The critical care team rapidly transitioned education activities to videoconferencing
and as team members became more accustomed to social distancing educational activities,
the educational value and satisfaction has increased. However, small team educational
activities continue to be important, as well as one on one education to stay connected
and encourage team interaction.
We added a secure ZOOM software platform in 2018 to increase family engagement during
multidisciplinary rounds. This had led to increased involvement of parents on rounds
in the prepandemic era. Surprisingly, the survey results revealed parental participation
via videoconferencing was lower during the study period than we anticipated. We speculate
that this may be due to the change in visitation policies during the pandemic, as
the waiting areas had been closed and closure of many businesses or transfer of work
to a virtual environment enabled families to be able to be at their child's bedside.
In addition, the cardiac team has frequent discussions with the parents and include
a daily update after rounds and therefore may not have been perceived as necessary.
However interpretation is limited as we did not directly survey the patients' families
to gauge their response to this change in rounding practice and will need to engage
parents more in the process by actively adding them to the videoconference call when
not physically present
Technical challenges are always a likely barrier when implementing a new process that
is highly dependent on audio, visual, and software. We selected to use ZOOM that was
supported by hospital internet technology (IT) who ensured security; however, this
could be implemented on any secure Healthy Insurance Portability and Accountability
Act (HIPPA) compliant software meeting platform. The other participants on rounds
used a mix of hardware devices that included hand-held smart phones, laptops, and/or
desktops with a webcam. Having participants on both audio and visual assisted with
managing the conversation and flow of rounds. The wide lens camera and directional
microphone incorporated into our telecart enabled the participants to both see and
hear the bedside team and the patient/family. The internet speed was adequate with
upload and download testing speed between 90 and 100 megabits per sec (Mbps). A secure
texting application allowed for communication of meeting ID and passwords to the rounding
team, as well as coordinating timing of the initiation of rounds, and facilitate breaks
needed to tend to emergencies on the unit. To manage participants on mute or participants
that needed to tend to something else, our team used the chat feature in the ZOOM
software to indicate when someone needed to step away or point out that someone was
on mute.
Maintaining patient confidentiality with the use of videoconferencing was of utmost
concern. Primary measures to ensure confidentiality and patient privacy included the
sole use of a secure texting application and HIPPA compliant video software. However
daily reminders of patient confidentiality and videoconferencing etiquette are key.
We instituted a brief reminder by the attending physician that includes appropriate
speaker volume, proximity of presenting provider/speaker to the mobile microphone,
limiting surrounding conversations, and ensuring secure locations of remote team members.
Limitations
Although this project only describes our early pilot process and has several limitations,
including survey-based results, small number of respondents, and short study period,
the change was instituted during the height of the pandemic and uncertain, stressful
circumstances for the staff. Although it is unknown if this novel rounding process
helped to minimize the chances of spreading SARS-CoV-2 during bedside rounds, we found
great benefit in this process as it facilitated the participation of all team members,
as the nonessential members (i.e., clinical pharmacist, nutritionist, and case manager)
were required to work from home. However, further investigation regarding the perceived
differences in staff satisfaction between the medical and cardiac rounding teams and
how to improve remote trainee educational activities and team engagement are warranted.
The pandemic has rapidly changed many of our traditional work processes and some potential
work processes for permanently. Video-conferencing can be an effective method to facilitate
social distancing during multidisciplinary rounds but has also been shown to enhance
communication between the family and the health care team.[9 ] There are endless possibilities for its use to engage and connect with families
in the care of their child.[10 ]
[11 ]
Future Direction
The introduction of videoconferencing to facilitate multidisciplinary rounds was expected
to be a short-term solution for our PICU to maintain social distancing during the
COVID-19 pandemic. Although there are barriers to address, we have also observed potential
benefits that question some of the traditional ICU practices and whether there are
opportunities to rethink our rounding practices. For example, what is the long-term
utility of videoconferencing to effectively bring patients, families, multidisciplinary
team, and subspecialty teams together for rounds and for other opportunities.
Conclusion
Although we have entered unprecedented circumstances, maintaining the best practices
at ICU are critical to achieve optimal outcomes. Multidisciplinary rounds are an integral
ICU process that must include collaborative evidenced-based management that is family
centered and strives for efficient but high quality and safe care. Video-conferencing
is a feasible solution to safely conduct multidisciplinary rounds while maintaining
social distancing during the pandemic. Incorporating videoconferencing into our traditional
rounding practice may be advantageous in improving team and family access to rounds,
workflow efficiency, rounding structure, offers creative teaching opportunities, and
family engagement opportunities. However, further investigation is needed to address
how to improve parent participation and optimize educational aspects of rounds which
are central to trainee learning.
