Good afternoon, and thank you for joining us for this session, Who Should Be on Rounds? The Evolution of ICU Patient Care Over the Past Five Decades. First off, we have Dr. Samuel Tisherman taking us back to Once Upon an ICU, the Inception of Critical Care Rounds and the History of ICU Rounding. Then Dr. Marilyn Shalom will bring us through an Evolution of Partnership, a Nurses' Perspective, followed by Dr. Emily Owen for Respiratory, Pharmacy, Dietary, and Mobility, the Generation of Multidisciplinary ICU Rounding. Then I will bring you into the session, What's the Patient Got to Do With It? The Evolution of Patient and Family-Centered Care in the ICU Rounding Process. And finally, Dr. Ruben Peralta will take us into the future, Look at Us Now, Diversity at its Best in Rounds Around the World. Thank you, and I hope you enjoy this session. Greetings. I'm Sam Tisherman. I'm a surgical intensivist at the University of Maryland, and today I'm going to speak to you about the history of rounds. I have no disclosures. What I'll do is go through the development of ICUs, talk about the evolution of physician training in critical care, and then spend some time on ICU structure and how that plays into rounds. So let's start with ICU development. This always starts with a discussion about Florence Nightingale, who really pushed the idea of intensive nursing care by bringing the sickest of the sick patients in the Crimean War together for a group of nurses to care for them. On the physician side, there's not a whole lot I could find in terms of history, except Osler was certainly a big proponent of bedside rounds. His focus was mostly on teaching other residents and students, but also nurses were clearly involved with rounds with Dr. Osler. Now, getting into actual ICU development, one of the first developments was the development of a neurosurgical ICU of sorts, it was really just a neurosurgical care unit by Walter Dandy at Johns Hopkins. There were two bedrooms, and this is just a picture of what he called the brain team that took care of these patients in these units. The really intensive care took off with the polio epidemic in the early 50s. Here you can see all of the iron lungs, the nurses taking care of the patients. Bjorn Ibsen is one of the first developers of a ICU-type place where he described a place for all patients with respiratory problems, where it collected in a special department where they were under constant observation by a team consisting of an epidemiologist, ENT surgeon, and anesthetist, all working with the help from an excellent and capable laboratory. One of the things that he did was do tracheostomies on a lot of these patients, and then they were manually bagged by this army of medical students and extra nurses, with the senior anesthetist being Dr. Ibsen overseeing the whole team. He did make some interesting comments about leadership in an ICU. He brought up the notion of a patient who comes in with diabetic ketoacidosis that might be managed by an internist, or a patient coming in with a perforated ulcer that would be managed by a surgeon, and a patient needing intensive therapy for pulmonary complications or shock that would be managed by an anesthesiologist. But what if you have a patient who comes in with septic shock from a perforated ulcer who develops DKA and then pulmonary complications? The question is, who is in charge? And this will be something that's important when we talk about open versus closed ICUs. In the late 50s, Hal Wild developed the idea of what he called the Shock Ward at USC, medical and nursing specialists supported by engineers and technicians who would utilize monitors, measurements, and alarms in real time, such as to have capability for timely intervention, and thereby greater likelihood of reversing immediate life threats. And I thought this was kind of an interesting couple pictures from this Shock Ward, where on the left you can see a man at the computer station, and on the right, there's a small machine on the desk that is actually spewing out patient data. They have a camera focused on this machine that is then attached to the TV, which is on the left side of that picture. So it's really just the beginning of what we now know as bedside monitors. But Peter Stafford is really credited with having the first ICU in the United States, and the point was to try to concentrate sick patients in one place where there's continuous attention by physicians, there's a select group of well-trained nurses, there's a concentration of equipment also for resuscitation in monitors, and there's a decreased need for duplicate equipment throughout the hospital. This was at Baltimore City Hospital, it was run by the anesthesiologist because of their expertise in respiratory care and resuscitation, but surgical and medical residents provided the general care of the patients. Around the same time in Uppsala, Sweden, two ICUs began, one was a general one run by the anesthesiologist, and one was a thoracic one run by the thoracic surgeons, but they noted that surgeons, internists, and anesthesiologists all rounded together in these units. Peter Stafford then moved to Pittsburgh and noted that before 1965, there really was not an organized ICU, it was what he called an improvised unit with nurses and on-call health staff, anesthesia, medicine, and surgery, and then in 1965, he started a truly dedicated multidisciplinary ICU, but he did note some challenges that are still things that come up today. One was that more ICUs that are needed were built, although right now it seems like we're in an opposite situation. There was fragmentation or departmentalization where each ICU was run by a different department and that he felt was a major problem across the hospital. There's a lack of continuous coverage by experienced physicians, lack of rapid mobilization of available talents, and one of the biggest things that he complained about for years was that the most inexperienced health staff, meaning the interns typically, were sometimes given power to control the care of the sickest patients in the hospital. But he did note the importance of a team at the bedside with the patient at the center of that, the nurses, physicians, social workers, what they called intellectual therapists, which we now call respiratory therapists, those that had to be an administrative component, which a nurse manager and a physician medical director, lab personnel, point-of-care testing was very important to them, and engineers to manage all of the equipment. Well, now let's move to physician training in critical care, and this is specific to adult training in the United States, where even though Peter Saffer started a multidisciplinary training program at the University of Pittsburgh, the evolution of training developed along departmental silos of medicine, anesthesiology, surgery, and most recently, neurology. So anesthesiology critical care made a lot of sense at the time because of the anesthesia-style monitoring of airways, ventilation, hemodynamic support in the operating room, and these real are the first trainees in critical care. Then we come to pulmonary and critical care medicine, where certainly the understanding of lung pathophysiology is very important in the ICU, the management of complex respiratory diseases, pulmonologists actually understand pressure-volume loops. It's beyond me as a simple surgeon, but the idea of internists, pulmonologists, and cardiologists getting involved in the ICU was really pushed by Hal Weil, who was actually a cardiologist that began the shock ward. So like other fields of intensive care, there's been subspecialization over the years. There are typical medical ICUs, but we also have coronary care units and oncology units in certain hospitals. Will Shoemaker was the one who really pushed the notion of surgical critical care. Surgeons understand anatomy, they understand physiology, they understand the risks and the potential complications of major operations, so it makes sense that they're involved in the ICU. It also made sense that surgical units evolve from the post-operative recovery room, and as I've already mentioned, the work by Dandy and staff are prior to this. So surgical care has changed dramatically over the last couple hundred years from relatively straightforward operations performed under ether to very complex, sophisticated operations that are done in these hybrid operating rooms that look quite futuristic, but these are what's already out there today. So there's a lot of subspecialization in surgical critical care also. This includes cardiac surgical units, transplant units, trauma units, neurotrauma units, burn units, and others. More recently, neurointensive care has really become a bona fide critical care specialty. The interventions that are now available for stroke, status epilepticus, neurotrauma, and multimodality monitoring of the brain have really changed this field dramatically. And because of that, we've gone from neuroscience-based units that are somewhat general to more specific neuro units and neurotrauma units. And training in this field has been pushed by the Neuro Critical Care Society as well as the United Council of Neurological Subspecialties and the Society of Neurological Surgeons. So now we have critical care being the main focus, but you can get to critical care from pulmonary and critical care medicine, surgery, anesthesiology, and neuro, and there are other specialists who can participate in these training programs, particularly emergency physicians. Now let's look at the ICU structure. It's an interesting commentary by Tobin and Grendick in 1983, where they commented that physicians, and by this it meant internists, are more willing to relinquish control and accept the CCM physician as the final authority. Some surgeons are very reluctant to adopt this approach, even though they admit that activities in the operating theater may prevent their ability to respond promptly to life-threatening emergencies in the ICU. Interesting how that's still somewhat true today. So let's talk about open versus closed units. An open ICU is kind of like the Wild West, where anybody can admit a patient and take care of them. It's just a matter of concentrated nursing care and monitoring. There's an open unit with a potential for a consult to an intensivist service, semi-closed where there's a mandatory consult to an intensivist, along with the primary surgical team, and then a closed unit where the intensivist manages all of the patient's care. So this is an example of a study of what happens in an ICU when it goes from an open unit to a closed unit. This is a medical intensive care unit, and when they closed the unit, the apathy scores actually went up, so the patients were a little sicker, mortality went up a little bit, but most importantly, the actual to predicted mortality went down. There were no changes in length of stay, laboratory, or radiology utilization or pharmacy charges. And it's an interesting commentary that the nurses were more confident in the judgment of the intensivist. What about surgical units? This is an example from Penn, where the surgeons could admit the patients to the ICU, and they had a choice of consulting a dedicated service or taking care of the patients themselves. The outcomes were that there was less time spent in the ICU by these patients, fewer resources were utilized, fewer complications, and lower total hospital charges. Now we're going to talk a little bit about high-intensity versus low-intensity models of intensivist coverage. High-intensity means it's a mandatory intensivist consult or it's a closed unit. Low-intensity means it's an elective consult or it's an open unit, and this was proposed by Pronovost many years ago. This is just one study looking at the outcomes related to this. This is a study in Pennsylvania of over 100,000 patients, and they looked at whether or not there were multidisciplinary rounds and whether or not it was a high-intensity physician staffing model. If you had low-intensity and no multidisciplinary rounds, that was stated as an odds ratio mortality of one, and then if you had multidisciplinary rounds, mortality decreased. If you had high-intensity physician coverage on top of the rounds, mortality decreased even further. This plays into the LeapFrog standard. LeapFrog Group is a group of companies that have banded together to promote safety and quality in patient care. They state that ICUs should be managed by intensivists who are present during daytime hours and provide clinical care exclusively in the ICU. They should respond promptly when not present on site, and they should arrange for other physicians, advanced practice providers, or certified nurses to reach the patients within five minutes if they can't be there. And they must lead daily multidisciplinary team rounds. So one really important part of rounds from the physician side is to make sure that everybody on rounds understands what's going on. This is just an example of the use of a daily goals form. I'm sure that we're going to hear more about this in other presentations. But in this study, they showed that by using a simple form like this, both the residents and nurses had a better understanding of the plan for the patients. And of course, in the multidisciplinary interprofessional team to manage the patients, all these people need to be involved. Maybe not necessarily all on rounds at one time, but need to be available and involved. So a couple of final comments about who can or should be there but not there. We could spend a whole hour talking about the use of telemedicine, but certainly the 24-7 tele-intensivist is a real concept that is utilized in a number of hospitals. But there has to be on-site care planning done by an intensivist, hospitalist, anesthesiologist, or emergency physician. But by LeapFrog standard, this could be appropriate. Well, who shouldn't be there? I just threw a couple things in here. This is actually a study that an applicant to our program told me about where they decreased the number of workstations on wheels that were available on rounds. They found that this decreased the simultaneous conversations that were going on during rounds and actually improved hearing. So it was more appropriate and focused interaction by the team without having so many computers around. And finally, again, a nod to Peter Stafford. This is a cartoon of him keeping the Grim Reaper out of the ICU. Death is not the enemy, but occasionally needs help with timing. So I'd like to thank the program committee for giving me the opportunity to speak to you today and hopefully giving you a better sense of the history of ICU development, ICU training, and the structure of intensive care units. Thank you very much. Hello, everyone. My name is Lynn Shalom, and I'm the Director of Research for Patient Care Services at Barnes-Jewish Hospital at Washington University. And I am honored to be on the panel to discuss ICU rounds and evolution of partnership. I will be presenting the nurse's perspective. I have no financial disclosures. I do have a disclosure that I used some of the images from Google, and I have the disclosure that I've been a nurse for 40 years with 38 of those in the ICU, both as a bedside nurse and a clinical nurse specialist. And so there's the potential for a faulty memory. So I started in 1983 in the surgical ICU, and this is what rounds looked like, that there was an attending anesthesiologist, residents, and medical students. And you can see missing from the picture is the nurse or respiratory therapist or any other professionals. So what really happened at that time was that there were pre-rounds, and that was when the nurse and the resident or medical student would discuss the patient, what occurred overnight, any concerns that we had. And then during rounds, the resident or medical student would present the patient to the rest of the team, including the attending anesthesiologist. Then orders were written and handed to the nurse. It had very much of a teaching focus. There was no family presence. And when I think back on that time, there must have been a lot of errors. I know that as a nurse, often I was in the background listening, and I had to be very skillful at asking questions to present a concern that I might have and bring that up during rounds. Then after rounds, we, again, used our best communication style to clarify and correct any misunderstandings or orders that were of concern with the resident or medical student who would then take it back to that anesthesiologist, which was never perceived very well. So we had to, again, be very skillful at that process. So then, again, in a surgical ICU, the surgeon rounds. This is what they looked like. Again, the attending surgeon or the surgical resident for that patient would round with the resident or medical student. And sometimes the nurse was present. We were asked questions about what was going on with the patient. So this is a visual of what that looked like, where it was the patient at the center and the R and the RT were kind of off outside of the rounds. I then worked for a few years in the late 80s and early 90s in a community hospital. The rounds there were, the charge nurse was on rounds with either the attending surgeon or admitting physician, and the bedside RN participation greatly varied. However, that did start to change during the 90s when critical care physicians, often they were moonlighting fellows who would sometimes talk with the nurse. And then as that evolved to the intensivist, there was definitely a change in that the bedside RNs and respiratory therapists began to be engaged in the rounds. And I attributed this change to the professional organizations with which I've been involved, one being the American Association of Critical Care Nurses, who value the collaboration to ensure patient and family-focused care, and definitely the Society of Critical Care Medicine, who support the multi-professional approach throughout all of care, and that includes during rounds, the participation of nurses and all professionals during rounds. So this is what I believe rounds look like now in the 21st century, and they have continued to evolve with more and more family presence across ICUs around the globe. So the patient and family remain at the center. It is led by a skilled critical care intensivist, a multi-professional team including pharmacists, respiratory therapists, dieticians, depending on the patient, maybe social workers, physical therapists. In terms of nursing, the bedside nurse is present. Many ICUs have clinical nurse specialists who bring forward quality improvement, advanced technologies, advanced knowledge of the nursing, and then our nurse practitioners and advanced practice providers, as well as being supported by consults and the other support team members. We've developed some tools to support rounds, and one of those is a rounding checklist, which we published on in 2009, and we demonstrated that we had a reduction in errors of omission in order to provide best practices. The surgical ICU is now a 36-bed surgical trauma ICU, and they continue to update their rounding checklist as best practices emerge. And some of the best practices are that we can remove lines, review daily, and discuss among the team if a line is still needed or any other tubes that can be removed to reduce hospital-acquired infections. However, we still have opportunity for improvement. My colleagues and colleagues published two papers in the last few years looking at data communication during rounds, and they found in a 26-bed medical ICU, even though there was a structured interprofessional rounding script and use of EHR at the bedside, the fellows who were observing observed that 96 percent of patient presentations included at least one laboratory misrepresentation, with a mean of six per patient. The team was encouraged to speak up after the presentation, and only 7.8 percent of the time was the misrepresentation corrected, most often by the attending physician and second by the nurse. The errors most frequently were seen with the infrequently ordered lab test. They then carried that further and examined other aspects of rounds, including drips, imaging results, vital signs, et cetera, and again, there were frequent data omissions despite time allotted for input from the other providers. There were omissions of about 38 percent of the overall available data, and the interprofessional team this observation time supplemented with available data only 4.1 percent. The greatest improvement was within continuous infusion meds. There was 24 percent omission by trainees, which decreased to 5 percent when there was ICU team input, and I imagine that input came both from nursing and from pharmacy. I can only imagine what the level of omission was again during the 1980s when we first started. This study by Kao and colleagues examined the impact of a patient-centered structured round in a medical ICU, and you can see that they have a structured template and time period for each discipline to participate, and they found that family participation improved and that the healthcare workers perceived that there was improved communication of patient management goals and clarity of task assignments with the structured process. Some of the items that the nurse discussed were pressure injuries, ongoing concerns from overnight, the spontaneous awakening trial, and then the charge nurse facilitated the R and the RT preparedness for the next patient round. So why should nurses be present during rounds? Well, basically, we are in the room where it happens 24-7. We can compile and summarize the data for the past 24 hours. We can tell that story sequentially. We are advocates for the patient and family. We have always been that. We help prepare them for rounds, what rounds is going to look like, when they can ask questions and then on rounds, when we've identified something with the family or patient that they want to bring up, we help to stimulate that discussion by bringing it up and allowing them to have a voice. We're definitely present for rounds when other teams are present. So let's say it's the fifth day that nephrology is seeing the patient, they may not go see the rest of the ICU team and we can communicate that with the full team. We're present for care by other healthcare professionals like the physical therapist, speech therapist, et cetera. Here are the nursing domains that K.O. and colleagues discussed and then to clarify orders and ensure that there's understanding by all of the team that this is what the plan is. And so here are some of the nursing domains, again, pressure injuries, but really any skin alterations, first to detect allergies, reactions, sedation, pain management and restraints, the tolerance of medication titration weaning, as well as other therapies like VADs and other treatments, PCLS and mechanical ventilation, CRRT. We encourage the dietician to be present, but if they're not, definitely the nurse can present on nutrition tolerance, as well as any elimination issues. And then definitely the family and social needs, encouraging them and discussing any family dynamics, language barriers, et cetera. So why don't nurses regularly attend? Well, from my experience, I had written down a few ideas and then it was validated by Walden et al. They conducted a Delphi methodology study and included up to 75 participants, including physicians, nurses in a multitude of other disciplines. And the main barriers that they identified was that there was a lack of standard time, knowing when the rounds were going to occur. Nurses also have patient care responsibilities that prevent them from attending rounds. In the United States, often nurses have two patients, so it can be the acuity or care of the other patient, or it can actually be the care of the patient being rounded on, but they're actually having to provide the care at that moment behind a closed curtain and they can't hear or participate. They may be off the floor, and Walden also identified that nurses believed at times that their voice was not valued or not requested. So Kips et al., in a study recently published, developed a scheduling tool with a prioritization algorithm, which was intended to improve attendance by both RNs and families. This was done on a pediatric acute care unit. The algorithm was based on acuity, based on the service of that resident who was going to be presenting the patient, and they also examined did it impact the time for learning and teaching. They found that it did not, but it did increase family and nurse involvement. The rounding schedule was posted at 7.30 in the morning. So if you're having challenges, that may be a good approach to take. We have tools that support rounds, both during and after. Many hospitals, ICUs, have gone to goals whiteboards, could be a laminated sheet, so that everybody can see the goal at the time of rounds and then throughout the day as other individuals come in to see the patient and definitely the family. Our team developed a glass door template that has the information located on it, and you can see we have both AM and PM goals. We found that it did decrease errors, especially errors in communication with the team. Then recently, we added a communication bundle, and you can see in the bottom right corner, we have a chat emoji, and that is filled in when the first conversation occurs, because our goal is to have a conversation with all family members in the first 48 hours. Going back to the community hospitals, I haven't worked there since the late 90s, but there's definitely the impact of the tele-ICU can be felt, bringing both the expertise of intensivists and CCRNs to the bedside. It's been very clear during COVID care that the EICU has been instrumental in providing that crucial care to small community hospitals, caring for acutely ill patients that they've not seen before, and triaging patients to the academic medical centers when necessary. I also searched on the AACN website because they have a program called Clinical Scene Investigator, and there were a couple of community hospitals that work to improve rounding. This one that I have cited with the link to the site was an 8-bed ICU and a 40-bed community hospital, and you can see that they had hospitalists that provide the medical service with access to intensivists. However, once they began a formal rounding program, they saw improvements in outcomes and improved feedback from patients and families. I believe this sums all of what I've been trying to say. This is an editorial by the co-editors of the American Journal of Critical Care back in 2014. Dr. Cindy Munro is a critical care nurse, a doctor prepared, a researcher, and Dr. Richard Savelle is a critical care medical director. In their editorial, they spoke about transactive knowledge in the ICU, and they stated that patients and families deserve no less from their providers, and they were discussing all healthcare providers, all of the disciplines, the multi-professional. And optimal synergy among personal knowledge, shared knowledge among the healthcare team, and robust sources of information and data. And that's really what ROUNDS is centered on, providing that knowledge, engaging the patient and family, and using robust information and data. So in conclusion, I'm so happy to say that the nurse's voice is being heard. It has evolved significantly in the last 50 years, and certainly in the 40 years that I've been in critical care. We have much to contribute, as does all of the interprofessional team members. It's good to see that we now have a voice and a place in the circle. I thank you all for your attendance and listening, and I look forward to our discussion at the live panel discussion at SCCM Congress. Thank you very much. I'm Emily Owen, and I'm a clinical pharmacy specialist at Barnes-Jewish Hospital in St. Louis, Missouri, practicing in our surgery, burn, and trauma ICU. Thank you for continuing to be with us as we talk through the history of the ICU and ICU rounds. You've heard a little bit about the development of the ICU and nursing involvement, and now we're going to talk more about the development of the interprofessional team. Interprofessional rounds are a critical forum for exchange of information and decision-making in the ICU. They help with the safety culture and have been shown to reduce adverse events, morbidity, and mortality. Each member of an interprofessional team has a different background and skill set that they bring to the table to take care of these critically ill patients. The Society of Critical Care Medicine recommends the inclusion of critical care nurses, respiratory care practitioners, pharmacists, and other non-physician critical care professionals within each ICU. During this presentation, we will focus on the workings of an interprofessional team and the four roles of respiratory, pharmacy, dietary, and mobility. As you heard in the previous sessions, there are multiple members of the interprofessional team. What started out originally with mostly just a physician as well as bedside nurse has really blossomed into a team full of several different professions, including pharmacists, respiratory, physical therapy, occupational and speech therapy, a dietician, social worker, as well as clinicians in training. There's also been an increased growth in inclusion of the patient and family as members of the ICU team. And then with more recent years, there's also been more involvement of tele-ICU or EICU as members of the interprofessional team. A team is a set of two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal and who have each been assigned a specific role or function to perform. As team leadership has progressed, it should balance authority with inclusiveness while establishing shared goals and fostering a sense of shared responsibility for patient care. Team members should be able to talk openly about mistakes and difficulties in order to create a culture where there is no fear of retribution for clear and candid communication about potential problems. Effective team performance is contingent upon cooperation, coordination, coaching, communication, and cognition between team members. Successful ICU teams are able to exchange information and work together on some shared goal or task, such as managing the complicated care required to take care of ICU patients. Unlike traditional teams, ICU teams are low in temporal stability as members of the team may change from day to day. In spite of this, they function because the persons fulfilling each position are expected to bring their specific shared knowledge about caring for critically ill patients and their shared expectations about their specific role within the ICU. Formal and informal handoff processes also contribute to team functioning. ICU teams are also different from many traditional teams by their unique physical and emotional constraints that affect team performance, things like the near constant alarms, uneven lighting, poorly placed equipment, and space limitations. Because of these issues, effective communication is necessary for the ICU. There must be the ability to transfer information, ideas, and opinions across team members with a widely varying background, different expertise, and skill levels. Because of this, ICU team members must trust in others' knowledge, skills, and training so that the teams can perform in a high stakes situation despite little or no shared history. Because of the need for teamwork within this setting, there are many different qualities for building this collaboration. Things like cooperation, dependability and reliability of team members, intelligence and participation in shared decision making, willingness for team members to listen and provide open dialogue, modesty and good communication skills, as well as the accessibility to the team when needed. It's also important for team members to be teachable and a good team player. Besides patient care and daily rounds, members of the interprofessional team can participate in a variety of different other collaboration opportunities. Things like grand rounds, quality improvement projects, specific initiatives like code team or rapid response team, scholarly writing projects, professional presentations, community projects, and research. The AHRQ defined a couple of qualities of a high performing team. High performing teams have team oriented cultures where they include each different member of the team as part of the team being able to share their knowledge. They have shared beliefs in providing excellent care to their critically ill patients. They're able to communicate in an informal way but also a direct way so that people are comfortable sharing but important information can be purveyed. They also take a collaborative approach to problem solving including multiple different professions instead of just one. Within the ICU team, each individual member might have separate goals or have common goals. These goals might not always align amongst providers but at the end of the day, everybody's there to take care of the patient. Patient outcomes are oftentimes the most important goal that we think about providing that these patients have the best clinical outcome. Oftentimes mortality rates are looked at within the ICU. However, these are not always the best metric because we take care of very severe patients as well as end of life care. Other important goals of the ICU team include improving health related quality of life among ICU survivors, improving quality of death and dying, acting as efficient stewards of our healthcare resources, and tending to the needs of family members of our critically ill patients. Because rounds are time and resource intensive and there's a lack of or there's a risk of misreporting or misinterpreting data, emphasis has been placed on improving the rounding structure and process. There is no single optimal structure to rounds. Standardization of what time rounds start and location for rounds improves rounding effectiveness by facilitating greater participation among team members. This also improves team attendance. It should also emphasize a systematic approach not only to patient data presentation but also to the formation and documentation of treatment plans, timing of team member input, allowance for questions and clarifications, and summary of the overall goals of care for the day. There are standardized communication tools that can also be used. Things like a daily checklist or daily goal sheet for the patient, a door communication card or board, or the SBAR method, which is summary, background, assessment, and response. So now we'll transition into each of the different four specialties. Respiratory therapists have been participating in the care of the critically ill patient nearly since the development of the first ICUs. Respiratory therapists typically oversee the provision of mechanical ventilation. They work with the team to monitor and promote airway management, including oxygen therapy, mechanical ventilation management, aerosolized medication therapy, cardiorespiratory monitoring, and patient and caregiver education. They play an essential role in both intubated and non-intubated critically ill patients. And they play a partnership in determining the optimal way to ventilate a patient as well as physically manipulating ventilators and playing a role in AVG monitoring. Although mechanical ventilation is collaborative by nature, respiratory therapists possess unique expertise and experience in how to operate the ventilator. Their involvement is associated with lower mortality in critically ill patients, and they contribute specifically to the optimal provision of spontaneous breathing trials, early mobility, and implementation of the PAD guidelines. Pharmacists have been involved in the care of critically ill patients since the 1970s, and their role continues to evolve with specialization in critical care offered by the Board of Pharmaceutical Specialties. Pharmacotherapy for critically ill patients is complex as pharmacokinetics is often altered by organ dysfunctions and abnormal physiologic states such as sepsis. Drug administration and dosing can be highly influential on patient outcomes, and clinical pharmacists provide a unique expertise on drugs as the certified specialists in the science and clinical use of medications. Pharmacists with specialty training in the ICU are equipped in recognizing the needs and the problems specific to the critical care patient, and they work with members of the team to foster effective and safe medication therapy. They assist clinicians with pharmacotherapy decision making and drug dosing, playing a role in reducing medication errors and improving medication safety by identifying drug-drug interactions and assuring appropriate initiation and discontinuation of medications. The presence of a clinical pharmacist in the ICU is associated with lower adverse drug events, improved patient outcomes, improvement in infection control management, anticoagulation therapy, sedation and analgesia utilization in the ICU, as well as adherence to multidisciplinary protocols and bundles such as sepsis and pain agitation delirium. Dietitian's roles within the interprofessional team has been growing over the past three decades. They've been participating in the ICU team since at least the 90s, and in 2009 Aspen partnered with SCCM to develop the first nutrition guidelines for critically ill patients. Dietitians provide unique expertise for patients' nutritional needs and must account for the problems that feeding protocols can often have that are contingent on therapies like mechanical ventilation, patient's level of alertness, and immune system functioning. Dietitians work to improve the nutritional health and promote the recovery of the critically ill patient. They also perform important tasks such as placement of feeding tubes, writing of orders for enteral or parenteral nutrition. When nutrition is provided according to the recommendations from a clinical nutritionist, patients reach their nutritional goals faster. And dietitians are associated with increased ventilator free days, lower infection rate, and lower mortality rates. Although less often mentioned as members of the interprofessional team, physical therapists have been participating in patient care within the ICU for many years. Some of the earliest discussion of their role in the literature dates back to the late 1990s and early 2000s. Physical therapists provide services that restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities. Early rehabilitation is safe and feasible, but it's also essential for functional and cognitive outcome improvements. Recently ventilated patients receiving early physical therapy have decreased ICU and hospital lengths of stay, shorter durations of delirium, better functional outcomes at discharge, and more ventilator free days. This list of members of the interprofessional team is not all inclusive. A wide variety of specialized professionals participating in patient care and rounds helps to bring expertise to caring for these complex patients. As critical care progresses in the future, I look forward to the continued work and inclusion of all of these different professionals within the interprofessional team. Thank you, and I'm happy to take any questions at the end. Hello, and thank you for joining us today. This next topic is entitled, What's the patient got to do with it? Patient and family engagement on ICU rounds. I have no financial disclosures, but I too have pictures downloaded from Google. For this session, we will look at different aspects of patient and family integration into the concept of patient centered care. First, we will review the traditional or physician centered rounding model, whereby there is only passive participation by the patient, if at all, and look at some concerns for active inclusion of patients and families on rounding discussions. Next, we will look at the benefits around active patient and family participation on ICU rounds. Finally, looking to the future, we will discuss best practices to balance concerns versus benefits in order to optimize patient centered care. As you all know, multidisciplinary ICU rounds are already complex. Teams may be very large and include the providers, which are attendings, fellows, residents, students, APPs, the bedside nurse, the pharmacist, the respiratory therapist, and in some places, the dieticians, social worker, and or even case management. As such, the large size of the team usually means that rounds discussions are held outside of the patient's rooms. Sometimes, patients or their family members are invited to listen in on rounds, but due to the technical and highly structured presentations, they may be more passive observers rather than active participants. In some units, the entire multidisciplinary team discussions are held outside the room, with the patient and family then being updated inside the room by a select few members of the team after all discussion is already concluded. The discussion surrounding passive versus active patient and family engagement on rounds has been ongoing for at least the past two decades. Increasingly, there is more acceptance of patient and family presence on ICU rounds, but there remain some concerns regarding active participation. Some of the concerns raised include prolonged rounding time with the patient or family interruptions of presentations and discussions with questions or possibly off-topic comments, reduced medical teaching for retrainees, constraints on candidate discussions due to concerns regarding confidentiality and privacy, or even challenges with family dynamics, and in addition, there may be concerns for increasing family stress with the technical discussions, especially if the patient and family member have limited medical knowledge or other barriers to having full insight into their medical conditions. All and colleagues conducted a multi-centered observational study of over 300 individual rounds on over 200 unique patients across three Canadian hospitals. They compared three cohorts. Families who were present and participated on ICU rounds, families who were present in the ICU but did not participate on ICU rounds, and families who were not present in the ICU during rounds and did not participate. This was the majority. They found that family attendance on rounds was associated with a longer duration, but did not actually impact trainee teaching, nor discussion of prognosis, nor quality of rounds. Indeed, the authors advocated that family attendance in rounds may enhance communication and complement subsequent family conferences. Levin et al. evaluated family participation on a pediatric ICU rounds at a single tertiary care children's hospital. This was a prospective cross-sectional mixed method study, which included objective measures of direct observation as well as subjective measures of surveys for English-speaking families and providers during family-centered rounds. What they found was that family presence increased the length of family-centered rounds despite the family spending a small amount of time speaking, thus suggesting that longer rounds are actually due to changes in provider behavior when families are present. Additionally, non-English-speaking families may need more support to be able to attend and benefit from family-centered rounds. They also found that families and most providers reported benefit from family presence during these rounds. The authors put into caveat that providers should be aware of the perception of their behaviors in order to optimize the experience for families. In particular, nurses and fellows reported more perceived limitations on patient discussions. To remember these concerns and barriers, it may be time to dispel them as old myths and outdated practices. Because, as you see, when rounds and discussions are held outside of the patient's room, the exclusion of active participation by the patient, the family member, or their spokesperson leads to danger, the danger that the patient may actually get lost in the mix. At the end of the day, we all strive to provide the best possible care for our patients. And so, increasingly, the shift in paradigm continues towards a more active patient and family engagement on ICU rounds. Not only is it the right of the patient and family to know what is said about them, but it may be that they have valuable input for the team. One amusing example that happens is that discussion of home medications. Instead of having the team look up in the EMR for the patient's medication refill history, the team could very easily turn to the patient or their family member and ask if they're still taking that medication. Sometimes you'll be surprised at how engaged and informative the patient can be. In all seriousness, though, the American College of Critical Care Medicine did assign a task force in 2004 to put out recommendations asking and advocating for more family-centered care. With respect to rounding practices, the consensus recommendations was that patient and family members should be given the opportunity to participate on rounds. Not surprising, much of the earlier literature reflecting on and supporting patient-centered care come from the pediatric and neonatal ICUs. One Australian neonatal ICU conducted a single-center survey-based crossover randomized trial involving parents for infants admitted to the NICU with expected length of stay greater than 11 days. A total of 72 parents were enrolled in the study, with 63 completing this trial. A total of 39 healthcare provider surveys were also completed. Additionally, nine healthcare providers and eight parents participated in interviews or focus groups to augment the team's understanding of how parental presence on clinical bedside rounds was beneficial. A majority of family and providers, greater than 95% and 90% respectively, agreed that parents should be allowed to attend bedside rounds. There were still a few providers who raised concerns regarding patient and family privacy, increased duration of rounds, reduced teaching opportunities, and increased healthcare provider stress. As you can see, they're a relative minority in the mix. There was a greater majority agreement that parent participation was beneficial in terms of improving knowledge, engagement, communication, and collaboration with the medical team. As such, improving communication tools and standardizing rounding expectations may improve patient and family experience. Manash and colleagues developed a standardized process for attending rounds, which they evaluated on eight medicine services using a clustered randomized control methodology. While not strictly ICU rounding practices, this group did have interesting and relevant findings after over 240 rounds on over 1,800 patient encounters per study arm. Standardization of rounding practices led to increased compliance with best practices. Furthermore, standardization of rounds decreased rounding time overall. Because these rounds were standardized, they were actually shorter in duration, even though the perception by the trainees may be that the rounds seem to have lasted longer and had therefore lower trainee satisfaction. The standardized rounding model was also found to increase patient satisfaction and patient perception that they are more cared for by the medicine team. At the core of our interprofessional care in the ICU are the patient and family. So then comes the question, what next? How do we engage our patients and families in a more patient-centered care world while balancing all the other needs, duties, and obligations of our charges? In a large, multi-institutional ICU effort spanning 63 combined adult and pediatric ICUs across 34 states, Kleinpill and authors conducted a national collaborative to promote family engagement in multiple types of critical care processes. Ten of these centers had projects directly related or involving patient care and family-centered rounds. Some of the collaborative's collective successes, challenges, and mitigation strategies are noted in this table. At the end of the day, culture change is hard, and getting buy-in at all levels is a common theme for implementation. But with persistence, collaboration, education, and program champions, all things are possible. Cal and colleagues conducted a prospective non-blinded and non-randomized parallel group study over an eight-week period where they were at an academic medical center and compared standard and structured rounding with status quo in a medical intensive care unit. Under the standard and structured rounding, there are specified roles and expectations for presentation from all members of the team as listed here. Similar to Manash and colleagues, it was no surprise, therefore, that Cal et al. found that structured rounding format actually decreased rounding time and improved overall patient, family, and provider satisfaction. Indeed, the SECM has also published guidelines and recommendations for family-centered care in 2017. Family participation on ICU rounds and presence during resuscitation efforts are strongly encouraged. In this past year, however, much of the world's focus and resources have been on the COVID-19 pandemic. As a consequence, many of the patient and family-centered care initiatives have been put on hold. With social distancing and increased PPE usage, there has been increased patient isolation from both family as well as healthcare providers. With visitor restrictions, there has been decreased family participation on daily ICU rounds. However, as we rebuild into a brave new world, the use of technology provides an option for continued patient and family engagement. Prior to the COVID-19 pandemic, there was already much interest in the use of tele-ICU technology for increasing family participation in pediatric ICU rounds. In this publication, Yeager and colleagues reported a proof-of-concept study that they conducted indicating that remote parent participation on pediatric ICU rounds is both feasible and enhances parent-patient provider communications, as well as offering the parents reassurance about their child's care. Providers reported a high level of satisfaction with minimal disruption to daily workflow from the technology. The authors concluded that technological advancements to streamline teleconferencing workflow are needed to ensure program sustainability. This was published two and a half years prior to the COVID-19 pandemic. In the midst of the pandemic, Dr. Galton and her partners described their experience with the development and implementation of virtual rounding, virtual baby monitoring, and virtual handoff practices in the neonatal intensive care unit during the pandemic. It is a brave new world that we face, but we can change how it impacts our patients by harnessing the power of telehealth in ways previously thought impossible. And with this, we should be able to bring forth, again, bring the patient and family back to the center of ICU rounds, back to the concept of patient-family-centered care. Thank you for your attention. Greetings. This is Ruben Peralta from the Haman General Hospital Haman Medical Corporation and the Haman Trauma Center in Doha, Qatar. I'm delighted to be part of the Who Should Be On rounds, the evolution of the ICU patient care over the last past five decades. I'd like to talk to you about diversity, ICU around the world. I have no conflict of interest to report diversity, the ICU rounds around the world, the Qatar experience. I'll talk to you basically about the ICU development and the trauma ICU in Qatar, the trauma critical care education training and rounds, and the trauma system performance in Qatar. As you may know, Qatar is part of the GCC countries in the Middle East around the Persian Gulf. They are oil-producing countries, which consists of Saudi Arabia, United Arab Emirates, Bahrain, Kuwait, Oman, and Qatar. Doha is the capital, and it's an outstanding city, clean, safe, it has a lot of cultural background. The Hema Trauma Center was established in 2007, and up to date, we receive around 7,000 evaluated injured patients a year, and admit around 3,000 patients a year. It's accredited by the Accreditation of Canada with distinctions as a Level 1 trauma center, the only one outside of Canada. Also report to the National Trauma Data Bank and to the TICWP. The trauma center is the only Level 1 academic center in the country. It consists of a new state-of-the-art trauma emergency tower of approximately 300 beds, three helicopters with 24-7 operations, and a simulation center. During the COVID pandemic, the trauma center was built with all the facility, including HIPAA filter and isolated room with negative pressure to provide the optimal care to those patients. This is part of a five, seven-year-old photo of our group. This is a new tower in the evening hours. The clinical bedside and teaching room has been transformed from a nursing, doctors, physician rounds to a multidisciplinary rounds where fellows, residents, attendings, nurses, along with social workers, respiratory therapists, nutrition and dieticians, clinical pharmacists, and physical therapists are participating in the daily rounds and also in the evening rounds. The question that we asked before was why to establish a trauma and critical care fellowship program in Qatar, and there were many reasons. One of the reasons was that the second-largest sport event in the world was awarded to Qatar and it was the FIFA World Cup that will be hosted in 2022. It did imply an exponential and massive explosion of tourism, construction activities, and influx of visitors to the country. Trauma was the leading cause of death in Qatar, especially in a population less than 45 years of age, like many countries in the West. We noticed that we had increased the volume of admission in the trauma systems with increased injury severity score, requiring more critical care service, and there was a shortage of trained doctors in clinical care in Qatar and the Middle East region. As previously stated by Bruno Bost, the Leapfrog Group, and the University of Washington Group, physician staffing, critical care training staffing, is related to the enhanced clinical outcome in critical ill patients in a systematic review published in JAMA. The fellowship was established for training and evaluation of fellows in the six core competence according to the ACJME, which are patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skill, professionalism, and system-based practice. Also, we focus and give emphasis in procedural proficiency to our fellows in professional development. The aim of the program was to enhance patient safety, medical care, and professional satisfaction through the introduction of an advanced ACJME structure trauma surgical critical care fellowship program in Qatar. After two-year implementation, a review of clinical impact of the trauma critical care fellowship program and the trauma service was conducted. We used evaluation tools as part of the ICU resources evaluation of patient outcome rating tool, sponsored by the Society of Critical Care Medicine and other quality agencies. It consists of 16 index elements in three categories, physician management, multi-professional team, and quality process. We perform a review of the trauma center at JAMA pre-fellowship era. As you can see, the MD trained staffing critical care physician was deficiency in the 24-7 coverage in the ICU. The fellowship by 2018 provide a total physician or the surgical trained physician that works in our trauma center were critical care trained. In two years later, we perform and as you can see, the critical care trained physician covering the units was covering a 24-7 basis without deficiency. And as of December 2020, we are trained and engaged more than 50, five-zero physicians in trauma, in critical care, and emergency surgery. Those physicians come from general surgery discipline, anesthesia, and emergency department. Also, we noticed a reduction in the high severity score in your scoring patients greater than 25 or their mortality after the establishment of the fellowship. This is a pictorial description of fellows activities during their academic training. As you can see now, fellows are engaged with the supervision and the evaluation management of the severe injury patient across the continual care of the institution. Recently, we have a challenge by automatic compressed device as they look as to look as three, but many of the patient comes in severe and extremist. In our fellows, we have the opportunity to engage in a multiple resuscitation skill, including REBOA, activation of the mass transfusion protocol, along with the nurses and debriefing. As you can see, we engage in interprofessional care and teamwork across the continual management of the severe injury patient from the trauma resuscitation unit of VA to the ICU, to the operating room, to the hybrid OR, to the intervention radiology, to transfer to the different clinical facilities and inclusive to travel abroad. This is an example of patient and family engagement with critical management. The decision is taken with the family permission and this patient underwent ECMO with a combined of severe traumatic brain injury and severe chest and lung injury. Multiple family meetings were entertained and performed and the patient survived. The evolution of our catheter trauma system has been published and we focus in injury prevention and education and research of our staff, which include the ACGME Structured Trauma and Critical Care Fellowship Program, pre-hospital care, level one trauma center establishing maturation and the rehabilitation phase of our patient. I'd like to take this opportunity to congratulate the Society of Critical Care Medicine and their organizing of this session for the invitation and privilege to present this topic. Thank you. Okay, it looks like we are live. Thank you everyone for joining us on this wonderful session today. I've got our awesome panelists here on stage with us. I'm happy to answer the questions. We have a fair number of questions from the chat box. I'm just going to start firing them off. Okay. First off, Dr. Cheshireman, we really enjoyed the citation on less wiles on rounds might improve ability to hear. Since COVID, we don't bring wiles into the COVID unit trying to consolidate ordering before and after physical rounds. Are there best practices or good side effects with COVID with more emphasis on team based inpatient communication and less fixation on computer order entry? There's a lot bundled into that question. Fortunately or unfortunately, I wasn't very directly involved with our COVID unit, but I think my understanding is similar to kind of what was being asked there that people weren't as much at the bedside because they're out and away from that patient. In our place, they're actually out beyond an airlock. So they would often do more table rounding and communicating with the nurses in the room using iPads. But I think the point is a good one of we all sit there focused on the computers and not focused on our conversations. We're focusing on the patient. I don't know whether COVID or people that are more directly involved in the COVID unit per se have changed their practice or will continue to change their practice after doing this. I'll add it. There's pros and cons to both parts of it because I'll also add it. Sometimes our nurses are concerned that things are discussed on rounds and they start implementing them, but the order isn't actually in, which means they're practicing outside their scope. So it kind of goes both ways. If you want to get orders done in a timely fashion, you kind of need the computers for that. Do we all need to be staring at them at the same time? No. And certainly one thing that I would encourage is maybe having like one person who's putting orders in, but everybody else is talking and that person is listening too, and we're not all just staring at computer screens. What about you, Lynn? What have you guys been doing differently during COVID time? Well, I too have not been working in the COVID unit, but from my understanding is the way that Sam described it is that the rounds are happening outside. And in a talk earlier this week about ABCDF bundle with palliative care, one of the speakers, Dr. Nelson, cited that when she rounded up in the COVID unit that nurses weren't present. And so you've lost the family voice and you've lost the nurse's voice. And so it definitely has challenged the idea of multidisciplinary rounds and family engagement. Are you guys doing anything differently in Qatar? We have a vaccinated hospital for COVID patients, but in trauma patients, we cannot have a vaccinated hospital. We have to deal with that. And I think what we're doing is we have universal precaution, the extra PPE for any patient that comes until the test is negative. But we're trying to use the limited staff and most of the senior staff to, for example, intubate the patient, second year fellow with anesthesia, and the multidisciplinary approach. But like you said, just family touch of the rest of the team are really restricted because of the COVID transmission. Okay. Thank you. Next question. The average age of bedside nurses seem to be getting younger. Do you think the age and experience of the nurse makes a difference in their comfort level with participating in rounds? And one could actually extend this to all of our allied support services as well, pharmacy, et cetera. And how could this comfort level be improved? Does it need to come from attending engagement? Let's start with- Yeah, I'll start that one. As we all age, obviously the newer staff seem even younger and younger, but that was us one day in the past. And I would say what's happening in education now really helps that new clinician because the movement has been towards interprofessional education. So I have observed that and see how the medical student, the nursing student, the physical therapy student, the pharmacy student, at least at WashU and Barnes-Jewish has really helped each discipline to understand the contribution of the other disciplines. And then I do think it's important to... Emily, you noted it that we have to be good team members. So we want to support those new nurses, pharmacists to gain their voice, to gain that confidence. And that comes from the attending and all of the team members to allow them the chance to ask a question that we might know the answer to. We all know it, but it's new to them. So giving them that space to ask questions and to gain that confidence. Other thoughts, Emily? Yeah, I completely agree with Lynn. I think just to highlight the importance of giving them the space to answer their question or to either provide that information or answer questions and asking them if they have anything else to add to rounds. And I think one really simple thing that also helps is making sure that each team member knows each other team member's name, because by learning each new nurse's name, by learning each new team member's name, that builds a level of comfort that also makes people more comfortable to speak up when they may feel less incorporated into the team. No, that's actually a very good suggestion. And sometimes I think we all know each other so well that we sometimes forget to include or introduce ourselves to the new member of the team. So certainly doing that more often is helpful. One thing I sometimes do is I'll introduce myself to the patient. And in that process, we're introducing everybody in a roundtable fashion without necessarily calling someone else as being the new person on the block, so to speak. I just want to add that, for example, in the new nurses over staff, just participating, for example, in briefing in the briefing and the trauma resuscitation unit, the same thing with the trauma ICU, and also trying to invite them to participate in family meetings. It's like an art that they develop as a part of the professional exercise when you do family meetings, especially in complex cases. I'll just add that it's critical that the attending or the most senior person is there sets the tone for the group, that everybody's on a level playing field, everybody's contribution is important, and call people by name so they feel like they're clearly a part of the team and ask for their input. Absolutely. Okay, next question. Does anyone have experience of interprofessional rounding in the evening with the night team? This group is considering starting more formal rounds to focus on sleep and promoting some of the elements of the ABCDF bundle, which may have changed since morning rounds. Sort of as a follow-up question to that is, how does tele-ICU get incorporated into these evening rounds? I can speak to what we do in the evening, which is that our unit has a fellow and two providers that are covering the unit at night, and they make evening rounds. I suggest they do that on 839 o'clock, but they'll get the charge nurse, they'll get the respiratory therapist, they'll go to each bedside nurse, review the goals from the day, see where things are going, and they can talk about things like making sure the order's in for anything to help patients get sleep, any other issues that should be addressed before the night gets too late. I just want to add that we do the same, but we come as the consultant of attending the week. We come in the evening rounds to supervise the fellows, but the same is the rest. We're trying to make sure that the pre-op is okay, that we have the ordering of SBT and awakening for the morning, and so forth. And of course, the family meetings that happen at night. For sure, and sort of as a tag along to that too, there was a question about other professionals being available either on these evening rounds or being available as a consultant 24-7, notably pharmacy, but also referring to other consult services. Yeah, we don't offer 24-7 clinical pharmacy services, but we do always have an on-call pharmacist. So even when the daytime pharmacist that's in the ICU is gone for the day, there is the availability to call that pharmacist. We're also very lucky that we have satellite pharmacies in or that serve all of our intensive care units. And so they also have pharmacists that are available to answer questions, but far less involvement than during the daytime. Okay, thank you. Sorry, this is a question to all the panelists. Are there differences in how family-centered rounds are performed in North America versus South America versus Europe versus Asia? There has been some limited evaluation of the family communication in the year of COVID about video versus telephone. How can we continue to improve patient-centered rounds? I will say that there isn't much necessarily in the literature, but certainly culturally, you can imagine there are some differences in the approach to family participation and also what's the family's role at the bedside relative to the provider team and the medical team. But certainly, the year of COVID has highlighted how we can all be very creative in terms of getting families engaged. I thought that one group with the tele-video conferencing with the family on rounds was amazing. I don't know that we all have that sort of resource or technology to be able to have dedicated iPads for patients and families or to be on rounds with us, but certainly lots of innovative ways to try to keep them engaged. Your thoughts? Maybe Ruben, any differences? Yes, we use technology. Sometimes in the family, they have cousins that want to participate. They can have it with a FaceTime or iPad. But the good thing about Qatar is that we still have restrictions, but the family is allowed. Even now that we started a new restriction for the second wave, the family is still allowed. Family visiting time is allowed with limited time, around 15 minutes, but it's still allowed to see the patients with a proper PPE. And I would just add that not only the use of iPads, but a lot of the tele-ICU platforms allow for connection, and that's what we've been able to do with our tele-ICU, is to use that platform. And even before COVID, there was some discussion last February at SCCM with our nursing group and that discussion of using that tele-health platform to engage with family members who can't visit. Yeah, it's certainly been a challenge. I mean, I've always been a big proponent of having families at the bedside, and it's, I think, a wonderful way to have them engage in many ways with patient care and keeping them informed. The only thing I would add is that we made sure that we document conversations. We make sure that the providers and the nurses talk to patients' families every day, and we document it in one place so everybody knows that, oh, the nurse talked to the mother this morning. Now the provider might talk to the mother again, but knows exactly what issues may have been brought up by the mother. And so good old phones work. We also do use Zoom and iPad, and we're lucky to have a patient and family care liaison that can help set up Zoom calls You have to be a little careful with making sure that we have some limitations on it, because we just don't have the bandwidth to let every family member talk whenever they want and for how long as they want. So we do have some limitations, but I think if you tell people those limitations up front, they're okay with it. So kind of going along those same lines, one of the attendees asked the question of how to prevent patients or families from sabotaging rounds when they just have that big laundry list of questions that they need to ask the team. So I'm going to turn it over to you, have that big laundry list of questions that they need to ask the team. So since that question was directed at me, I will start even though. And what I usually do is as I do my introduction to the patient and the family at the beginning of each round, I will tell them that this is going to be focused discussion and maybe more technical. And so if there are additional questions or if there are things that we discussed that they may not fully understand that I or some member of our team would circle back and go over in more detail with them. So that sort of sets the expectations of what rounds are going to be, that we value their voice and their input, but that if there will be a lot of questions, we may have to circle back and complete the discussion. I don't know if that's what the rest of you guys do or how you guys manage the patients and the families. I think from the nursing perspective, again, being present with the patient and the family throughout the day is that we help to explain the rounds like you just did, explain that before rounds start, and that you may not have the opportunity to get all your questions answered. We'll talk after rounds with you and then the presentation will be then the provider, the physician or nurse practitioner primarily overseeing your care will come back and talk with you. And then making sure that we keep them communicated of when that's going to happen because their concern is always, I'm going to leave the ICU just when that physician or provider is going to come talk to me, right? So trying to help with the coordination of that. And I think giving them an opportunity for the patient when we come in the room, they often feel like they don't want to interrupt. They see the process. So giving, again, explaining to that patient, go ahead, ask that question, or do you have any questions? Giving them the opportunity is really important. Yeah, I'll just say that I would do the same thing that you mentioned, Kathleen. I mean, we all know there's some families that will sit there and just listen and not ask anything. And there are ones that will start asking all kinds of questions. There are some that bring out a notebook and then you know you're in trouble. You just have to kind of say, okay, I'm happy to answer all your questions. Just let me finish rounds. I'll come back and talk to you or have the provider or fellow come back and talk to them. And then it's really important for the nurse to note that and make sure that it happens and that connection is made. Otherwise, we all get busy and it slips by the wayside. I don't know how many times a patient or a family member will say, oh, I haven't seen a doctor all day or I haven't talked to anybody for days. And meanwhile, you've been talking to them all day. So it's important to make sure we do circle back and they get their chance to ask their questions. So I just want to add the same thing that we do. But I tend to be a little bit more proactive and do family meetings, especially in complex cases. But unfortunately, we round twice in the evening too. So we're going to get exposed to another family meeting and repetition again of the same approach. And especially it's a little bit cumbersome when it's more than one or two services. For example, the patient need a spinal surgery and also need abdominal surgery or orthopedic surgery. So you'll have probably to engage in the multidisciplinary teams. We have an advantage. We have a trauma psychologist in our team. And also that we engage her, especially for patients that has, you know, psychological burden to the trauma. I think it really is important. And it's also communicate with, we have a lot of patients that are expat so that the family is outside of the country. And she's a great cushion to, you know, just to bring the news and the comfort to the patient and the process. This is important. Sort of the converse does in some ways playing devil's advocate, there are, and that might leave someone to provide no scrambling later to clarify their needs. And sometimes quick grounding may be the only choice if it's been a crazy morning in the ICU. What would you suggest cases to increase communication and discussion so that the safest and best care can still be provided? You're breaking up a little bit there, Kathleen, but I think I saw that question in the chat and it was directed at me, so I guess I'll start. Well, I think some of that kind of comes back to the same issue of the family member and time is short sometimes and you have to realize, okay, what do we need to do right now? Let's get that done because it's important for patient care and then circle back to do more details later. And just like we triage where patients go, we need to triage our time too. So sometimes we do have to kind of think about what do we really need to do right now as a team and then what can wait till later and come back. And then obviously the important part of that is making sure we don't forget about it. And one of the other things that sometimes will come up is, well, what are the patients in the operating room when we're making rounds on them? Should we talk about that patient or should we just delay that conversation until later? And you know, depending upon the circumstances, both of those answers are appropriate. So it's a matter of just kind of triaging our time and triaging what the team needs to do and getting the work done, but also making sure we're having all the conversations we need to have. And it doesn't have to be just a single, okay, now we're talking about this patient, now we're talking about that patient. You know, sometimes we keep walking around and getting all the patient care done. I think sometimes this is where those communication boards, communication sheets, whatever communication device you have set up at your ICU can be very helpful, right? I know certainly at WashU with the communication wall, the glass doors, it's great because it's a good way to not just tell the team members amongst the different multidisciplinary practices, but also the family, you know, what are our goals for today? And what should they be looking forward to or not, and sort of helping them manage their expectations as well. And especially if you have to round quickly, then at least jotting down the next thing gets missed, and then you can circle back and remind everybody where things are supposed to be. Okay, moving on, we have lots of questions. In the larger ICUs, there's often allied health members who are assigned to the ICU, such as yourself, Emily, for as our main area of focus. However, in community hospitals, these professionals may have to cover several areas in addition to the ICU. And so how should these members best communicate their expertise to the ICU team if they cannot be present on rounds? I think just going and meeting the team and letting them know that they're covering that area is a good starting spot. And being available via phone or via text message or communication, whatever communication system that that facility uses. And then having a consistent time if able to check in with different areas that they're covering. So perhaps they'll check in with their first ICU at 8, and then their next ICU at 9, or however their schedule permits. I think another thing that can happen is to utilize any tools available within the EHR to help triage the most important patients to look at or to evaluate on a daily basis, and then follow up with the team. But to provide their contact information to the team, as well as they can reach out to the team, but that the team knows who to reach out to as well when there's a question that does come up. And I would add, I agree with everything that you said, Emily, and the glass doors that I talked about and Kathleen just talked about, that there's a section on our doors where the consults can ask questions. And so then as they come back to see another patient, check in on that patient, and see, and by having that contact number that Emily talked about, that can really close the loop then. I also work for the VA, and the VA is in many respects more of a community hospital, even though we're attached to a large medical center, right? And certainly a lot of our services do have multiple obligations through the rest of the hospital. And what we do, not once a week, once a day, we have a 30-minute multidisciplinary rounds on all the patients on this given service. And they do that with the medical services, the surgery services, etc. And so that also is another added opportunity where you have a brief focused conversation about patient and their needs or any requests from the consulting services as well. And this is run by the ICU director for the surgical services. Speaking of the ICU physician, there's a question about whether a physician should have ICU assignments when they're also being drawn to other places, such as the surgeon to the OR, the pulmonologist to the Bronx suite, or to clinics. And in other words, can someone be a part-time intensivist? What are your thoughts about that? Well, I'll get started with saying they shouldn't be. And certainly if you look at things like the LeapFrog project, that would not fit in with the LeapFrog standards of care that the person who's assigned to the ICU should be assigned to the ICU and not have any kind of responsibilities outside the unit. That's why we have intensivists. Now, recognizing that it's maybe easy to say that at a Bay Academic Medical Center as opposed to other institutions. So certainly having somebody at least makes multidisciplinary rounds is an important part of ICU care. That person might have other responsibilities and that's the way it has to be. But ideally, my answer would be they should not have any other responsibilities. I agree with Dr. Trishima. You know, we have a schedule, a block schedule, for example, a block week in the ICU. Your main responsibility is to take care of the patient in the intensive care unit. We don't try to do calls or do elective surgery or even trauma calls because you never know when the patient can decompensate. And then, you know, then you have to ask for help between two places. And I think it's no part of the quality that we're going to serve to our patients. I think I would agree that the ideal would be that the intensivist is solely focused and dedicated to the ICU and nothing else. But I think the reality for many medical centers is that the intensivist wears many hats. And oftentimes, you have many other competing responsibilities, whether as an acute care surgeon, that might mean backing up the trauma surgeon on call, or it might be administrative duties or education. But that being said, you know, do you have any suggestions for proposing cost-effectiveness approach to justify dedication of these team members to the multidisciplinary rounds? I'm sort of paraphrasing and blending in another question here. Are there any publications that can be utilized in discussions with administrative leaders or the C-suite to advocate for the dedicated intensivist, the dedicated pharmacist, et cetera? I think across many professions, there are cost-effectiveness studies that show the importance of each of these different professions, as well as the multidisciplinary team as a whole. Most often, they're in very specific ICU settings, whether it be the cardiothoracic or surgical. I think as you look through the different professions, that it has been well documented that interprofessional care has decreased ICU, as well as hospital length of stay, increased patient safety with decreasing adverse events. And so, some of the cost-effectiveness comes from having the kind of assumed cost of saving days in the hospital, of decreasing mortality, of decreasing some of those events. So, that might be able to help you initially get those positions approved or get a short-term position approved. But then I think it's also really important that we're good at documenting what we do on a daily basis. And when we are able to make changes or perhaps prevent something from happening or shorten an antibiotic, it's harder to capture when a patient would have stayed for seven days, but then they're discharged Very true. Lots of C-suites, like data-driven reports, right? So, it's cost savings as opposed to necessary and return on investment, right? Okay, here's a tough one. Would this not be the right time to design ICU models that include chaos theories, sensitive dependence on the initial conditions? This is already being discussed within the nursing literature and may reduce the negative exponential effects of the initial conditions. So, what would be the right time to design ICU models that include chaos theories, sensitive dependence on the initial conditions? This is already being discussed within the negative exponential effects that a delayed response causes within a complex system as a sepsis or septic shock. As we know, delayed responses add more variables and complexity, making it impossible to have patients be compared to any other patient or group of patients, and at that point become their own controls. At the same time, we should not start analyzing patients from the bioengineering standpoint, bringing the concept of open and closed thermodynamic systems to decipher the sometimes massive energetic needs, oh good lord, that the hyperdynamic phase of sepsis produces and what we might miss the chance to address, which goes back to chaos theory. Anyone want to tackle that one? I'll just maybe talk a little piece of that because I'm not totally sure of all everything that was in there because I just gave a talk where I focused on the fact that if you look at cardiac arrest, sepsis, trauma, the things that we do in the first few minutes, the first hour or two, I mean, here in shock trauma we're talking about the golden hour or people talk about the platinum ten minutes or whatever it is in trauma, and the same is true of sepsis, that's why we have the sepsis metrics and the one-hour bundles and all that, and that fits in with a sort of chaos theory issue of those things we do up front have huge impacts later on, so I would second that idea that jumping on people and fixing the physiology is critical. Once we get the ball rolling, then we have daily rounds and that's more of hopefully maybe catching up on anything we missed in that early resuscitation and making sure we keep the ball rolling in the right direction. I agree with that, yes, but I think also there's a lot of challenge in the implementation. When you have this electronic medical record, sometimes to activate a sepsis pathway, you may have to spend a few minutes on it, so I think it's a combination of technology and also empower many people in the team like nurses, you know, they can activate the process, so instead of the doctor alone and with the supervision, and I think we'll save some time, especially in the time-sensitive approach to those patients. Going along the lines of time-sensitive approaches, what are your thoughts on who should enter medication orders, especially either on a planned round or during a very time-sensitive situation? Should it be the resident or the pharmacist? If I'm going to start with that, I think the residents is a part of the educational process that I kind of started and also the pharmacy too. I think what we do is difficult cases with multiple medications with a clinical pharmacist around with us. I think it's a great example of the theft of the rounds because we have a clinical specialist to deal with interaction, some medication and support, but we use both and depend how busy is the service, but the residents and our fellows, they start. I agree. I think there's benefits to both. I think in the teaching environment that it's really helpful for the resident to be able to learn the correct, you know, dose route frequency for entering the orders. However, in the rapid environment, oftentimes when that order needs to get put in, then I would say whatever provider is available, whether it be a pharmacist or whether it be a resident should be the one that puts that in within the scope of what their state allows. I know specifically within Missouri, pharmacists don't have prescribing practices. As pharmacists, we can help assist with order entry, but we don't actually order or sign the medications. It still is under the physician or advanced practice provider name for who is signing the order. But I think that the other piece of that is to, for the situations where it can't be built, is to try and help build in order sets or order panels or similar types of help from the electronic health record to help ensure that these types of orders are put in correctly with as much pre-built information or appropriate answers or doses or what have you selected so that the providers can also help be guided through that process as much as possible. And I'll just add I agree with everything you both just said. When it's a non-urgent on rounds, having the resident so that they can learn, enter the orders, having a check on that though. So at the end of rounds, is it clear? Is it correct? Does the nurse understand those medication orders and what the titration, et cetera, that that piece needs to be completed? Definitely closing that loop on the communication, right? And then sort of tagging onto that, Emily, as you mentioned, there are several algorithms and bundles available for referencing when to care for patients from a glycemic control to antibiotic regimens. What do you see as your role as a pharmacist on the team with regards to monitoring and recognizing and communicating when patients are not following the normal trajectory? Is there a quick conversation with the physician? When would you tend to do a more in-depth education with the team as a whole? Yeah, I think one of the benefits of being on the team is that I'm oftentimes one of the most consistent players on the team. Our residents rotate through relatively frequently. Our fellows are on for a couple of days and our attendings do one week stints in the ICU at a time, although they're there much more consistently as well. But oftentimes, Monday through Friday, I'm the person that's there. In addition, myself and the other pharmacists that I work with are the ones that are oftentimes helping and or building these order sets and bundles. And so we know them very well, as well as the reasoning behind why some of the things are put in place. And so when we have deviations from these protocols, it sometimes is a spur-of-the-moment discussion, whether it be, you know, this is our normal sliding scale that we use for these types of patients. Is it okay if we go ahead and switch them from this scale to this scale so that we get appropriate control, versus if there's additional questions or those situations where additional teaching or information should be given to help that new provider learn about some of those more specific ins and outs, then I think it can be a little bit more in-depth discussion. And some of those in-depth discussions, as we talked about in one of the earlier questions, might be as a little more in-depth teaching after rounds, so we can do a shorter answer during actual rounds and then follow up after rounds to describe some of the different protocols or practices and why they're there without having to take up a bunch of time during rounds. But that definitely emphasizes why it's so important to have a multidisciplinary team, right, and have a multidisciplinary team approach, because we all own a different piece of the patient, so to speak, and coming together as a whole makes us all smarter. Okay, kind of turning the last 13 minutes towards COVID, how have you guys experienced changes in rounds and input from all the multidisciplinary professionals during the COVID pandemic in your ICUs, or have you seen any impact? I know for us... Okay, you're going to start. Go for it. It's a pain. I think the first wave was a little shocking for everybody. A lot of it was timid, you know, PPEs, utilization, and compliance. The second wave, now most of our team are vaccinated. You know, it's a little bit more difficult, you know, different approach, but I still is, you know, operating and we're doing our procedures when you don't know the results of the COVID, it's stressful for some of our staff, you know, pregnancy, you know, you can see, you can feel it, and we're trying to avoid those patients that are vulnerable emotionally or physically that, you know, don't be involved in the resuscitation process with those patients. As you can see, we started with the box, then became the plastic, and then for intubation, and you can see the technology, you know, has changed a lot, including with the mask, you know, the mask, you know, we still use the PPE and the shield, but in the operating room and in some procedures, it's really, you can see the happiness of the team when the nurses call you that the test is negative, because you start taking off a lot of layers, and then, you know, and it's, you know, the surgery becomes easier. So technology is going to help us because most of the tests now are faster, and unfortunately, I think in the second wave, we're still unfortunately, I think in the second wave for all of us, the variants, you know, especially in the UK, the Brazilian P1, and the South African, they're really contagious, and you can see the distribution of the targeted infected persons are changing from the normal coronavirus to this variants. So I urge everybody to, you know, to use protection, and even though the test is negative, but to continue the protection, and keep the distance, and also hygiene. Thank you. Emily? Yeah, I would echo very much what was said. I think with the initial first wave, we had kind of the dispersion of the multidisciplinary team as we were unsure about exactly how this was going to affect all of us within the ICUs, even not working in a COVID ICU, as well as PPE. And so from my standpoint, many of our allied health providers either worked from home or would look up patients from their office, and we really tried to minimize how many people were at the bedside on the rounding team, making sure that we were able to socially distance as much as possible, which sometimes is difficult in a really small or even decent-sized ICUs, the hallways aren't huge. And so I think that that was our initial phase. And then definitely the other huge gap that we're still noticing is the lack of the family on rounds to where as pre-COVID, we often would encourage family members and often have them present during our morning rounds to be there for the patient discussions. And during the initial phase, there was no family allowed within the hospital. And then now, so we do let families in, but their visiting hours don't start until noon, at which time most of our rounds are finished, and so they're still not participating in rounds. And so even though we've kind of re-had our team reform, I think we're still missing that huge piece that I'm hoping that as we start to see some of these additional efforts that we'll be able to work back in. Definitely. I think the loss of the family presence at the bedside has been very palpable for many of our units, right? And sometimes you kind of get so used to having them there that you don't really know what you're missing until it's gone in some ways. But I'm hopeful that with technology, or like Sam said, pick up the phone, maybe there's a way for each of our places to figure out how to get those families back and engaged, if not necessarily on morning rounds and some point through the day. But ideally, maybe we can get them on morning rounds and figure something out that would help. I know certainly when our pharmacist was out because she was told she couldn't come into the hospital to protect herself, we would actually have her on virtual rounds with us every morning, and we would have her on a cell phone. And communication is a little challenge. You got to work through the kinks of who gets to talk first, et cetera. But it's certainly something more than nothing. And over time, we did figure it out a little bit better. So that has been really great. Our teams are all back in the hospital and working as we did before. I think the other piece that is less a part of our routine is spending more time as a team at the bedside, in the patient's room, outside the room, but we're not going in, and probably even less than we used to for non-COVID patients. So that's another piece of this change, I think. Yeah, especially for your patients who, you know, they are already intubated, they're on a bed, they're not going to be interfacing with you on FaceTime via the iPad or whatever communication device, right? And that loss of the human presence at the bedside has become a very big issue. Sort of going along those lines, one of the participants asked, how have we dealt with giving prayer and last rites to COVID patients by clergy that are restricted to coming into the ICU? Have you guys done it in your various institutions? Well, at this point, we do have clergy come into the units and they can, they, I'm not sure exactly how much to do with the COVID positive patients. Again, I'm not saying in my unit, but they're back in the hospital and doing what they can. I'll throw one quick interesting aside of, we've got a couple instances where, since we don't have visitation of family members, but the question comes up, what if the family member is a clergy member? And is that person actually the clergy for this patient? And then does that meet the criteria for an exception to the visitation rule? And that's led to some interesting conversations, but no, I mean, for us at the moment anyway, they're around and pretty much doing what they had done in the past. Ruben? Yes, we do the same, you know, there are many religions here and, you know, we'll go through the channel of permission and they can come to the room and just with all PPE and interact with the families. It's more restricted than before, that's for sure. Lynn or Emily? We are allowing clergy in our non-COVID ICU. I honestly don't know that I can speak to what we're doing in our COVID ICU for clergy, but in our non-COVID ICUs, we are allowing them in. Over at the VA, we have a zero visitation policy for patients and for family members, except for end of life, like very special circumstances. But that being said, in the life and having the clergy present is one of them. We have been fortunate to have unit-specific iPads, not patient-specific. Well, we have some patient-specific as well, but the clergy are allowed to come to the bedside if they are able, and if they're not able, then at least we can bring them in via a communication device so that they can have some face-to-face time with the patient if not being physically present. So, these are challenging times for everyone. Okay, in the last few minutes that we have, there's a question regarding thoughts on specialty teams as adjunct to the ICU team for procedures and nurses to communicate with family members, and then this is also related to the COVID times. Lynn, I'm going to direct that one to you. Can you say that again? I didn't- What are your thoughts? I'm sorry, I didn't hear you. What are your thoughts on using specialty teams as adjuncts to the ICU team, for example, procedural teams for central lines or nurses to communicate with the family members in place of some of the providers communicating with the family members? How do you see that change during COVID? I think COVID has definitely led to a lot of innovation. As those approaches are used, we have to really, though, make sure that the whole team understands the plan, understands what's happening so that the correct information is being delivered to the family, for example, that that procedure team knows everything else that's going on with the patient, not just what they've come to do. And so, I think that's communication, communication, communication continues to be that challenge when we add those type of specialties or offshoots to the care. Definitely. Well, I think we're at the top of the hour now. So, thank you all for a wonderful presentation, wonderful discussion. Thank you to the SCCM for the opportunity for us to present and have this discussion. This has been really great. And thank you to all the attendees for joining our session. Enjoy the rest of the day. Thank you. Thanks. Thanks a lot, Ryan. Thank you. Thank you very much.

ICU rounding

history of ICU rounding

evolution of ICU rounding

healthcare professionals in ICU rounding

patient and family engagement in ICU rounding

models of ICU structure

role of nurses in ICU rounding

respiratory therapists in ICU rounding

pharmacists in ICU rounding

dietary specialists in ICU rounding

physical therapists in ICU rounding

COVID-19 impact on ICU care

telehealth in ICU rounding

interprofessional rounding

technology in patient safety

multidisciplinary approach in ICU rounding