Enhancing Patient Care by Strengthening Rounds

Sharing patient information with coworkers happens constantly in the veterinary clinic. During appointments, veterinary nurses/technicians may speak with owners and examine the pet in an exam room. They then have to supply that information they collected to the veterinarian in a clear, concise, and thorough manner. In the intensive care unit or emergency department, shift changes necessitate the sharing of patient information. Patients may move from the primary care of one specialty to another in referral hospitals (e.g., surgery to critical care) and important patient history must be provided. This information sharing is known as patient rounds, or patient hand-off, and is a critical transition time for patients.

Rounds are often seen as a chore, something to get through as quickly as possible. This should not be the case, as rounds are essential to proper patient care. The aim of rounding is to provide excellent patient care by effectively communicating with coworkers to ensure patient safety and continuity of care. They do not need to be extensive or take a long time, but they do need to be complete and thorough. For rounds to be effective, there needs to be active involvement of all parties, strong communication, and a sturdy framework in which to conduct the rounds.

Understanding Rounds

Rounds can be defined as the transfer and acceptance of the responsibility of patient care. They are performed whenever the person in charge of the patient is changing. Veterinary team members give and receive rounds, making them a formal and active recognition of the transfer of care. Rounds may be given cage-side, where everyone involved can see the patient, or separately, away from the patient.

Cage-side rounds have the benefit of allowing eyes on the patient that is being discussed and provides the veterinary team members being rounded the ability to ask questions based on what they are seeing. This increases the likelihood that problems will be noticed earlier and gives medical staff the opportunity to connect with patients.

Separate rounds may be quieter, with no barking dogs or machine noises; however, without the patient as a focal point, it can be very easy to get distracted.

Focus and communication are among the most important parts of rounding. The time for rounding should be set aside and others put in charge of patient needs to allow the person giving rounds to focus. They need to concentrate on the facts that are important for the receiving staff member to know. Unnecessary information can be just as problematic as incomplete information because it can make rounds confusing for the receiver. Use common language to avoid misunderstandings. Only use abbreviations that are well-known or avoid using abbreviations at all. Rounding should be a discussion, and the person receiving should feel free to ask questions without interrupting the team member providing the information. This does not mean questions should wait until the end of rounding; instead, they should be asked at a natural break in the conversation.

It is not uncommon for people to think they are communicating effectively, when in fact the understanding between the giver and receiver of information is different. Patient safety is compromised when communication breakdowns occur. Direct, clear, and concise communication and specificity ensure that all parties have a mutual understanding of the care plan moving forward.

While studies in veterinary medicine are limited, there are a number of human medicine studies that show ineffective rounds are common and can result in patient harm.^1-5 The Joint Commission Center for Transforming Healthcare estimates that 80% of sentinel events (patient safety events that result in death or serious injury) occur due to communication breakdowns during patient transfer.⁶ Communication failures include incomplete information, distractions, or misunderstanding between the people rounding. These errors result from human error and forgetfulness, incorrect information recall, illegible or confusing records, and lack of standardization.

Tools That Facilitate Effective Rounds

The human memory isn’t perfect. It is a rare person who has perfect recall or an eidetic memory. Instead, we remember the highlights and our brain fills in the rest. In addition, memory can be affected by mood, tiredness, distraction, and many other factors. Forgetfulness and incorrect recall are a common mistake during rounding. Using an aid or tool to help remember information is strongly encouraged and has been proven effective. One study found that verbal-only rounds had an information retention rate of no higher than 26%; however, when the receiver is taking notes during rounds, that retention rate was 31% to 58%.⁷ Most interestingly, the use of preprinted forms that had patient details already on it in combination with verbal rounds had an information retention rate of almost 100%.⁷

Preprinted forms can take the shape of a formal table or a more informal document (CLINIC RESOURCE). Filling out the forms prior to rounding will allow the receiver to focus on important points and make their own small notations without having to write down every detail they are told. These forms allow for the synthesis of all patient information in a single place and overcome the problem of illegible or incomplete records as well.

Human medicine has identified various structured systems for ensuring efficacy and retention of information during rounds. These tools minimize error by providing a framework that is standardized and easy to learn.⁸ Effective communication is emphasized to ensure that both the giver and receiver have a mutual understanding of the patient status. SBAR and I-PASS are evidence-based mnemonics created for human medicine rounds that are frequently used as a framework for rounds in veterinary medicine as well.

The SBAR

SBAR is a fairly basic structure that was designed to hit major points of a patient’s condition. The acronym stands for: Situation, Background, Assessment, and Recommendation/Request (BOX 1). It is most often used when rounding during an appointment or triage as it only covers basic patient information. However, this system can be a valuable resource in situations that require immediate attention (BOX 2). It is imperative to be specific when using this tool in emergent situations. Instead of asking, “Can you come look at the patient?” say, “I need you to come look at the patient now and make sure he is stable.” One of the benefits of the SBAR framework is that it fosters critical thinking. The person sharing information has to assess the problem and provide a recommendation for next steps. If they cannot find an appropriate recommendation, they can request guidance as to what should be done.

The I-PASS

The I-PASS mnemonic covers 5 major areas that are important for rounds: Illness severity; Patient summary; Action list; Situation awareness; and Synthesis recap, given by the information receiver (BOX 3). This device is particularly useful when rounding staff that will be taking over care of the patient for an extended period of time, as it is more effective for communicating complex information about patients (BOX 4). This structure ensures that all of the important patient information is shared and provides a time for the receiver to acknowledge their understanding. The synthesis portion of the tool is the most important as it ensures that the receiver has not only been provided with all of the relevant patient information but that they have correctly understood it. Many of the printed forms used for rounds are modeled after this mnemonic.

Psychological Safety

The final element that is necessary for successful rounds is psychological safety. In veterinary medicine, there can be a lack of trust and respect between different services, shifts, longtime versus newer staff members, or between people with clashing personalities. This can cause intimidation, arrogance, and communication failure. It is important to remember that the patient is the top priority. Petty disagreements, feelings of superiority, and personality differences should be put aside to ensure the patient is getting the best possible care. By promoting an environment of psychological safety where staff feel comfortable asking questions, making suggestions, and raising concerns during rounds, patient safety is preserved.

Summary

Most veterinary professionals have never been taught how to give or receive appropriate rounds; therefore, implementing new rounding strategies will take time and guidance. Providing training, including time to ask questions; examples of printed forms; and practice rounds will ensure that every staff member feels comfortable providing thorough and relevant rounds. Training can minimize communication issues by addressing them before they become a problem and helping staff know how to respond when they feel communication is lacking. Receiving inadequate rounds from a previous hand-off does not excuse a veterinary team member from giving an incomplete round to the next shift. It is each team member’s job to know what is going on with their patient; therefore, in addition to rounds, reviewing the patient record will give each team member a complete picture of their patient’s condition. With simple procedures in place and a little bit of practice, patient rounds can become the backbone of excellent patient care.