President's Message - Interdisciplinary Rounding - Collaboration at the Patient Care Team Level
by Linda Fred, ICHP President
March 31, 2015
Here at Carle, we have been working for about six months on redesigning how our hospitalist service’s multidisciplinary rounding teams function. It has been a very interesting and challenging experience. I’d like to just ramble for a few paragraphs about some of the history and evolution of multidisciplinary rounding services that I’ve seen over the course of my career.
My first exposure to pharmacist decentralization and rounding was about 25 years ago. At the time, I was working primarily second shift and I wasn’t doing much rounding personally – because in a community hospital with community-based physicians, not much rounding happened in the evening. In fact, the hospital wasn’t doing much in the way of formalized multidisciplinary rounding at all. The pharmacists were decentralized and available on the floor, on both first and second shift (although scaled back in the evenings), but rounding with a team was happening very minimally. Again, with community based providers, formalizing something like interdisciplinary rounds presents additional challenges.
A lot of the work at that time was still distribution focused, too. A pharmacist or a tech would visit the units, pick up orders, and determine if there were any issues (e.g., missing doses and similar things). If we had a problem with an order, we might track the provider down in person to have that conversation. That was always so much easier than having to page them after they left. There were consult orders for things like discharge education, dosing, and interactions/adverse events. I feel like we were loosely considered part of a provider team. They certainly missed us when we weren’t there. But a lot of the collaboration was almost an afterthought. The patient would have a problem, and the first time we would hear about it was after everything else was exhausted, and someone would say, “Maybe we should ask pharmacy”. I think a lot of that was driven by the fact that the pharmacists weren’t consistently present at the time care decisions were being made. So the providers became very used to making the decisions with the expectation that if there was a pharmacy issue, we would come to them. And, that’s pretty much how it worked. I’m sure academic centers were farther along in the evolution of clinical practice – but in community hospitals, this wasn’t an uncommon model.
About 20 years ago I relocated to Urbana and began working at Carle. One of the biggest differences between this environment and my last one was the close affiliation – and eventually joint ownership – of the physician practice and the hospital. The second thing that became a big driver of multidisciplinary rounding was the development of hospitalist services. Hospitalists become masters at navigating hospital systems. They rapidly began to understand the interconnectivity of all the services and how they all have to work together to successfully achieve the discharge criteria that will move a patient to the next level/site of care. Having a patient spend another day in a bed because we couldn’t facilitate their DME needs, or the physical therapist’s assessment didn’t get scheduled, or the case manager didn’t know it was a nursing home placement, or the home infusion pharmacy didn’t find out until 6:00 p.m. that they needed a prior authorization on a drug or that the patient needed teaching on a home pump – ties up the bed, dissatisfies the patient and the family, and costs the hospital money. Hospitalists are often the biggest and best advocates for having a full team rounding approach because they see first-hand the value of having all services in the same room at the same time to problem-solve for the patient.
I’ve seen several iterations of “rounding”, sometimes based on convenience or geography, sometimes based on provider preference. I don’t know that one is inherently better than another. Teaching services often physically round on patients by walking room to room and having someone (often a resident or student) present the case. The team discusses that day’s issues and updates the plan of care. Each service brings up relevant issues, the residents and students get quizzed a little, and decisions are made as a group. Some services do more of a table-top version of rounds sometimes called “care conferences”. Rather than physically moving room to room, the group congregates in a conference room and rounds are conducted by the team with the medical record, if not the patient, in front of them. Some rounds are “global” patient rounds, where all patient care needs are discussed; some are service specific, such as ID. Some rounds are very focused on discharge planning needs and patients not ready for discharge are rounded on separately. The type of rounds, their structure, or the location are less important than the philosophy of having the input of an entire team of providers, sharing insights specific to their areas of expertise, and driving the care of the patient in a coordinated manner.
One rewarding aspect of our current redesign project is the enthusiastic support we are receiving from the medical staff. The pharmacy profession is maturing to the point where we are respected and desired members of that collaborative team. It is especially gratifying to have our Hospitalist Providers say things like, “The new model can’t work unless we have the entire team there to support our physicians. We need therapy services, case management, nursing, pharmacy – everyone at the table.”
I had a provider say to me today how appreciative he is of the strength of our pharmacy services. He said during physician recruitment, he tells prospective new providers that we have great pharmacy services, Board Certified staff, and that pharmacy is one area he never has to worry about. His wish list, as we met today to talk about current and future services, was more clinical involvement of the pharmacists in care delivery decisions.
I’ve worked my entire career in community hospitals and this has been my dream – that pharmacists are sought after; that we are recognized for our skills; that we are appreciated as more than just the people who provide the physical product. We are enjoying a wealth of opportunities right now in collaboration with multidisciplinary teams. I hope that my experiences at Carle are being replicated elsewhere – and that my fellow pharmacists are making the most of them.
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