Critical Access Hospitals Make Interprofessional Rounds Work for Them

A critical access hospital in Minnesota has successfully adopted a practice more commonly found in large teaching hospitals—regular interprofessional bedside rounds with a physician participating.

Todd Lemke, clinical pharmacist at CentraCare Health Paynesville, said the twice-weekly bedside rounds program started about 3 years ago. The rounds support transitional care services at the central Minnesota health system, which includes 5 critical access hospitals and a 489-bed acute care facility in St. Cloud.

Lemke said the Paynesville hospital uses swing beds to provide transitional care to patients who are finishing an acute care stay at the St. Cloud facility but aren’t ready for discharge to their home. Patients from the local community who were admitted to other hospitals in the state are also sometimes transferred to Paynesville so they can be cared for closer to home.

While at CentraCare Health Paynesville, the transitional care patients can receive services, such as i.v. antimicrobial or diuretic therapy and postsurgical rehabilitation, that need not take place at a larger hospital.

Lemke noted that the Paynesville hospital has long had a very low 30-day readmission rate. By transferring transitional care patients to Paynesville, the St. Cloud hospital gains beds for acutely ill patients, and the health system benefits from the Paynesville facility’s ability to manage patients with minimal readmissions.

Before implementing the bedside rounds, Lemke said, the hospital had instituted a daily interprofessional huddle, or “sit-down rounds,” during which available healthcare providers gathered in a conference area to discuss each patient’s case.

“We found that one of the things that was missing from our sit-down rounds was the patient,” Lemke said. “You really want to have the patient involved in their care.”

The other missing piece was a physician. That role was ultimately filled by an internal medicine physician who works at the hospital’s attached family practice clinic and is the primary care provider for most of the transitional care patients.

“He is one of our own physicians,” Lemke explained. “We have dedicated physician time that’s blocked out for these rounds—they’re on Tuesdays and Thursdays at 2:00. So that provider is blocked out for 2 hours each of those days to be working on transitions of care.”

Also on the rounding team are a nurse, the pharmacist who is on duty that day, a social worker, a dietitian, and the physical, occupational, and speech therapists who work with the patient. Family members are also invited to attend and ask questions.

“Sometimes we’re in the room for 10 minutes, sometimes we’re in the room for a half hour. So it does take up most of the afternoon once we get going,” Lemke said.

Lemke said each transitional care patient has personalized predischarge goals that are written on a dry-erase board in the room. These goals might include working with nurses and pharmacists to learn how to self-administer insulin and working with a therapist to practice dressing or feeding themselves or negotiating stairs.

He said the rounding team uses the electronic medical record system to input medication orders and other changes “in the room, real-time with the patient.”

CentraCare Paynesville is a level IV trauma center that also provides acute care services to the community. But Lemke said transitional care patients usually account for about 60–70% of the admissions to the hospital each week.

He said the twice-weekly frequency of the rounds is just right for the hospital, because the patients are stable and don’t normally have large day-to-day changes in status.

He also said the hospital’s patient satisfaction scores have improved since the rounds were implemented. He credited the involvement of patients and their families for those improvements.

“They feel more satisfied with the hospital. We found that we have better communication on our team,” he said. “We all know what each of us is doing to help take care of the patient. So, that’s definitely another benefit.”

Aspirus Medford Hospital, a critical access facility in Wisconsin, also conducts interprofessional rounds to improve transitions of care.

Inpatient Pharmacist Codee Peterson said the rounds take place Monday through Friday at 10:30 a.m. and include all inpatients and observation-status patients, or about 4–12 patients per day. The sessions are referred to as patient engagement rounds.

“We’ll introduce ourselves and . . . go over the progress from the prior 24 hours,” Peterson said. The team discusses with the patient and family members the treatment goals, tests that need to be done, and medication changes. She said the team encourages patients and family members to ask questions and raise any issues of concern to them.

“We’re trying to really make sure we’re answering questions that the patient has prior to the discharge so that we’re not seeing them back in the hospital,” she said. “And we’re making sure that their transition out of the hospital is coordinated as well, whether that be to their primary care or even an assisted living or long-term care facility.”

Peterson said patients are commonly admitted for the treatment of chronic obstructive pulmonary disease, heart failure, or pneumonia. During the rounds, the pharmacist often addresses questions about antimicrobial use, such as switching from i.v. to oral formulations.

The rounding team includes a nurse or physician assistant who works as a hospitalist under the supervision of a clinic physician.

The physician doesn’t directly participate. But that will soon change.

“We’re actually transitioning, right now, into a telemedicine program. So our telemedicine M.D.’s . . . will also be included in these patient engagement rounds,” she said.

David Caron, pharmacy director for Martha’s Vineyard Hospital, a critical access hospital in Oak Bluffs, Massachusetts, said the hospital’s interprofessional rounds take place Monday through Friday and involve a physician—but the rounds occur outside of the patient’s room.

Staff Pharmacist Valci Carvalho said the sessions are “focused on coordination of care” for transitional care patients.

“The doctor gives a brief overview of what’s going on with the patient and if there are any updates,” he said. The case manager or nurse supervisor then queries participants from other departments, including the pharmacy department, about issues relevant to the patient’s progress.

Staff Pharmacist Orchid Motahari said the hospital previously conducted bedside rounds. But she said concerns were raised about the rounding process disturbing patients while they rested. And, she said, some patients weren’t comfortable with bedside discussions involving staff members who were also their neighbors on the small island.

She said the current process gives pharmacists, who may not personally meet each patient, a way to become familiar with their care.

Caron said the daily sessions foster closer relationships among different departments at the hospital.

“I do think that, long term, our presence, our ability to communicate, does lead to better overall care of the patient,” he said.

[This news story appears in the October 1, 2018, issue of AJHP.]