The idea of “family-centered rounding” may sound like a daunting task: coordinating a dozen schedules and cramming 12 or more people into a small hospital room to meet with patients and their family members.
But those who have tried it say it's worth it, because it improves communication among physicians, nurses, and other patient caregivers, and it makes the patient's family members feel more like a part of the team.
“The big advantage of family-centered rounding is family engagement and getting the family involved in the process,” said Dr. Glen Tamura, medical director of the inpatient unit at Seattle Children's Hospital, which has been using family-centered rounding (FCR) for about 5 years. “We are really trying to engage families and get their feedback on the plan, as well as make sure they understand how we think their child is doing.”
Dr. Nanci Rascoff, a third-year resident who has participated in FCR at Seattle Children's, agreed. “I like that we give them this role and responsibility to become really involved in their child's care,” she said. “It's easy to give them the 'worried parent' role, but by including them in the rounding process, they are empowered to become part of their child's care plan.”
Dr. Rascoff said she sees a change occur in the parents, even if their child is only in the hospital for a few days. “On the first day, they are like a deer in the headlights, overwhelmed and thinking, 'There are 12 people in the circle and they're in white coats and they're talking about my child.' But then a transition happens, and they join us the next day with a notebook in hand filled with questions. It gives them an additional focus and outlet for their concerns.”
Another benefit to having the whole care team and the family there is that the afternoon “rework” that happens with some cases can often be avoided, said Dr. Tamura, who was one of several speakers on the subject at a pediatric hospital medicine meeting in Tampa.
“When the family isn't present, the [care] plan seems reasonable to the team, but for some reason it won't work,” maybe because there is some issue with the patient that the team didn't know about. But later when the intern tries to get consensus on an alternative plan, “the resident has gone to continuity clinic and the attending has gone somewhere else, so the poor intern is trying to get everyone to agree on a plan when the team has scattered. A conversation that could be completed in person in 10 seconds can take the intern an hour or more to resolve.” With family-centered rounding, Dr. Tamura said, “we avoid that 90% of the time by having everybody there so we can have this discussion and resolve those issues at the time.”
Building a Team
At Seattle Children's, the FCR team includes the attending pediatrician; all of the house staff—residents and interns, and medical students if they're on the team; a team coordinator; a care coordinator who makes home care arrangements; a nutritionist; and a pharmacist, who can be very helpful with specific cases.
“We had one patient who had a urinary tract infection that was very hard to treat,” Dr. Tamura said. “We had pharmacy [with us] on rounds, and we said to them, 'Look at the options and tell us what's reasonable and get back to us with answers.' Them being there means they understand what we're really grappling with.”
Team coordinators are not clinicians, “but they help the team get prepared by making patient lists and letting the team know how many patients there are to round on. As we move through rounds, they call the nurses ahead of time so they know we are coming. They know the most efficient route through the hospital.”
Having a care coordinator on rounds to help create a discharge plan with the family can also help prevent having the plan fall apart on discharge day, said Dr. Tamura, who is also assistant professor of pediatrics at the University of Washington. “We can make sure the family feels comfortable with the discharge plan and is confident they can do all that we are asking them to do.”
Making an FCR program work requires buy-in from hospital management, Dr. Tamura said. Before FCR, “people were used to showing up whenever and having the residents at their beck and call, and you just can't run a family-centered rounds program this way. We created a system where attending physicians have standard rounding times, but it wouldn't have worked if they weren't told that they had to be there. Someone at the top has to say that.”