All right, so my sub-talk in this session is the nuts and bolts of effective ICU rounds. My name is Will Bender. I'm one of the pulmonary critical care faculty at Emory. I also serve as the medical director in one of our ICUs at Emory St. Joseph's Hospital as well as the site director for critical care at Emory St. Joseph's Hospital as well. So a couple of different leadership roles, which I think gives me a little bit different perspective as I give this talk. I have nothing to disclose. And so for today, I'm going to globally review some of the variability that is seen in patients in patient care rounds in the ICU, going to highlight, I think, key members of the care team that should be part of all patient care rounds. And some of this may be intuitive, but I think potentially learning about some of the evidence behind it and the reasoning behind it is something that we don't always know about. We're going to look at, I'm going to briefly chat about some of the tools that we can use to help facilitate rounds, and then also look through some of the components for a favorable rounding environment and culture. So the first thing I'd like to just start with is just thinking about the concept of patient care rounds. And I often, my wife is not in medicine, so I often describe my day to her, and she often wants to know what rounds is and what rounds is like. And she finds it fascinating that we spend so much time rounding and discussing things. She's in PR and marketing, where everything is just, they rip through with high yield stuff all the time. So when I was kind of putting together this talk, I ran this slide by her, and she seemed to like it. So if you guys hate it, you're going to have to take it up with my wife. But patient care rounds, it's a scheduled forum for providers. And on the surface, rounds seems like a fairly straightforward concept. We're going to review the patient's condition in progress. We're going to talk through potential therapeutic diagnostic options for them going forward. We're going to discuss and make care decisions for the patient with the ultimate goal of having them achieve their goal, which ideally is them getting out of the ICU, getting better, going to the floor, and getting out of the hospital. And I like this diagram here, which is from a critical care medicine article back in 2020 from Stallings et al, where they reviewed some of the use of bundles in the ICU. But the nice thing I like about this diagram is it just reinforces the focus in the ICU, the focus in patient care rounds is on the patient. And you can see there are a slew of inputs, there are a slew of providers, there are a slew of team members that are focused on caring for the patient. But the overall focus is on the patient. And so with that being said, when we look at that concept, and it sounds fairly simple, we're going to focus on the patient in this open forum and discuss their plan of care. When you then begin to think about various ICU structures, various ICU workflows, it's easy to see how and why a lot of variability exists in ICU rounding practices. So I'd like to highlight a little bit of this variability as well. I think all of us have experienced it as we've gone to work in different ICUs. But I think seeing it in the literature can really kind of take hold about what sort of cultural practices are different in each ICU and how that can affect change and opportunities for improvement in the ICU. So this is some data from Holodinsky et al. And it's from back in 2015. And basically, the authors surveyed the medical directors of just medical and surgical ICUs across Canada about their rounding practices and then opportunities for improvement in their rounding practices in the ICU. They looked at a total of 111 ICUs. And they highlighted a number of variabilities across the board. So with regards to staffing, 98% of these ICUs had attending physicians present for rounds. 85% of them had pharmacists present for rounds, which is what we'd kind of expect for most of our ICUs, at least in the US, and what we think about a good multidisciplinary rounding team. They also looked at a variety of rounding practices. Interestingly, 79% of them, as you can see here, only had a standard start time. 48% of them reported some semblance of a rounding tool use. 94% of them noted an open environment where everyone had a voice. But interestingly, that dropped to 86% when they were asked to ascertain if it was actually a collaborative environment for discussion. So this variability is highlighted even further. And this is a very busy table. So obviously, you don't need to digest everything in there. But this is a similar project out of Germany, where the authors surveyed a large number of ICU executives in Germany, ranging from physicians and nursing leaders. And they garnered most of these responses through two large German intensive care unit societies. A total of 390 responses were garnered. They made an attempt to make sure there was not overlap between the ICUs. There still was a little bit. And this table highlights questions about who participated in rounds, just who was in rounds in each ICU. And so again, it's a very busy table. But 51% of these ICUs surveyed it and noted that the bedside nurse was present at rounds. So only about half of the ICUs, when they did rounds, had the bedside nurse present. Pharmacists were never in rounds in 55% of these ICUs. And the attending was noted to always participate in rounds in only 57% of these ICUs. Some of these ICUs had house staff, as you can see by the delineation of residents as well as fellows. So there may be some overlap between attending and fellows. But again, just looking at pure participants in rounds, there's a lot of variability in how they do things in these ICUs. Stepping into the United States, and this is a seminal paper that I'm sure many of you are in the audience are aware of, but from Kim et al in the Archives of Internal Medicine back in 2010, they looked at the effect of multidisciplinary care teams rounding in the ICU and the effect of these care teams rounding on ICU mortality. And their study population consisted of hospitals as well as patients in the state of Pennsylvania. And so this is kind of their basic figure one from their table, where they broke down how the patients were grouped. And about 48% or so of their patients were structured or grouped into a low-intensity staffed ICU that had no formal multidisciplinary care team rounding process. And so the first table from this paper actually highlights this a little bit further. There were a total of 54 hospitals in this study cohort that had low-intensity staffing and no multidisciplinary care rounding process. And so not surprisingly, the characteristics of these hospitals are a little bit on the smaller side, although 20% of them were noted to have some component of teaching to them. And these ICUs were predominantly combined ICUs as well. So obviously, there's some variability that exists in ICU practices. And I think with the recent COVID pandemic, all of us were akin to that as well, some of us being called to work in different environments that we usually work in and starting there on our first day and realizing things are done a little bit differently than where we usually work. But I think as we start to look at the actual composition of teams during rounds, I think the number and availability of team members we know, not everyone that is involved in the care of an ICU patient can be there every day at every moment to weigh in on the patient. But I think there's a certain core group that should be part of rounds, and I think the literature bears that out. So I think the first area to kind of highlight, and this is almost intuitive at this point, is the physician. And so we know that physician participation has been shown to improve care and delivery in the outcomes in the ICU across a number of publications. 2015, the Society of Critical Care Medicine noted that an intensivist-led, high-performing, team dedicated to the ICU is integral as part of effective care delivery. But I want to just highlight in the Kim paper again, they noted that, again, having a high-intensity staffing model with physician presence produced a mortality benefit for patients in the ICU. But interestingly, amongst ICUs that had a low-intensity staffing construct, so physicians not available all the time, either by phone or directly, but that did have a multidisciplinary care rounding process established, there was a mortality benefit for these patients seen. And that can be seen in the bottom part of this table right here. So I think that, you know, raises some credence or lends some thought to, well, you know, if you are in a smaller hospital and you don't necessarily have consistent physician availability for whatever reason, still having some formal rounding process take place is going to benefit patient care. Bedside nurse, obviously, I would argue, and I think almost everyone would probably agree that they're the most essential participant in the ICU. More direct time spent at the bedside than any other rounding participant. Depending on census, they can be up to 33% or 100% of their time tied to that patient's bedside every day. They are the key driver of the daily care plan, the one who delivers a number of the modalities. And they can also oftentimes offer an incredible perspective on the current condition of the patient, how the patient has done to treatment responses, the overall care preferences of the patient, as well as outcome expectations, what the patient is thinking, what the family is thinking as they go through their ICU stay. I think another key member of the rounding team that should be almost thought of as a core element of the group is the critical care pharmacist. They obviously play an important role with pharmacotherapy decision making and dosing. They can reduce medication errors, improve medication safety. In now a seminal paper published by Leap et al. back in the late 1990s in JAMA, they looked at the integration of pharmacists into critical care rounding. And as part of this project, it was kind of a two-phased operation. But they noted 398 interventions were recorded with their first iteration of integrating pharmacists into care, with 366 of them being related to actual orders that were entered potentially incorrectly. 362 of those orders were then accepted by physicians. In another part of the paper, adverse drug event rates were noted to drop precipitously with the introduction of pharmacists into rounds, making rounds infinitely safer. And there was also a noted cost benefit associated with having pharmacists on rounds. In this paper from Louison et al. from the pharmacy literature, they looked at the use of critical care pharmacists as part of a two-part initiative working on ICU length of stay, ventilator use, and sedative use, as well as expenditures. And this was in a large teaching hospital. In the first phase, critical care pharmacists did some direct management of the pain, agitation, and delirium bundle on multidisciplinary rounds. And they did that in 35 patients while their usual standard of care was approached in the other 35 patients. And then the second phase of their study looked at the expanding pharmacist coverage over the course of about six months in this ICU, and that ended up reaching about 436 patients. They noted a 46% reduction in continuous infusions of sedatives. This led to reductions in ICU length of stay, total hospital length of stay, and then cost savings approaching $1.2 million in direct costs for the hospital, as well as close to $200,000 in drug costs. So obviously, in the ICU, complex respiratory care is often part of many patients' stays. They received advanced pulmonary treatments, a variety of modalities for oxygen delivery, and then a slew of mechanical ventilation strategies, you know, lung protective ventilation, proning practices, all the way over to spontaneous breathing treatments and working towards getting folks extubated. And I think involving respiratory therapists in rounds can help ensure accurate respiratory care data is presented to the team and can subsequently be digested and implemented into the care of patients. Two recent papers in the actually pediatric literature looked at structured multidisciplinary rounds with respiratory therapists providing standardized respiratory support. The first paper by Renner et al. looked at it in a pediatric ICU and a pediatric CCU, and then in Gannett, they did it in a NICU. In both instances, the respiratory therapists actually led portions of rounds with standardized rounding tools to enable delivery of the respiratory information to the team, which then enabled the team to digest all of the relevant respiratory information and then make appropriate plans of care. I don't want to talk too much about family, because some of my colleagues are going to go through this as well, but I think it's important, highlighting, and at least in my brain, I think it's important thinking of the family as an important part of the ICU team. Patients very rarely move through their ICU experience alone. Families are unprepared for the stress associated with both the acuity of their loved one as well as the overall complexity of the loved one's ICU admission. And then all of that can be exacerbated by the fear of the unknown. What's going to happen next? What's going on next? What procedure are we having today? That sort of thing. And so getting families involved in rounds certainly improves collaboration of the family and improves shared decision making, opens doors to transparency, lets the family see how these decisions are being made. I'm sure some of you have rounded in the ICU and have had family members remark about the size of your team that is involved in the decision making and care of their loved one. I think it also allows for direct and rapid communication about preferences. And we're all familiar with the stack of records from the outside hospital, 85% of which are never correct. The pre-ICU medical history is oftentimes best handled by the family itself. And then I think one of the important things as well is giving us insight beyond the critically ill patient in the bed. Who is that person? Who is that patient's father? What were they like before all of this? What are they pushing to get back to? Having them as part of rounds, I think, enables that information, obviously, to be delivered to the care team and give the whole care team perspective on who that person is. Again, I'm not going to touch too much on tools right now because my colleagues are going to look at this a little bit. But I think thinking about tools as part of ICU rounds is important because it allows for a standardized approach to each patient. You can take patient data presentation and parse it into a rounding script. On the right is an example of one of the rounding scripts we use at Emory. This was a nursing-driven project with input from physicians. And this script basically runs from top to bottom. And some of our ICU's nurses present on a daily basis. And we have the nurses stick to the script to allow for consistent delivery of information. And also, as we're dealing with staffing crises and folding new staff into units, it keeps things fairly simple. As I often tell some of the newer nurses, hey, just stick to the sheet. Don't need to worry about anything else. Just tell me what's on the sheet, and we'll figure it out. At the same time, I think collating output from rounds discussions into daily patient goals checklist is important. We can get a reduction in communication barriers, an increased quality of communication. And then it can also push folks to think about and adhering to practice guidelines. And I just wanted to briefly highlight, just because it's, again, a seminal paper from Dr. Pronovost, looking at the use of a daily goals form in their ICUs at Johns Hopkins. The use of the daily goals form, which involved team members checking off on if they could actually verbalize and understand what those goals were, resulted with some of the data on the right side of the screen, with improved understanding on the top graph of what the actual daily patient goals were by the care team, as well as a drop in the ICU length of stay. I think one of the last things I quickly want to touch on is just the overall environment of rounds. I think maintaining a consistent environment is important. Consistent start time, consistent location, making sure the team is composed, the rounding team is consistently composed of who you want there and what everyone's role, and everyone knows their roles. You want to limit interruptions. And interruptions in an ICU is almost a laughable thing to think about. All of us have been on the phone with a loved one at home or something, and they're going, what is that beeping in the background? That sounds important. And you're kind of like, yeah, it's fine, no big deal, it's somebody beeping. But interruptions are more prevalent than probably thought. And this is, again, I wanted to highlight some of the data pulled from the Holodynski paper looking at the Canadian ICUs. 46% of their survey respondents noted that rounds were usually or always interrupted. And these are the various sources of interruptions that can be seen here with the darker shades indicating their frequency. I also wanted to highlight this kind of neat paper from Alvarez looking at an Australian ICU in a teaching hospital where they basically looked at communication events by providers in the ICU. And they highlighted, and then they looked at various types of interruptions that occurred, whether those interruptions were communication interruptions or what they called turn-taking interruptions, where someone interrupted an ongoing event and then turned the conversation into a completely different event. Basically this graph here highlights how much of nurses, junior residents, and senior residents' time was focused on communication over the course of a 24-hour period in the ICU. And then 35% of that time with regards to the senior residents, and then 39 and 38 respectively for the junior residents and nurses, was occupied by conversation-initiating interruptions. Interestingly, turn-taking interruptions outnumbered the number of conversation-initiated interruptions. And lastly, most of these turn-taking interruptions were initiated by physicians themselves. So a lot of times we think of, oh, I'm the physician, I'm helping to run rounds or part of rounds, I'm being interrupted by other things, whether it's call for admissions or anything like that. This paper actually kind of produced some data that kind of flipped that on its head and showed that actually physicians were the ones initiating a lot of these interruptions. And so I think that leads me into my last point about rounds and ICU culture. And I think the idea of interruptions is kind of interesting to think about, and the fact that maybe physicians are driving a lot of these interruptions. And as I tell my two-year-old sometimes, that's a lot of not taking your turn. And so I think when you think about ICU rounding culture, you want to make sure that there's mutual respect amongst providers. There's good communication, there's good collaboration, there's good teamwork. And all of that gets highlighted and pushed by having mutual respect. I think it starts from a physician leadership standpoint, but I think focusing on less of a hierarchical model and more on a servant leader type model is a good way to approach that and think about it, where you as the physician leader on rounds are coaching towards the common goal, which again, as we talked about at the beginning, is meeting the needs of the patient. Interestingly, a paper I highlighted here by Noel in the German literature showed that when hierarchical relationships were removed in rounds in German ICUs, nurses felt more empowered to contribute to rounds and felt more like their voices were being heard. So in summary, there's significant variation in ICU rounding practices. Some of that variation is, I think, a reflection of local environment and culture, but some of it is also a reflection of staffing practices. I think key team members for effective and efficient ICU rounds likely include a physician, the bedside nurse, the pharmacist, a respiratory therapist, and a patient's family. ICU patient care rounds can be made more effective by using tools like rounding scripts and daily goals. And then properly configured rounds, I think, consist of both good, consistent structure as well as a culture of mutual respect among providers. Thank you. Thank you. Good morning, everyone. So my name is Ryder Postanek. I'm an assistant professor over at NYU School of Medicine. I'm going to spend a few minutes this morning talking about the integration of families in the ICU and really trying to understand how their role has evolved over the last several hundred years, and especially over the last few years where we have a little bit more data, and seeing how we can optimize integrating families into our ICU culture as well. The way I usually like to start my talks is to look back at the history of medicine, because I think that's the most fascinating part, where we learn a little bit how medicine evolved and what we've learned from our history and how we've gone to the point where we are right now. And I'll speak a little bit about what families want, what the data shows as well, what do they choose to get from rounds, how do they want to get involved in rounds, when are they available to round, and then also a little bit about the perceptions of the staff involvement in rounds. And then essentially at the end, we'll focus on how rounds are affected by family involvement as well. So as I said, I think the history is something that's incredibly fascinating for us. Obviously, over the last several hundred years, the role of the family and the caregiver relationship between hospitals and the way they're integrated in medicine has changed significantly. Up until about the 19th century, we had a very different culture until then, where the families were mainly there to help with the feeding, assisting with general care, but they didn't really have another role as far as discussion. They weren't part of the medical team as we've come to know now in the last several years as well. That changed actually in the 19th century, in the late 19th century, where it became much more rigid and organizational structure. There were very strict visiting hours, and a lot of that had to do with the implications or the assumptions that families would affect rounds, medical rounds, the way they were conducted back then, that the families could potentially bring prohibited items, such as alcohol or different things, toxins or anything like that, to the bedside, or that there were also a conduit of infections as well. And that evolved as our understanding of how infections are transmitted as well. So the integration of families changed significantly, where we had very, very, very limited short hours where the families could come to the bedside. And obviously, a lot of these cultures and everything have been changed by the opinion of the historic policies that we've had, and rather than evidence. And obviously, over the last 15 to 30 years or so, we've gotten a lot more evidence to really understand the impact of having families at the bedside and how important they really are to be an asset, to be integrated into the ICU and in the hospital culture as well. So I mentioned a little bit about the history, and really, if you think about, we hear paternalism mentioned a lot, right? Well, what is really paternalism? This is the way medicine had been practiced for hundreds and thousands of years, where there was one person that essentially made the final decision, which was at that point the physician. A lot of that was very variable, and that had to do with essentially because this was a essentially apprenticeship model. And so you had different people that came to work with physicians and learned from them, and they guided them and they followed them. But there was a lot of variability. There wasn't reproducibility as far as the care is concerned. The management strategies were very, very different. And once we learned that really there is so much variability, there wasn't real benefit from this paternalism structure, there's essentially a pendulum swing. And that happened around 1970s, where the physician was then seen as a consultant. What does that mean exactly? Well, at that point, the families and the patients were given the direct role of making the final decision. They were given all the information, and they wanted the families and the patient to make the decision for what they thought would be appropriate, and the physician was taking a step back. And then we had another pendulum swing in the last 80s and then early 90s, where we have more of a shared decision model, where the families were integrated more into the medical team, into rounds as well, and where their role was much more visible. And the information that they were given was then used to make a decision how patient care should move forward. Obviously, end-of-life care is something that's very significant, especially as it evolved over the last 30 and 40 years. And looking back, again, the history is so fascinating. These are some pictures that I'm going to share from Bellevue Hospital, which are some historic pictures for over the last 150 years or so. So this is a picture, essentially, of what the rounding team used to look like. And here, there's a picture of Dr. Stephen Smith, who was the founder of the Bellevue Hospital Medical College, and he was a general surgeon. And the medical team really consisted of the physician, and then the apprenticeships, and then other consultants that were there, obviously the nurses as well that were aiding. But their input was very, very minimal. And as you can see, there's a lot of patients in that room, and a lot of physicians and providers or nurses that were there, but there's no family involvement whatsoever. The ward structure back then was also very, very different. They had a lot of beds that were in one small area. So the medical team took care of the different wards that were involved. And then, as we evolved and we moved into the early, essentially, this was during the flu pandemic, the influenza pandemic in 1918 and 19, we had patients that were staffed all throughout whatever room that was available. Families were not permitted to the hospital at that point. We had patients in the hallways, in small rooms, in corridors, closets, anywhere there was space. And this really was reproduced again, essentially, a few years ago, as we've seen. This was during the COVID pandemic, where families were not integrated, were not allowed to come into the ICUs, not allowed to come into the hospitals again. The way we interacted with families also changed, and I think a lot of that has to do with how we involved them. At that point, we had more telecommunications. We used iPads. We used FaceTime. We tried to bring them in, even though they physically couldn't be there. And when we look back at it, we want to see, well, really, there's two different models. There's the traditional medical model, and then there's the patient-centered model. And what we really see is that the traditional model that had existed up until the 1990s or so was more focused on the disease and focused on treatment of the disease. So the patient's perspective was usually ignored, and really, the physician was making the recommendations, trying to get the input. But really, it's the disease process and it was the disease-oriented care that took precedence. That's changed, and the invoke topic now is this patient-centered medicine. So what does that really mean? Well, at this point, the patient is the one that is at the focus of the disease process, but also of everything that's happening. Their involvement is incredibly important in making a decision about how treatment should progress. And we see that the patient and the physician really share this decision-making process. And if the patient can't participate, at that point, we have the families that are sort of in that role as well for them. And really, this changed a lot, and this is what we see now as being sort of the highlight of where medicine is, especially in the ICU, where family involvement and patient involvement is so, so, so critical. And the reason we're getting at this point and trying to have more families involved is that, well, our expectations and our understanding is changing significantly. There's this emphasis on meaningful engagement. So we want the family to speak up, to be involved, to essentially come and be at the bedside so they can help share in this decision-making policies. And we see that, but when we look at the data and we try to understand where and how families are really involved, it's still not really universal. I think just quickly, by a show of hands here, how many of the physicians here involve families at the bedside in rounds? So what's interesting, if we do a poll actually across ICUs of around 40 countries, about 43 percent, so I would say about 40, 50 percent as we had here, really allow family participation during rounds. And really, and actually what's interesting is that there's a variability of how many family members actually attend rounds or whether they're actually permitted to attend rounds. So we see that there's up to about 40 percent or so when family members are involved in rounds, and really that stays around the same thing for families across the country and across the world as well. So they're not as involved as we'd like them. But the families are critical, obviously we know that, right? They're essentially a constant across the continuum of care. They're always there to help the patient, not only in the ICU or in the hospital when they're there, but also when they get discharged. We see that they actually provide a significant direct care involvement, essentially about, we're saying $640 billion a year in cost that could be saved by having the families take care because of everything that happens after they leave the ICU or leave the hospital, their direct involvement is so, so critical. We do know as well that families suffer significant mental health issues. One of the topics that's really critical in this is the post-ICU care syndrome that also affects families where they have PTSD and long-term depression that is significantly impactful, not only in them, but also the patients, and that affects how they are involved and how they take care of their loved one after they leave. And we know that really the family engagement really is incredibly important in making the decision and the care for them. So we know that if they're involved, this could potentially decrease their fear, decrease their horror, the horror and understanding of what's happening, the helplessness as well, and it can potentially improve family psychological outcomes as well. And we see that it can potentially also increase the patient medical condition by being present, by advocating for their loved one, by participating in the care as well. So what do we see and what do we understand about how or how do we feel about the families being involved in patient care or being at the bedside? So this is an interesting study that surveyed physicians and nurses and hospital staff and then families as well to understand what essentially was the preference for the families to be involved in ICU rounds and what would they want to get out of it. So they looked at families and then they looked at providers as well to understand what their overall expectations were. What's interesting is that the big goal here was just focusing on rounds and not family meetings. And we see that overwhelmingly the providers and families did agree. There's a slight difference in that the providers and physicians and staff thought that they just wanted to plan for the day. The family really just want to focus on the plan, but they also really want to have time for questions, which we can see as well and want to have a carved time where they can participate and ask questions that could be addressed in the present moment at that time. The focus on diagnosis and treatment was slightly different as well. The treatment process, the providers thought that overall they didn't really want to focus on treatment and we see that about 15% of providers thought that the families wanted to focus on treatment, but really about 40% of families are the ones that really wanted to spend more time focusing on what the plan for the day was going to be. And then if we look at what we thought about the role of family members during ICU rounds, so what should their role be? Again looking at family and providers, overall we see that they all agreed they should be there for listening, they should be there for sharing patient information when it's really, really critical. But really the decision making process of it is what's interesting. So providers really thought that we want families to be there so they can help and aid in the decision making process. Taking this further, when we surveyed these families as well and the staff, we see that about 38% of providers really estimated that there's moderate family members that are interested in participation in rounds versus about 97% of family members. So family members really, really wanted to be involved, but we thought the staff, the providers really thought that maybe they don't want to be involved. So overwhelmingly, we see that families, they want to be there and they want to be present. When we look at how they want to attend and the effect on stress, providers and physicians and staff were really, really worried that rounds were going to provide a lot more stress for them, but families didn't really feel that way necessarily. Similarly, when we're focusing on the effect of ICU rounds attendance of the comprehension of patient clinical situation, we thought that, well, we're probably going to confuse them a lot more by providing and talking and giving them all this information. In reality, families didn't really feel that they're going to be confused that much. They didn't feel like that they were going to be stressed that much, they really just want to be present so they can understand a little bit more. And then when there's another survey that looked at essentially medical directors and providers, they found that they really wanted to have patients at the bedside, but interestingly, when they surveyed the nurses, approximately 64% of nurses disagreed, and part of that had to do with the fact that they were worried about the increased workload. They were worried that there was going to be prolonged rounds as well if they were going to be present, and that had to do with essentially they feel like if the family's there, they may impact how their work with the patient is going to occur, which is not necessarily accurate from our point of view, but the nurses have a significant way at this. And compared to physicians when we look at it as well, the nurses and staff, they're much more likely to avoid open and honest discussion about prognosis. This in part has to do with the fact that the nurses and staff may not feel comfortable making those decisions, right? So we want the physicians are the ones that really and the house staff, the APPs are the ones that would feel more comfortable sharing that decision. And then the question becomes, well, how can we involve families and how will it affect essentially the time that's involved in rounds? If we have families involved, there's this perception that it actually may affect how long rounds take, right? So if we have families that are present, we're worried that if they keep asking questions or if they're, we spend a lot of time trying to explain everything, and really actually what was fascinating is that if you have a structured model where the families are told essentially what time we're going to have rounds, when they can be potentially present, and everyone has a dedicated role that's on the rounding team. So the house staff or the APPs, the nurses or the respiratory therapist find that actually rounds become much more efficient. So if you have a structured model to your rounds, that actually decreases the amount of time your rounds are going to take. The families understand what the role is. And then also we find that actually there's a decreased amount of time that you have spent in post-family meetings as well because they understand what's happening. So essentially your family meetings that are much, much shorter. They don't take one, two, three hours because they've been participating in rounds, and they understand essentially what the disease process is occurring, what the potential outcomes may be for the patient, and so their input is much more significant as well. And the benefit of that is that they found that by including the families in a structured model, essentially we're able to decrease the time of rounds, and most of the rounds finish by noon, essentially finish in a short time span than unstructured rounds where family involvement was come and go, it wasn't very detailed when they should be there. The team dynamics were not very clearly set. And this essentially shows how the items that are discussed in the educational point of having a structured model actually was significantly higher. So by having a structured model, we were then able to discuss more about the patient. There's more input from the residents, from the nurses, from the respiratory therapist. The educational component is also significantly higher because there is this model of discussion and focusing on learning as well, and it becomes much more efficient because everyone understands their role and what they have to do on rounds. The significant barriers though are that family dynamics change, right? There's varying levels of health literacy amongst family. There's many different family members that have work or different obligations, so they may not be present. Some families may not be local, so their travel time may be significantly high as well, so they may not be able to participate directly. And again, if there's sort of not structured time, it's unclear when they should be present or when they can come, that really is going to affect your outcomes and affect your integration of families in the ICU culture. So if we look back a little bit about what the facts and fiction may be, we see that really the family presence are not really going to slow down rounds. That's essentially fiction because if you have a structured model, you have a way of integrating the family and you want to do this proactively, you're able to decrease your potential round time and you get to a point where it becomes much more efficient. The family is involved, the family is aware, they have this shared decision model as well where they can impact rounds, but they also their understanding increases significantly as the days go on as well. The quality of teaching is not affected either, again, because this is where you can focus on topics that come up. You can, your rounds are not going to get prolonged, so you can continue the educational model that you already have in place in your ICUs. And then when we look at do family members now want to be included in rounds, well, we know that they actually do. They crave for this because I think they understand their role as well in this shared decision model to be present and to help with the care for their loved one as well. And it's on us to really understand how best to integrate them. And do we think that the family presence on rounds is going to affect anxiety? Well, it is to a certain extent, especially up front where they're learning the disease process, they're understanding that their loved one is in an ICU. But at the same time, if we help share and explain what's happening, this may decrease the potential long-term outcomes and long-term consequences that affect families as well. The depression, the PTSD, the PICS-F, as we described it as well. So in conclusion, we say that family presence has changed significantly over the last several years, but so has our role as physicians as well and our understanding of how to integrate families, our understanding of how to share information with the families as well. Families do want to be included in rounds, and the big issue with this is, well, are they able to? So when are they able to be included in rounds? But they definitely crave that information. So if we have a structured model, I think that's going to be the most beneficial. The timing and the structure doesn't get significantly affected as far as when families are integrated. So we see that rounds are actually probably shorter if they're integrated in a productive manner, in a structured manner. And there's benefit to both the family and the patient if the families are included in medical rounds. Okay? Thank you. --Okay. So to give homage to our title, I have a picture of my kids with our cats. And I like to think, like, just like we need tools and techniques to parent, we also need tools and techniques to run our rounds in the ICU. So I'm Carrie Hanna. I'm also an assistant professor of medicine at NYU. Objectives, really, I'm just going to go over a few tools and techniques we can use, one being the ABCDF bundle, another being ICU checklists, and third, sort of the future, using artificial intelligence during rounds in our ICUs. So the ABCDF bundle, what is it? So A, assess, prevent, and manage pain. B, both spontaneous awakening and spontaneous breathing trials. C, choice of analgesia and sedation. D, delirium. Assess, prevent, and manage. E, early mobility and exercise, and family engagement and empowerment is our F. And this has really been shown to both enhance evidence-based practice and reduce errors. Well, let's see some evidence behind it. So this, again, the ABCDF model, a big component of it is the focus on delirium and doing these things to reduce ICU delirium, but does it work? So this is a 2021 meta-analysis looking at studies between 2000 and 2020. And as you can see, unfortunately, it did fail to show a reduction in ICU delirium, which you can see here. Failed to show a reduction in ICU delirium duration. So didn't really work there. Although, it did show a reduction in patient days with coma, which you can see here. Month of stay, and 28-day mortality. So there's definitely some positive benefits. This is another meta-analysis actually done in a nursing journal. Very well done. And I thought I should include it here because, again, we want to promote our multidisciplinary involvement and also our multidisciplinary academics. So this study actually did show an effect and a positive effect of delirium incidence and duration being reduced with incorporation of the ABCDF bundle. So what about checklists? What are they? So this is a checklist that we actually use in our Bellevue ICU. And many checklists include these sort of subtopics. Ventilator issues, mobility, DBT prophylaxis, lines, Foley's, nutrition. Medications with a focus on antibiotics, start day and discontinuation day. Utilization, do we need daily labs? Do we need daily chest x-rays? And really an effort to reduce unnecessary time and unnecessary testing. And communication. As Dr. Postanoku just highlighted, is family updated? Was family involved on rounds? What's the code status? And then we also have the medication list imported in our checklist, which is incorporated into Epic. But do they work? So this is a 2010 Urban Level 1 Trauma Study which focused on the ventilator bundle. And it does show that incorporation of the bundle, actually they had improved compliance as you went three, six, nine months and out further. And then you can see here on the right side that really they did show some reduction but not statistically significant as far as in death, gastrointestinal hemorrhage, PE, ICU, and hospital length of stay. But when you did control for confounding variables such as GCS, Apache score, and age, you actually did see a clinically significant reduce in ventilator-associated pneumonia. So okay, probably does help in some degree. But there's a recent randomized, actually, controlled trials in Brazilian ICUs that was published in JAMA. And unfortunately, the incorporation of ICU checklists really had no benefit. You can see here the primary outcome was in-hospital mortality, had no statistical benefit in favoring its use. And then you can see a variety of secondary outcomes, all of which really had no benefit. So this was discouraged. But maybe the use of the checklist itself isn't enough. Maybe we need someone to say, hey, did you do the checklist? Like I tell my kids, hey, did you put your laundry in the laundry basket? So here, this is essentially looking at, and this is actually a single center study in Northwestern Memorial Hospital in their medical ICU. And they use a resident who is not involved in the direct patient care as the prompter. And you can see here, this is the, all right, well, sort of see here, okay. So this is comparing, essentially, their Apache predicted death with what their death was. And you can see in the prompted group, they actually had a reduction in mortality. And this is just another way of doing it in severity quartiles. And you can see in the red is the prompting. Sorry, this laser's really not working. But you can see the red groups did have a reduction in mortality. And on the right-hand side, you can see a reduction in ICU length of stay. So perhaps, not just a checklist, but having someone remind us to do the checklist will have even more benefit. Now, do we like them? So this was an interesting study that actually just looked at qualitative aspects. So this is actually from a physician in an ICU. I'm not gonna read the whole thing. But it's basically saying that runs are running more smoothly. The resident knows when it's their turn to talk. The nurse knows when it's their turn to talk. So again, putting some structure into rounds in a multidisciplinary approach. And this one's saying, I have an order. It helps me. I know when to do a family meeting. I know exactly what we're going with code status. I like where we're going. But what don't we like about it? So this says, perhaps they can cause harm if people focus too much on the checklist and not enough on the actual patient and the patient assessment. And kind of, if you look at everybody as a format, you're not looking at them as an individual. So one of the negative aspects is that do checklists depersonalize our patient care? And then this one is saying it's redundant, it's meaningless, a waste of time. So another is that people get frustrated because you're repeating a lot of these things both in your progress note, in this checklist, in the resident note. How many times are we gonna repeat the same thing? So, last tool and technique is ambient artificial intelligence, which is sort of the future of medicine. So where are the ICU applications of ambient AI? So really, we might be able to prevent data fatigue, infection control, and monitoring of patient mobilization. For this talk, I'm gonna really emphasize how it helps us prevent data fatigue. So this is actually very interesting and I was very enthralled with reading about what the Mayo Clinic has for artificial intelligence. This is one of the things they have. And it's essentially called process aware and it's a novel acute EMR, that interface that contains built-in tools for error prevention, practice surveillance, and decision support and reporting. And it essentially creates this screen of all the important data that you will need, both on your rounds and for your notes, and allows you to focus on that and not get caught up with all the unnecessary normal labs, or I shouldn't say that, sometimes a normal lab is very necessary, but the things you need to focus on. And this study actually showed that the incorporation of this interface had a reduction in central line infections that was statistically significant, ventilator associated events, central line use, assessing discontinuing central lines when you're no longer needing them, catheters, antibiotics, discontinuing antibiotics, and again, ventilator use per day in the hospital, compliance with lung preventive ventilation. A lot of positive things. And when they controlled for again, severity by Apache score, the odds ratio for hospital and ICU mortality actually showed benefit of using something like an artificial intelligence software that is prompting you to look at the clinically significant data. The problem with these studies is it's very difficult to control for confounding variables so the best they could come up with is a suggestion that software such as this will help reducing negative patient outcomes and improve the positive ones. So conclusions. The ABCDF bundle is an evidence-based guide for clinicians to coordinate multidisciplinary patient care in the ICU, but its utilization has yielded variable results in the literature. Studies assessing checklists have found contradictory results. The single center study I mentioned in Northwestern did show that prompting may actually have an enhanced effect. So maybe we need someone to tell us and remind us to do it. And then third, efficient organization of information in the ICU with AI systems has the potential to improve important patient outcomes. And I think the most important point is this. Perhaps there's a super additive benefit of utilizing all of the above. So again, to remember, parenting, ICU rounds, tools and techniques are essential. Thank you. My name is Miriam Kau, so as it pulls up, so in the interest of time, I will roll right along. Okay. So again, I'm going to be discussing teaching across disciplines during the ICU, and as you can imagine, when I mentioned this topic to my husband, who's a gastroenterologist, and then one of the other PCCM docs in my group, both of them had different ideas of what disciplines really mean. So I'll ask you guys what you think, too. So I'm actually in Houston. I'm one of the assistant professors in PCCM, but I'm also a CCU medical director from the critical care half, so I have a little bit of a unique view of how to do teaching in different ICUs. So I'm going to just quickly ask, before I even go over the objectives, how many of you guys actually run a medical ICU? Okay. How about surgical ICUs? A couple. And then cardiac or any other ICUs? Okay, so a few, but mainly the medical ICUs. Okay, so I'm going to discuss some challenges to teaching in a multidisciplinary setting in the ICU and really talk about how to create a culture that's conducive to teaching, but to be honest, a couple of my colleagues actually use the studies that I'm going to mention, so I'm going to breeze through those a little bit, and then I'm going to discuss some of the teaching strategies that I saw were effective and I utilize as well in my ICU. So as we know, the ICU is really a unique setting where many members of the team come together. It's much different than a ward setting where you really have to utilize non-physicians to really run the rounds really effectively. So depending on the type of ICU that you're in, various different disciplines may come together. So when I was thinking about this topic, I actually thought about what our trainees have to go through the challenges of us teaching them while other people are there. But if you think about disciplines, really you can also think about the multiple disciplines that you're rounding with, pharmacists, respiratory therapists, nutritionists, physical therapists, and also sometimes you may have other members from maybe other disciplines, cardiac, surgery, et cetera. So you have a lot of different individuals that are really playing a part in your ICU. And so all of those also add to the challenges. So this is just a cartoon. So you guys know how this is. So you may have one empty bed, or maybe you have three empty beds. So you're like, I'm excited. Maybe rounds will go a little bit smoother, but all that does is leave the beds open for your rapid responses so you're ready for anything that's going on. All right. So there's so many challenges to actually being an efficient teacher in the ICU, right? And we have to deal with all of those every single day. So the number one thing I think we can all agree on is that when you have maybe 10 team members, the varying educational backgrounds really make it a challenge for you to even give pearls of advice that are applicable to all of your learners, right? Of course, the unstable patients will be there constantly, time constraints, and then your interactions with your consultants and other people who may take up your time as a physician attending. Again, I think this is mainly targeted to people who are running the ICU rounds, but trainees who are finishing will also see these same challenges as they're finishing up. Or if you allow your trainees to run the rounds, they may be facing these same challenges. So why is interprofessional collaboration so important? We know that in healthcare, poor communication really occurs very commonly, and this leads to inefficiency, medical errors, and just conflict within the team as well. So sometimes what happens when we're running in the cardiac critical care unit is that you have the cardiac unit and the team that's rounding, and the palm crit team that's rounding, and when we go in separately and talk to the patient, they may ask, when is my procedure? Well, I have no idea when the procedure is, so I feel like a chump going in there and saying hello, but I don't know when their procedure is going to be. So oftentimes, they may have more information than I do. So really, it's important for us to collaborate and lead rounds more efficiently. So this, I will take it back to one of the other lectures that you guys just heard, that interprofessional bedside rounds, really at the bedside, involving the family and the patient, is so important. So not just for efficiency of your ICU rounds, but also for teaching. So there's a lot of studies that show that this leads to increased communication. And also, the learners find that this actually increased the teaching pearls that they heard from their attendings and led to more efficient rounds. So what were the perceptions? So again, as I just mentioned, so one of the studies by Lopez showed that it actually impacted positively learning, and these types of rounds were more effective than rounds without structure. And it was funny to me that when I thought about what they mentioned as being without structure was probably rounds that many of us run. I know my ICU oftentimes runs like this, is that we round outside with a bunch of computers, we go through the data, we come up with a plan, and then we go inside and we discuss the plan with the patient. But what they meant by structured rounds was having their nursing, the family, patient at the bedside, and maybe even the consultants, and you all go in together and discuss with the patient what the plan is and go over the labs at the same time. So that's what they found to be a structured versus unstructured unit. And so there's a little bit of mixed data about the trainee satisfaction, but by and large they saw that trainees were actually happier doing rounds in that manner and thought that it positively impacted their learning. So this study by Stein, he looked at kind of changing the ward unit, but it just shows you that we have most of the tools like this in the ICU already. So what they did was calling the ICU team, or the ward team, an accountable care unit or a little bit of a clinical microsystem, which we have in the ICU. The only thing that we really, most of the ICUs didn't have is a structured interdisciplinary bedside round. They implemented this at Emory and they saw that before and after implementation of this, they found that the hospital mortality actually decreased significantly and the length of stay decreased as well. So aside from the teaching being improved, they also saw real data that this showed improvement. So I just wanted to show this is that we have unit-based teams, we have unit-level performing reporting, and we have a co-leadership between physicians and non-physician team members. So all we need is to kind of structure our rounds a little bit better and I know my colleagues kind of went through some of this data already. So next, I'm going to talk about what do our trainees think are successful behaviors of ICU teachers. And I really take it back to our trainees because those are the people that we interact with the most when we think about teaching, right? So and this study by, okay, well, the study that I was going to show you guys if this loads is that one of the people looked at, handed out surveys at Johns Hopkins and Washington University and two other universities to their trainees to look at what they thought were successful teaching behaviors by the ICU attendings. And they saw that what the trainees loved was people who loved education, they respected all the team members and valued their opinions, they took the time to really explain what their reasoning behind the day plan was, and really didn't care about if the ICU leaders were participating in a lot of research trials or had done formal teaching, but really it's what they did at the bedside and respecting the patients as well. So that's what our learners really care about. Okay, there you go. Sorry about that. Okay, so this was a 37 point survey that they handed out to their trainees and looked at what they thought was important. So these are some of the questions, very detailed that they talked about. It was out of a five point scale. And you can see that the higher points that were given were that the attending physician enjoys teaching the house staff and really shows empathy. What they didn't care about, as I mentioned before, was that if you have formal education training or what your research skills were, but really cared about your patient interaction and your clinical skills. So teaching in the ICU, I think what we can think about is thinking about three major concepts and then I'm going to go through some tips, right? So our direct teaching should be goal oriented and it should be targeted to the learner. So now the learner, depending on who you work with in your ICU, it could be a medical student, it could be an intern, a resident, a fellow. And at times, for us, we even have NP students or if you're thinking about your RTs, your pharmacist. So you really want to gauge where they are and what they would like to learn. And then utilizing simulation can be a very important tool. And then what we often forget is that feedback is really essential and it's challenging to accomplish but our trainees crave it. So I'm going to go through some of these tips and you all may be utilizing some of these anyway, but I just want to reiterate them. So again, you really want to set your goals for your trainees, okay? So you want to be clear with them about what your short and long term goals are after they finish their ICU rotation. If it's not a rotation for them, if you're going to continue working with them, even if it's a nutritionist or pharmacist, what you want them to accomplish while they're rounding with you. And this really allows you to engage with them constantly and maximizes their motivation and their self-learning. You want to create this non-threatening environment, right? It's a very, very high stress environment. And so you ask the trainee, are you comfortable with my teaching style? And that doesn't necessarily mean that you have to alter your teaching style completely, but maybe gauge what their comfort is with different teaching styles and maybe you can tailor it a little bit. And then again, your expectations. So set it at the beginning of you working with them. Maybe you're taking over from another attending and so you want to set your educational goals with them every time that you're working with a new group. And explain, and I know we mentioned this before, that disruptions actually are a part of workflow. So oftentimes, you may see trainees say that we have a lot of disruptions in the ICU. That's something that we cannot control at all. So I think setting a tone of that this may happen, but we're going to push through it and we're still going to find time to do teaching is very important. And again, so determine where your learner is. There are tools that you can utilize to gauge that, but simple, once you work with them a day or two and you're focusing on letting them present their patient, you may be able to gauge where your learner is and that allows you to really hone in on what you need to focus on teaching. And something that maybe some of the attendings may have forgotten, but I think a lot of us are working on this, is that we think about our trainees preparing, but as attendings, I think it's important for us to prepare as well. So what may that entail? It may entail us coming a little bit before rounds, reviewing all the patients and looking for the patients that are more interesting and picking some topics that we may discuss with them. Or you just know what your team, what the flow of the ICU is going to be that day and that way it makes for more efficient rounds. So you're not focusing on minutia and small labs that you need your trainees to go through. And then really allow your trainees to chime in and allow them to emphasize that critical thinking is what you're looking for. You're not looking for the right answers, the answer could be wrong, but you want them to understand, you want to understand what their thinking before that is. And this really allows them to understand that it's a safe environment and they can make mistakes. So taking it back to what we've been talking about, you really want to involve the patient, take it back to the bedside. And I think we've kind of gone away from that and now we're seeing data again that maybe patient-centered interdisciplinary bedside rounds are what's key. And this has shown to improve. Even the teaching pearls, we're seeing that they were more frequently discussed. So I know you mentioned this study in your talk, but I saw a different part from that same study that showed that actually teaching pearls were more frequently discussed when patients were involved in the rounds. So really think about that in your rounds. And again, be humble and acknowledge that you also may have knowledge gaps. And this helps your trainees. And we can't overemphasize that if you have some teaching strips, five to 10-minute talks that you may continue to give your lecturers and get some feedbacks on these teaching scripts and get learners to improve. Focus on simulation and then feedback. I don't want to overlook this. This is essential. So you may be giving constant feedback as well as summative feedback. And this encourages a learner to do some self-evaluation as well. So you want to observe your learner and give them a summative feedback at the end. So in conclusion, you want to identify your goals and your learners, create an environment in the ICU that's open and understanding, utilize your multidisciplinary structure to your advantage, and really provide feedback to your trainees. And know that the ICU is a unique learning opportunity that we can create an environment conducive to teaching across multiple disciplines. And that's it. Thank you, guys.

ICU rounds

family integration

rounding structure

team members

patient outcomes

medication errors

collaboration

communication

family involvement

teaching