Design and Implementation of an Emr-Based Interactive Multidisciplinary Checklist on the Inpatient Medicine Ward

Background:

One target for improvement of effective patient centered care on the inpatient medical ward is the mechanism for communication among the multidisciplinary care team (MCT).  The medical service at Stanford Hospital and Clinics recently implemented morning “team care rounds” (TCRs) that provided space for the MCT members, including the physician (MD), nurse (RN), case manager (CM), and pharmacist (Rx), to discuss the patients’ plan of care for the day.  We have identified three distinct areas for improvement: 1) Important multidisciplinary patient care issues are not consistently addressed during TCRs for every patient, 2) MCT members are not consistently on the same page regarding changes to plan of care throughout the day, and 3) non-urgent communication among MCT members often are disorganized and interrupt workflow.   

Purpose:

We describe the design, implementation, and effectiveness of an interactive checklist imbedded in an EMR-based message board in improving MCT communication. 

Description:

Our intervention is twofold: 1) a “team care rounds checklist” (TCR checklist) of ten standardized inpatient patient care issues divided by MCT roles that is embedded into an EMR message board and 2) a workflow that incorporates use of the TCR checklist to communicate non-urgent patient care issues.  The sections are: 1) MD – daily clinical goals, a yes/no section for discontinuing indwelling lines and telemetry; 2) RN – patient concerns, a yes/no section for wound care plan; 3) Rx – medication issues; 4) CM – discharge barriers, risk for readmission.  MCT members are instructed to update their respective sections prior to TCRs.  The checklist would guide discussion during TCRs and used throughout the rest of the day.  

Pre-intervention data ascertained over one month include subjective MCT member perception of communication quality, frequency of non-urgent pages to MDs by the MCT, and inpatient metrics including median time on telemetry and indwelling lines.  Three university medicine teams are assigned to the intervention group and the other two as controls.  Post-intervention data in the same categories will be collected after a three month intervention period, which will end in December 2015. 

Preliminary analysis of pre-intervention showed that RNs rated 1.25 and 1.7 pts lower than MDs in satisfaction of quality and timeliness of communication, respectively, on a 5-pt Likert scale.  All rated timeliness of telemetry discontinuation as “good” (3/5), but RNs rated 0.8 and 1.4 pts lower than MDs regarding timeliness of foley discontinuation and wound care plan implementation, respectively.  Pre-intervention TCRs did not consistently include standard patient care issues, with 0/11 observed TCRs included discussion of when to discontinue foleys, telemetry, and indwelling lines, and less than 30% included discussion of mobility, barriers to discharge, and medication issues.  Out of 528 pages to three residents and interns over two weeks, 65% were non-urgent.  Preliminary analysis of seven intervention and seven control TCRs  during the early intervention phase showed an increase in the number of patient care issues addressed by the intervention teams (mean 6.1 vs 4.8), most notably a 1.67-fold increase in discussion of discontinuing telemetry, indwelling lines, and implementing wound care.  

Conclusions:

Early observations of TCR checklist use in the intervention group are promising and our next steps are to continue to maintain intervention adherence and ascertain post-intervention outcomes.