It’s 11 a.m. in Clinical Teaching Unit (CTU) 6200, a medicine unit at Royal University Hospital, a group begins to gather near the whiteboard. Listening to the conversation, you quickly realize they are a diverse group with doctors, nurses, a speech pathologist, a physiotherapist, a pharmacist, an occupational therapist, a social worker, and a representative from client-patient access service (CPAS), to name a few.

Each are handed a list. “Good morning everyone,” says one individual. “We have 20 minutes. Let’s get started.”

Welcome to bullet rounds.

Staff stand in a hallway.

It’s just past 11 o’clock. Bullet rounds in CTU 6200 have begun.

For the next 20 minutes, CTU Team ‘Blue’ moves through the unit and reviews care plans for the day for patients as a team. It’s a process you will see repeated later in the hour by CTU Team Red and CTU Team Silver.

“It’s so valuable,” explains Jolie Hackman, an occupational therapist with CTU 6200 Team Blue. “Before, we met once or twice a week as a group for a few hours, and then spent a lot of time paging, phoning and trying to track down the other team members to talk about questions and concerns about a patient, or just to give other members an update to assist with discharge planning.”

Each patient who needs care from this unit is assigned to a team colour, depending on their needs and the physician care available. The rest of the members organize themselves to align with these three teams and work with the physicians.

The challenge was connecting everyone involved in the patient’s care in the right way at the right time.

So just over two years ago, Christina Sparrow was tasked with improving that. Hired to work with both University of Saskatchewan and Saskatoon Health Region, the CTU Nurse Coordinator looked at establishing interprofessional rounds to improve communication among team members.

“Our patient population often has multiple health issues, social concerns and physical limitations. So often, for some of our patients, they are medically stable, but can’t go home yet due to their mobility needs, equipment needs, or sometimes, social needs,” explains Sparrow. “Our physicians are excellent and offer so much, but are limited in securing those other resources. That’s why it’s so important for the entire team to work together and focus on the whole of our patient’s needs.”

Strong processes take time

In July 2013, after a few months of research and talking with front line staff and physicians who worked on the unit, and based on a recommendation from an outside consultant, the decision was made to launch bullet rounds. This started with the next round of medical residents who were arriving on the unit. These residents are doctors who are training to become specialists and are often the physician representatives for interdisciplinary rounds.

Dr. Michael Prystajecky, a senior medical resident, was there during that transition.

“Prior to bullet rounds, the team was not always on the same page regarding how close or appropriate a patient was for discharge,” says Prystajecky. “Communication through the chart can be challenging at times as we document information in different places”

A work in progress

The journey to today has had its challenges. In early days, the team would meet, informally and formally, to determine what was working and what wasn’t.

“This was really designed by the people who use the process every day,” explains Sparrow who says the key was to stay focused on what the rounds are for and adapt. Initially, she says members wanted to outline all they had done with the patient.

“The process of their work is really important, but what the rest of the team needed to know was the end result,” says Sparrow. “We focused on keeping things brief and away from story-telling. But we have had to balance that because sometimes anecdotes can really help illustrate what is happening. So over time, we arrived at 20 minutes as a more realistic timeframe and became more flexible so if we needed longer conversations, we would do it.”

Building blocks to a new model of care

A year after bullet rounds began in June 2014, many of these members found themselves in a warehouse, along with staff and physicians with Acute Care Pediatrics, focused on developing a new model of care called Care Delivery Review and Design 3P (production preparation process).

Prystajecky and Sparrow were both there. Prystajecky says they talked about CTU’s experience with bullet rounds and how it has improved interprofessional collaboration. They worked with other 3P participants to develop ways of increasing interprofessional collaboration and recommended dedicating interdisciplinary staff to teams, and locating a team’s patients in the same geographical area.

“The evidence (behind bullet rounds) is strong. (Daily interprofessional collaboration) decreases the patient’s length of stay, decreases hospital errors and decreases hospital admission costs,” Prystajecky says. “We also know there are other positive outcomes of collaboration including enhancing team communication and team building.”

“From a logistics perspective, a lot of our supports (Physical Therapists, Occupational Therapists, etc.), in their own areas, would print out a list, and then, their co-workers would write updates on their patients on that list,” explains Sparrow. “One person would sign up to attend rounds and bring all the information. But, they didn’t necessarily know the patient. They’d share the notes, but if the rest of the team had questions, they weren’t able to answer it. And, they had to be present for an hour, take notes and try to track down their colleague therapists for answers.”

Enter 14 Day Challenge and 90 Days of Innovation: Ready Every Day

Some of the recommendations out of the model of care work would be catapulted into action when the Region mobilized in late January 2015 during a long-term capacity crisis. This included ensuring that interprofessional staff were dedicated to each of the CTU teams, which meant they cared for those patients and attended bullet rounds.

“We now have therapies dedicated to a CTU team color (Red, Blue, or Silver) which has resulted in decreased caseload numbers and more time for treatment and care planning,” says Jolie Hackman, who has been part of the before and after evolution. “Being on a specific team color also allows for more consistency for patients as we strive to follow the patient throughout their hospital stay including if they are on another ward. Consistency of the team is also beneficial for the care team members as we know who to contact regarding specific issues and it allows for a more cohesive care team.”

Because Hackman is assigned to a CTU team, she is able to stay with her patients, no matter where they may be moved in the hospital. It is not uncommon for CTU patients to be physically located in other areas besides the 6th floor.

Read the second part of our bullet rounds story here.