Last week, we shared with you the story of how bullet rounds began on CTU (Clinical Teaching Unit) 6200 – today, we focus on where this continuous improvement journey has led us.

Supporting better teams through physical location of hospital beds

On the particular day we are talking about bullet rounds with Christina Sparrow, CTU nurse coordinator, there are 76 patients who needed the physician care offered by Teams Red, Blue and Silver in CTU 6200. But, CTU has only 52 beds, so some of these patients have been located elsewhere in Royal University Hospital.

Staff gather around a board in a hallway

The team gathers near a patient status at a glance (PSAG) board,

The team walks down the hall.

CTU team ‘Blue’ is quickly on the move during their daily bullet rounds.

A patient is assigned to a CTU team based on their medical needs and physicians best suited and available to provide that care. A patient’s doctor for CTU is not determined by the physical location of the bed.

Sparrow explains that the CTU physicians, and now the dedicated support team members, go with the patient no matter where they are physically placed. But the nurses don’t and this creates a challenge when trying to keep a team approach to care and ensuring everyone knows their patient.

“Co-location allows for the patient’s nurse to be present during rounds which can add valuable information regarding patient status,” says occupational therapist Jolie Hackman, a member of CTU Team ‘Blue’. “If patients are ‘off-serviced’ (physically located in a unit outside of CTU), the nurse is not always able to be present which does not allow for an update on the patient status from the nursing perspective.”

It’s why physically locating a team’s patients in one area became such an important piece of work during 90 Days of Innovation: Ready Every Day. But doing this is easier said than done given the pressing need to move patients out of emergency to a hospital bed.

It’s a work in progress that is being trialled with CTU Team ‘Blue’ and is proving its benefits.

“I have to say when I heard they were going to try geographically co-locating the patients in one area, I was skeptical because I knew it was difficult to do,” says Dr. Michael Prystajecky, a senior medical resident. “But I was happy to see it start. Just in terms of daily work, it takes us less time to get to the patients because they are physically close together, and the team is there. We know each other better as a team and we are more comfortable discussing patient issues with each other… It really helps to better understand the role of other occupations in a patient’s care. I feel like I know who I need to reach out to when I have a particular question.”

On this day, Prystajecky is working with Sparrow on the rounds. A nurse offers insight into a patient’s development over the last few hours. Prystajecky responds with, “Thanks, that is really valuable to know,” and the rest of the team adjusts their plan for the day.

“For Team ‘Blue’, it’s made such a difference because they are not doing as much walking. And, it helps the nursing staff be more involved in the bullet rounds,” says Sparrow.

The importance of nursing as part of bullet rounds

“Our research shows nurses feel less engaged in rounds despite rounds being highly valued,” says Prystajecky, who researched, with a colleague, healthcare providers’ perspectives of bullet rounds during his internal medicine residency.

Incorporating that valuable insight provided by a patient’s nursing team has been a challenge and was a recommendation out of the Care Delivery Review and Design 3P (production preparation process) last June where teams worked together to create a new model of care. A quality improvement event in October 2014 focused on ways to improve nursing attendance during bullet rounds which included supporting nurses to participate in bullet rounds, and outlining the information they bring to the discussion.

Patient status at a glance boards

Making information more visible is also some of the focused work that continues. The unit’s patient status at a glance (PSAG) boards on the unit were developed within last year’s model of care work, but evolved during the 14 day challenge and 90 days of Innovation: Ready Every Day.

“When we do bullet rounds, we gather around the PSAG board and find out if someone is getting ready for discharge and green or yellow magnets go beside their information,” says Sparrow. “This helps as a visual cue and gives us the opportunity to make sure information is correct or to add information.”

“The PSAG board is useful for planning our day from a therapy perspective,” agrees Hackman. “If we see a patient is scheduled for a test at a specific time, we can plan our therapy session around that proactively, decreasing the risk of a patient not receiving their therapy.”

The PSAG board is not perfect, admits Sparrow, and the team is continually trying to improve it and how they use it, as well as balancing the need to share information visually and the need to follow privacy legislation.

Information sharing is critical to the success of bullet rounds

After bullet rounds, nurses update the patient flow computer system on what was discussed. The 90 Days of Innovation initiative also saw some assistance in putting in place better documentation.

“One of the limitations was that we didn’t capture the conversation so if you weren’t there, you missed out,” says Sparrow. “Now, we keep the documents on a shared drive so people can access them any time of day. The good people at Sunrise Clinical Manager helped develop this. They took paper copies and generate this report daily.”

The next step will be to improve the documentation accessibility.

Reflecting back and moving forward

Working daily to improve bullet rounds, and all the supporting pieces with it, continues today on CTU 6200.

“When we initially switched to bullet rounds, the discussions were very medical focused with little information requested and provided from the inter-professional team,” says Hackman. “Now, it’s a whole team discussion and assists with providing holistic patient care.”

“There are some people who think at times that we are repeating information and that they didn’t learn much that was new today. But then, there are other days where everything changes,” says Sparrow. “If we had not had that conversation on that day, the patient care would have been delayed. Before, we’d see a patient who was medically stable and ready for discharge then it was discovered that, they need a wheelchair and don’t have one. Or, the patient needs home care set up, but CPAS didn’t know about this. Whereas now, everyone has an idea of the priorities of the day and have on their radar of what needs to be done to progress care.”

Sparrow says they still have barriers and challenges with bullet rounds, and with the unit adapting to all the changes that have come in recent months. But, she believes the improvements in care for patients, and in their work environment, is worth the journey.

“I am excited to see where this goes,” she says. “It’s a great process, and as an organization, I am excited to see how we will continue to change and improve to get better.”