Free On-line Access

SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

Ícone Fechar

How to Cite


 

Borges ML, Caruso P, Nassar AP. Carga de trabalho da enfermagem associada com frequência de visitas multidisciplinares: um estudo transversal. Rev Bras Ter Intensiva. 2021;33(1):82-87

 

 

2021;33(1):82-87
ORIGINAL ARTICLE

10.5935/0103-507X.20210008

Nursing workload associated with the frequency of multidisciplinary rounds: a cross-sectional study

Carga de trabalho da enfermagem associada com frequência de visitas multidisciplinares: um estudo transversal

Maria Luiza Borges1, Pedro Caruso1,2, Antonio Paulo Nassar Júnior1

1 Intensive Care Unit, A.C. Camargo Cancer Center - São Paulo (SP), Brazil.
2 Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.

Conflicts of interest: None.

Responsible editor: Felipe Dal-Pizzol

Submitted on February 24, 2020
Accepted on June 03, 2020

Corresponding author: Antonio Paulo Nassar Junior Unidade de Terapia Intensiva A.C. Camargo Cancer Center Rua Professor Antonio Prudente, 211 - 6° andar Zip code: 01509-010 - São Paulo (SP), Brazil E-mail: [email protected]

 

Abstract

OBJECTIVE: To assess the frequency of multidisciplinary rounds during ICU days, to evaluate the participation of diverse healthcare professionals, to identify the reasons why rounds were not performed on specific days, and whether bed occupancy rate and nurse workload were associated with the conduction of multidisciplinary rounds.
METHODS: We performed a cross-sectional study to assess the frequency of multidisciplinary rounds in four intensive care units in a cancer center. We also collected data on rates of professional participation, reasons for not performing rounds when they did not occur, and daily bed occupancy rates and assessed nurse workload by measuring the Nursing Activity Score.
RESULTS: Rounds were conducted on 595 (65.8%) of 889 surveyed intensive care unit days. Nurses, physicians, respiratory therapists, pharmacists, and infection control practitioners participated most often. Rounds did not occur due to admission of new patients at the scheduled time (136; 44.7%) and involvement of nurses in activities unrelated to patients’ care (97; 31.9%). In multivariate analysis, higher Nursing Activity Scores were associated with greater odds of conducting multidisciplinary rounds (OR = 1.06; 95%CI 1.04 - 1.10; p < 0.01), whereas bed occupancy rates were not (OR = 0.99; 95%CI 0.97 - 1.00; p = 0.18).
CONCLUSION: Multidisciplinary rounds were conducted on less than two-thirds of surveyed intensive care unit days. Many rounds were cancelled due to activities unrelated to patient care. Unexpectedly, increased workload was associated with higher odds of conducting rounds. Workload is a possible trigger to discuss daily goals to improve patient outcomes and to enhance the effectiveness of multidisciplinary teams.

Keywords: Critical care; Multidisciplinary communication; Staff engagement; Workload; Patient care team.

 

INTRODUCTION

Multidisciplinary teams are essential for the care of critically ill patients. Daily multidisciplinary rounds are correlated with numerous positive outcomes, such as the implementation of sedation protocols,(1) earlier mobilization,(2) fewer adverse drug events,(3) reduced use of invasive devices(4) and lower mortality.(5) In addition, multidisciplinary rounds using daily goal checklists are associated with improved perceptions of work and patient safety climates.(6) Multidisciplinary rounds may be even more important in strained settings.(7)

However, 20 - 30% of intensive care units (ICUs) surveyed in numerous studies do not perform multidisciplinary rounds.(8),(9) Given that professionals from diverse disciplinary backgrounds bring alternative perspectives that can lead to vastly different conclusions regarding specific aspects of patient care,(10),(11) multidisciplinary collaboration should be encouraged. In addition, communication failures may cause adverse events and prolong ICU lengths of stay.(12) Thus, the implementation of daily multidisciplinary rounds should be a top priority of quality improvement programs in ICUs.

We aimed to assess the frequency of multidisciplinary rounds during ICU days, to evaluate the participation of diverse professional disciplines responsible for critical care, to identify the reasons why rounds were not performed on specific days, and to identify whether two measures of ICU capacity strain,(13) e.g., bed occupancy rate and nurse workload, were associated with the conduction of multidisciplinary rounds.

METHODS

We conducted a cross-sectional study in four ICUs in an academic cancer center from October 2017 to August 2018. The study was approved by the Ethics Committee (number 2,430/17). Due to the observational study design, the requirement for informed consent was waived. We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.(14)

Our study was conducted in one of two unconnected main hospital buildings that has four ten-bed mixed medical-surgical ICUs. Patients can be admitted to any of the ICUs. During the morning shift, there was one physician and one nurse every five beds, a respiratory therapist every ten beds, and a nurse technician every two beds. There is also a pharmacist for every ten to 20 beds. Depending on the on-call schedule, the pharmacist may also be responsible for ward beds.

Multidisciplinary rounds are scheduled daily from 11 to 12 a.m. from Monday through Friday. The participation of physicians, nurses and respiratory therapists is mandatory. Pharmacists, nutritionists, psychologists, and infection control practitioners are invited, but their participation is optional. Rounds are conducted at nurses’ stations rather than at the patients’ bedsides. In general, the physician in charge presents each patient’s clinical status and proposes a diagnostic and therapeutic plan. All professionals discussed critical medical problems from their perspectives and suggested management strategies. Interventions must be documented and checked in electronic health records. Briefly, these activities can be summarized as requests for imaging and laboratory tests; drug reconciliation and dosing changes; withdrawal of invasive devices, such as central venous and urinary catheters; patient mobilization; and specialty consultations.

Although multidisciplinary rounds are considered part of the morning shift, they may be cancelled at the request of nurses or physicians due to emergent tasks that must be completed during the same time frame, such as patient admissions, transfers, or the performance of invasive procedures.

A nurse supervisor assessed daily whether multidisciplinary rounds were conducted in each of the four ICUs. If rounds were performed, she documented which professionals participated. Additionally, for all study days, she assessed the bed occupancy rate of each ICU and the Nursing Activity Score (NAS)(15) of all patients to measure nurse workload. A daily mean NAS for each ICU was calculated by adding the NAS of each patient and dividing by the number of patients hospitalized in the particular ICU on that day. If rounds were not performed, she asked nurses in charge why rounds did not occur and recorded the reason. The reasons were categorized as follows: admission of a new patient during the ICU round schedule time, bedside procedures being performed by the physician on charge at round schedule time, nurses involved in activities unrelated to patients’ care (administrative or educational activities), and other.

We retrieved data of patients admitted during the study period from electronic medical records. We collected the following data: age, sex, type of cancer (solid locoregional, solid metastatic, hematologic or no cancer/remission > 5 years), Eastern Cooperative Oncology Group Performance Status (ECOG PS), type of admission (medical, elective or urgent surgery), reason for admission, Simplified Acute Physiology Score (SAPS) 3, ICU outcomes (alive, dead or transferred to another hospital) and length of ICU stay.

The study’s outcome was the measurement of the frequency of conducting multidisciplinary rounds during ICU days over the study period.

Statistical analysis

Categorical variables are presented as absolute numbers and percentages. Continuous variables are presented as the means and standard deviations.

We tested whether bed occupancy and mean NAS were associated with conduction of multidisciplinary rounds by performing Student’s t-test. We also performed a logistic regression with bed occupancy and mean NAS as independent variables and accomplishment of a multidisciplinary round as the dependent variable. Odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for both variables included in the model. A p value of < 0.05 was considered significant. All analyses were performed using Statistical Package for Social Sciences (SPSS), version 21 (IBM Corporation, Armonk, NY, United States).

RESULTS

There were 223 days with scheduled multidisciplinary rounds during the study period. However, one unit was closed for 3 days for equipment maintenance. Consequently, we assessed the frequency of multidisciplinary rounds on 889 ICU days. Multidisciplinary rounds were conducted in 585 (65.8%) of these opportunities. Nurses, physicians and respiratory therapists participated in all rounds. Pharmacists and infection control practitioners were other frequent participants (Figure 1).

Figure 1 - Professional participation in multidisciplinary rounds.

The main reason for not performing multidisciplinary rounds was an admission of patients in the round scheduled time (136, 44.7%). On six occasions (2.6%), multidisciplinary rounds did not occur due to “no specific reason” according to the nurses in charge. The involvement of nurses in activities unrelated to patient care led to the cancellation of 97 (31.9%) rounds (Figure 2).

Figure 2 - Reasons for multidisciplinary round cancellation.

A total of 3,096 patients were admitted during the study period. The patients were predominantly male (1629, 52.6%), had a mean age of 61 (± 15.1) years and had predominantly solid cancers (2,790; 90.1%). Medical reasons (1,608, 51.9%) were more common than surgical admissions. Data on previous performance status were available for 2,298 (74.2%) patients, of whom 1,494 (65.0%) had absent or minor impairment status. A total of 275 (8.9%) patients died at ICU discharge (Table 1).

Table 1 - Characteristics of patients admitted during the study period
Variable  
Age 61.0±15.1
Female sex 1.467 (47.4)
Type of admission  
    Medical 1.608 (51.9)
    Elective surgery 1.310 (42.3)
    Urgent surgery 176 (5.7)
Source of admission  
    Surgical room 1.476 (47.7)
    Emergency department 818 (26.4)
    Wards 775 (25.0)
    Another hospital 25 (0.8)
Reason for admission  
    Postoperative monitoring 1.450 (46.8)
    Sepsis/septic shock 466 (15.1)
    Neurological disorders 163 (5.3)
    Cardiovascular disorders 148 (4.8)
    Renal and metabolic disorders 78 (2.6)
Type of tumor  
    Solid loco regional 1.384 (44.7)
    Solid metastatic 1.406 (45.4)
    Hematologic 206 (6.7)
    No cancer or remission > 5 years 98 (3.2)
SAPS 3 points 54.9±16.6
Performance status*  
    No or minor impairment (ECOG 0 or 1) 1.494 (65.0)
    Moderate impairment (ECOG 2) 442 (19.2)
    Severe impairment or bedridden (ECOG 3 or 4) 362 (15.8)
ICU discharge outcomes 275 (8.9)
    Alive 2.818 (90.0)
    Dead 275 (8.9)
    Transferred to another hospital 3 (0.1)
Length of ICU stay, days 3.0±4.0

SAPS - Simplified Acute Physiology Score; ECOG - Eastern Cooperative Oncology Group; ICU - intensive care unit.

* Data on performance status were not available for 798 (25.8%) patients. Results expressed as mean ± SD or n (%).

Table 1 - Characteristics of patients admitted during the study period

The mean patient NAS was higher on days with rounds compared with those without rounds (86.2 ± 5 versus 84.8 ± 4.3; p < 0.01). On the other hand, bed occupancy rates did not differ on days with or without rounds (93 ± 9.7 versus 93.5 ± 9.8%, p = 0.45). On logistic regression, mean patient NAS was independently associated with the conduction of multidisciplinary rounds (OR = 1.07; 95%CI 1.04 - 1.10; p < 0.01), whereas bed occupancy rates were not (OR = 0.99; 95%CI 0.97 - 1.00; p = 0.18).

DISCUSSION

Our study showed that multidisciplinary rounds in ICUs were conducted in less than two-thirds of ICU days. As expected, nurses, physicians, and respiratory therapists participated in all rounds, and pharmacists and infection control practitioners also participated often. Rounds were more frequent on higher nurse workload days. New patients’ admission and nurses’ involvement in activities unrelated to patients’ care were the main reasons for not performing multidisciplinary rounds.

Multidisciplinary rounds are essential to the care of critically ill patients because professionals from diverse disciplines have varied perceptions and recognize different aspects of medical problems.(10),(11) Multidisciplinary rounds are associated with positive outcomes for both patients(1),(2),(5) and interprofessional teams because they increase collaboration and understanding of daily goals,(12) facilitate the sharing of both similar and complementary insights,(16) enable consensus-based decision making, and reduce conflicts within teams.(7) The fact that multidisciplinary rounds were not conducted in greater than one-third of scheduled days is cause for concern. A strategy for the reduction of competing tasks during rounds should be addressed as a top priority.(17)

A positive finding of this study was the frequent participation of pharmacists on rounds. Pharmacist participation is associated with reduced mortality rates, lengths of ICU stay, and adverse drug events.(3)

Our finding of greater odds of conducting multidisciplinary rounds on days of higher nurse workload was unexpected. Because rounds may be disrupted by emergent multitasks during scheduled rounding time, we believed that rounds would be less likely during higher nurse workload days. The opposite finding may be due to a team perception that the care of patients with more critical illnesses generates higher workloads and, consequently, demands multidisciplinary discussions to establish daily goals. Nurse workload is one of the indicators of ICU capacity strain(13) and is associated with higher rates of burnout.(18),(19) In addition, high workload to nurse ratios are associated with increased mortality.(20) We suggest that nurse workload should be a trigger to discuss daily goals to improve patient outcomes, reduce risk, and enhance the effectiveness of multidisciplinary teams.

This study has both strengths and limitations. This was a pragmatic study that aimed to assess the frequency of multidisciplinary rounds and its association with bed occupancy rates and nurse workload. To reach these aims, our study covered almost 9,000 patient/days in 889 possible encounters. On the other hand, it was a single center study, and our staffing model may not reflect those used in many centers. Additionally, we did not address differences in patient outcomes, achievement of daily goals, or measures of staff wellbeing related to the conduction of multidisciplinary rounds.

CONCLUSION

Multidisciplinary rounds were conducted in only 65.8% of scheduled intensive care unit days. However, the professionals most responsible for directing patient care participated regularly. Rounds occurred more frequently on days of higher nurse workload. Admission of new patients and nurses’ tasks unrelated to patients’ care were the main reasons for not performing a multidisciplinary round. Future studies should focus on strategies to identify and decrease tasks that decrease conduction and/or participation in multidisciplinary rounds and to assess whether daily goals are achieved.

REFERENCES

Ranzani OT, Simpson ES, Augusto TB, Cappi SB, Noritomi DT; AMIL Critical Care Group. Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project. Crit Care. 2014;18(5):580. Link DOI
Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive care unit structure variation and implications for early mobilization practices. An international survey. Ann Am Thorac Soc. 2016;13(9):1527-37. Link DOI
Lee H, Ryu K, Sohn Y, Kim J, Suh GY, Kim E. Impact on patient outcomes of pharmacist participation in multidisciplinary critical care teams: A systematic review and meta-analysis. Crit Care Med. 2019;47(9):1243-50. Link DOI
Arora N, Patel K, Engell CA, LaRosa JA. The effect of interdisciplinary team rounds on urinary catheter and central venous catheter days and rates of infection. Am J Med Qual. 2014;29(4):329-34. Link DOI
Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369-76. Link DOI
Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, Machado FR, Salluh JI, Campagnucci VP, Vendramim P, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: A randomized clinical trial. JAMA. 2016;315(14):1480-90. Link DOI
Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, Benoit D, Heyland D, Joynt G, Français A, Azeivedo-Maia P, Owczuk R, Benbenishty J, de Vita M, Valentin A, Ksomos A, Cohen S, Kompan L, Ho K, Abroug F, Kaarlola A, Gerlach H, Kyprianou T, Michalsen A, Chevret S, Schlemmer B; Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009;180(9):853-60. Link DOI
Soares M, Bozza FA, Angus DC, Japiassú AM, Viana WN, Costa R, et al. Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study. Intensive Care Med. 2015;41(12):2149-60. Link DOI
Kohn R, Madden V, Kahn JM, Asch DA, Barnato AE, Halpern SD, et al. Diffusion of evidence-based intensive care unit organizational practices. A state-wide analysis. Ann Am Thorac Soc. 2017;14(2):254-61.
Sakata KK, Stephenson LS, Mulanax A, Bierman J, McGrath K, Scholl G, et al. Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients. J Interprof Care. 2016;30(5):636-42. Link DOI
Bordley J, Sakata KK, Bierman J, McGrath K, Mulanax A, Nguyen L, et al. Use of a novel, electronic health record-centered, interprofessional ICU rounding simulation to understand latent safety issues. Crit Care Med. 2018;46(10):1570-6. Link DOI
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5. Link DOI
Rewa OG, Stelfox HT, Ingolfsson A, Zygun DA, Featherstone R, Opgenorth D, et al. Indicators of intensive care unit capacity strain: a systematic review. Crit Care. 2018;22(1):86. Link DOI
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9. Link DOI
Queijo AF, Padilha KG. Nursing Activities Score (NAS): adaptação transcultural e validação para a língua portuguesa. Rev Esc Enferm USP. 2009;43(Esp):1018-25. Link DOI
Fontela PC, Forgiarini LA Jr, Friedman G. Clinical attitudes and perceived barriers to early mobilization of critically ill patients in adult intensive care units. Rev Bras Ter Intensiva. 2018;30(2):187-94. Link DOI
Rehder KJ, Uhl TL, Meliones JN, Turner DA, Smith PB, Mistry KP. Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit. Pediatr Crit Care Med. 2012;13(1):6-10. Link DOI
Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: a systematic review. Medicine (Baltimore). 2016;95(50):e5629.
Opgenorth D, Stelfox HT, Gilfoyle E, Gibney RT, Meier M, Boucher P, et al. Perspectives on strained intensive care unit capacity: a survey of critical care professionals. PLoS One. 2018;13(8):e0201524.
Lee A, Cheung YS, Joynt GM, Leung CC, Wong WT, Gomersall CD. Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Ann Intensive Care. 2017;7(1):46. Link DOI

Submission On-line

Indexed in

Scopus

SciELO

LILACS

Associação de Medicina Intensiva Brasileira - AMIB

Rua Arminda nº 93 - 7º andar - Vila Olímpia - São Paulo, SP, Brasil - Tel./Fax: (55 11) 5089-2642 | e-mail: [email protected]

Cookie Policy

GN1 - Systems and Publications