Family-Centered Rounds?

[wanderluster]

Which pediatric residency programs practice family-centered rounds?

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[tacrum43]

I don't know if there's a list or anything somewhere, but I can tell you that CNMC in DC has family centered rounds.

 

[synapse lapse]

I don't know if any program has it all the time, I would imagine it is up to the attending on service. That said my peds attending had us due family centered rounding and I hated it. I thought it was the most absurd thing to do, and most of the people on the team found it annoying. It was difficult to have a higher level discussion amongst us about management, and it was highly awkward to deal with social issues when rounding - i.e. we had one teenage girl who was suicidal, std positive, and we were supposed to round in the room with her parents there but obviously couldn't mention the std thing without her consent, and it was very touchy discussing psych issues. I am all for patient education and communication, but I personally see rounding as the time for the team to communicate patient status with the attending and decided management decisions... but what do I care, hopefully I'll be a rads resident and not have to round again after PGY-1 (*says prayer to the match gods).

 

[BigNavyPedsGuy]

Which pediatric residency programs practice family-centered rounds?

I think it highly variable within institutions. I know Cinncinnatti does a lot of research about it and for that reason, probably does a lot of it.

Studies show residents and students dislike family centered rounds, but patients like it more, which is common sense.

 

[JPeds]

I actually enjoyed family-centered rounds...especially in the NICU. We were still able to talk about the necessary physiology/pathology and parents did not understand all of what was going on, but I think it's important for parents of long-stay patients like NICU babies to be a part of the discussion and decision-making process. It allows them to feel connected to this baby they've never even gotten a chance to bring home. I also believe that it makes us better physicians to learn how to effectively translate our medical speak into words that patients/parents can understand, and doing this as part of family-centered rounds is highly effective. Parents often also bring up important points during rounds that otherwise would have been forgotten or never discovered - such as new symptoms, relevant PMH that previously no one thought to mention, etc.

 

[oldbearprofessor]

I actually enjoyed family-centered rounds...especially in the NICU. We were still able to talk about the necessary physiology/pathology and parents did not understand all of what was going on, but I think it's important for parents of long-stay patients like NICU babies to be a part of the discussion and decision-making process. It allows them to feel connected to this baby they've never even gotten a chance to bring home. I also believe that it makes us better physicians to learn how to effectively translate our medical speak into words that patients/parents can understand, and doing this as part of family-centered rounds is highly effective. Parents often also bring up important points during rounds that otherwise would have been forgotten or never discovered - such as new symptoms, relevant PMH that previously no one thought to mention, etc.

A major benefit is that the parents can not say they weren't informed by the team or that no one talks to them. Really, it works fairly well in a NICU setting. Common sense reigns - you may not want to discuss everything then and there, but on the whole it has been very successfully implemented in many NICUs.

On the other hand, I can see why it might not be a winning idea on the adolescent floor. Fortunately, that's not my department for sure.

 

[wanderluster]

I actually LOVE family-centered rounds. It it our program's policy to always do them. The reason that I asked which programs do this is because I'd like to go to a place that engages in them as an institution. I thought more people would have chimed in so we could make a list, but since that hasn't happened, I'll do a google search and can post what I find.

 

[JPeds]

Well, my home program (Eastern Virginia Medical School/Children's Hospital of the King's Daughters in Norfolk, VA) does family-centered rounds in the NICU. Additionally, the newly established hospitalist program has implemented family-centered rounds...I think this is new as of 4-5 months ago, but pretty popular so far.

 

[DrThom]

Cincinnati. Family centered rounds are a way of life here, you get used to it and the families really do love it.

 

[jonb12997]

there are some instances that it might not be as benefitial, but for the majority of times it really works well in my opinion. At my program, our hospitalists usually do family-centered rounds and the nurses/pharmacists/dieticians/case managers try to get on it as much as they can too. I does take a little bit longer sure, however, it saves having to go back later and talk to the parents and explain things to the nurses and other staff... It does tend to be a little bit harder with the subspecialists as you never know when they'll show up for rounds, but we try as much as possible.

 

[Complications]

Michigan does family centered rounds ... and I think it's superior to conference room rounds for many, many reasons.

 

[CrazyPeds527]

Rainbow also does family centered rounds - far superior (even with some of the drawbacks) to sit-rounds

~Crazy

 

[villa]

St. Joseph's in Phoenix does family-centered rounds in the newborn nursery, (which I think is the perfect situation to do so, as so much of newborn care is parental education). Families always have the option to opt out, but I've never heard of anyone doing so.

 

[twilightdoc]

I suspect that most programs do some form of family centered rounds now- it is the "next big thing" in family-centered care, which seems to be the "next big thing" in pediatric medicine. One problem, however, is the large number of patients who are on isolation precautions. It is impractical for more than a few members of the team to gown-up, etc. to go into the room as a group. One way to deal with that is to invite the parent(s) to join the group as their child is discussed. But if this is done in an open corridor, there are issues of possibly violating confidentiality. I seriously doubt if there is any program that does family-centered rounds on all of the patients all of the time.

 

[Complications]

I suspect that most programs do some form of family centered rounds now- it is the "next big thing" in family-centered care, which seems to be the "next big thing" in pediatric medicine. One problem, however, is the large number of patients who are on isolation precautions. It is impractical for more than a few members of the team to gown-up, etc. to go into the room as a group. One way to deal with that is to invite the parent(s) to join the group as their child is discussed. But if this is done in an open corridor, there are issues of possibly violating confidentiality. I seriously doubt if there is any program that does family-centered rounds on all of the patients all of the time.

Michigan does ... some services opt not to ... like heme/onc. However, it is service dependent, not situation. It is done with pts in precautions ... I suspect others do as well (Cinci).

 

[BigNavyPedsGuy]

I suspect that most programs do some form of family centered rounds now- it is the "next big thing" in family-centered care, which seems to be the "next big thing" in pediatric medicine. One problem, however, is the large number of patients who are on isolation precautions. It is impractical for more than a few members of the team to gown-up, etc. to go into the room as a group. One way to deal with that is to invite the parent(s) to join the group as their child is discussed. But if this is done in an open corridor, there are issues of possibly violating confidentiality. I seriously doubt if there is any program that does family-centered rounds on all of the patients all of the time.

I heard of one senior resident writing for precautions on almost every admitted kid just so he wouldn't have to stand through the pain that is family-centered rounds on those patients.

 

[oompaloompa]

Well, I'm much more wary of jumping on the family-centered rounds bandwagon. We do both at my institution and I can tell you that it's almost uniformly hated by the residents. Just my opinion, but I worry that it's another move away from "science-based methodology" to "customer service".

There's often something like 15 people involved from nursing, social work, case management, administration, pharmacy, respiratory, etc so it triples the time involved. It seems like everyone's opinions matter except the resident taking care of the patient. Every half-ass suggestion made by someone with no medical training has to be taken seriously, and in many occassions, carried out by the residents, regardless of agreement or evidence of efficacy. More than once I've thought about asking to be excused, because my presence is obviously not required.

My complaints aside, I think sometimes it can work well. The ideal situation is a strong attending who keeps the pace and shoots down the ridiculous crap immediately. Parents who are educated (or willing to be) are also a good combination with this.

Despite its amazing success in the business world medicine by committee isn't always a good idea.

 

[BigNavyPedsGuy]

Well, I'm much more wary of jumping on the family-centered rounds bandwagon. We do both at my institution and I can tell you that it's almost uniformly hated by the residents. Just my opinion, but I worry that it's another move away from "science-based methodology" to "customer service".

There's often something like 15 people involved from nursing, social work, case management, administration, pharmacy, respiratory, etc so it triples the time involved. It seems like everyone's opinions matter except the resident taking care of the patient. Every half-ass suggestion made by someone with no medical training has to be taken seriously, and in many occassions, carried out by the residents, regardless of agreement or evidence of efficacy. More than once I've thought about asking to be excused, because my presence is obviously not required.

My complaints aside, I think sometimes it can work well. The ideal situation is a strong attending who keeps the pace and shoots down the ridiculous crap immediately. Parents who are educated (or willing to be) are also a good combination with this.

Despite its amazing success in the business world medicine by committee isn't always a good idea.

I'm glad somebody on here finally said it!!!

 

[Stitch]

Well, I'm much more wary of jumping on the family-centered rounds bandwagon. We do both at my institution and I can tell you that it's almost uniformly hated by the residents. Just my opinion, but I worry that it's another move away from "science-based methodology" to "customer service".

There's often something like 15 people involved from nursing, social work, case management, administration, pharmacy, respiratory, etc so it triples the time involved. It seems like everyone's opinions matter except the resident taking care of the patient. Every half-ass suggestion made by someone with no medical training has to be taken seriously, and in many occassions, carried out by the residents, regardless of agreement or evidence of efficacy. More than once I've thought about asking to be excused, because my presence is obviously not required.

My complaints aside, I think sometimes it can work well. The ideal situation is a strong attending who keeps the pace and shoots down the ridiculous crap immediately. Parents who are educated (or willing to be) are also a good combination with this.

Despite its amazing success in the business world medicine by committee isn't always a good idea.

I have to agree as well.

Remember, the IQ of any committee is the IQ of the dumbest person on said committee divided by the total number of people on the same committee.

There are some great ways to do family centered rounds and actually get things done, but without a strong direction from an attending, I feel people are less willing to discuss non PC social matters, and a lot of time can be wasted dealing with some BS nursing protocol rather than doing what's right for the patient.

I'm all for communicating with the family and patient, and I agree that we as providers need to be better about such things. But there are ways to do that without inviting the whole floor to teaching rounds where EBM should be learned.

 

[TexasRose]

I'm glad somebody on here finally said it!!!

Yes!

 

[TexasRose]

There's often something like 15 people involved from nursing, social work, case management, administration, pharmacy, respiratory, etc so it triples the time involved. It seems like everyone's opinions matter except the resident taking care of the patient. Every half-ass suggestion made by someone with no medical training has to be taken seriously, and in many occassions, carried out by the residents, regardless of agreement or evidence of efficacy. More than once I've thought about asking to be excused, because my presence is obviously not required.


Despite its amazing success in the business world medicine by committee isn't always a good idea.

I like what you've said. I especially like the parts I bolded. They had me laughing out loud! So true!!!

 

[WhatUpDoc!]

Michigan does family centered rounds ... and I think it's superior to conference room rounds for many, many reasons.

Could you please elaborate on the superiority of FCR? The last few posts have made me 2nd guess the importance of considering this in regards to my match list. Thanks.

 

[BigNavyPedsGuy]

Could you please elaborate on the superiority of FCR? The last few posts have made me 2nd guess the importance of considering this in regards to my match list. Thanks.

Families that are surveyed like them. Support staff that are surveyed like them. Beauracratic attendings like them because they can advertise something new

 

[CrazyPeds527]

A caveat to the following statements: they ONLY apply when FCR are are done well:

Here are some things to like about FCR:
- Less pages from nurses later (they already know the plan)
- Less pages from pharmacy about the dose or TPN you are ordering (they were on rounds and already know the answer)
- Families feel plugged in and informed
- The families feel since the resident is presenting the case/plan that the resident is ACTUALLY in charge, and with good attendings, can be made to look good! This works well when the resident continues to check in during the day/night and work with the families.

Again, there are certain things that attendings do to improve/expedite/streamline FCR. Such as:
- Checking in with new families ahead of time, letting them know about the time constraints during rounds so they dont feel that it is open forum for them to ask unlimited questions, especially if they require in depth answers that should be best handled later
- Making sure the team knows about issues NOT to be discussed in front of everyone (i.e. social things - especially important with some med students who inevitably - although meaning well - may put some feet into mouths)
- Making sure to utilize bedside rounds for teaching while not pimping endlessly about esoteric stuff. Good if a patient has a physical finding for teaching.
- Delicately handling group issues and dynamics; if the senior residents are the quarterbacks, the attending is the head coach (if you like sports analogies)

I think the largest variables for FCR are the attending on service and group dynamics. When done well, it can save time. When done poorly, it can be nightmarish. As others have pointed out, because of patient and ancillary staff satisfaction (in addition to resident satisfaction, for the most part at our institution), FCR is likely here to stay.

 

[BigNavyPedsGuy]

A caveat to the following statements: they ONLY apply when FCR are are done well:

Here are some things to like about FCR:
- Less pages from nurses later (they already know the plan)
- Less pages from pharmacy about the dose or TPN you are ordering (they were on rounds and already know the answer)
- Families feel plugged in and informed
- The families feel since the resident is presenting the case/plan that the resident is ACTUALLY in charge, and with good attendings, can be made to look good! This works well when the resident continues to check in during the day/night and work with the families.

Again, there are certain things that attendings do to improve/expedite/streamline FCR. Such as:
- Checking in with new families ahead of time, letting them know about the time constraints during rounds so they dont feel that it is open forum for them to ask unlimited questions, especially if they require in depth answers that should be best handled later
- Making sure the team knows about issues NOT to be discussed in front of everyone (i.e. social things - especially important with some med students who inevitably - although meaning well - may put some feet into mouths)
- Making sure to utilize bedside rounds for teaching while not pimping endlessly about esoteric stuff. Good if a patient has a physical finding for teaching.
- Delicately handling group issues and dynamics; if the senior residents are the quarterbacks, the attending is the head coach (if you like sports analogies)

I think the largest variables for FCR are the attending on service and group dynamics. When done well, it can save time. When done poorly, it can be nightmarish. As others have pointed out, because of patient and ancillary staff satisfaction (in addition to resident satisfaction, for the most part at our institution), FCR is likely here to stay.

I've never seen or heard of family centered rounds going as well as you describe. I also challenge you to find some objective way to show that residents have more satisfaction. All the studies I've seen to date show that residents don't prefer them.

 

[kristing]

Which pediatric residency programs practice family-centered rounds?

MSU-KCMS does them on the peds floor. Also in the nursery.

 

[Tone2002]

Nurses are always welcome to join rounds when we come by to see the patients, to address any concerns they may have or even learn the plan. I see a lot more of this on the NICU side as oppose to the floor.

I have yet to see FCR run that smoothly as previoulsy mentioned. I prefer multidisciplinary rounds when they are needed. But FCR in my opinion are overkill in most cases, especially since in Pediatrics the turnover is so quick.

 

[CrazyPeds527]

I've never seen or heard of family centered rounds going as well as you describe. I also challenge you to find some objective way to show that residents have more satisfaction. All the studies I've seen to date show that residents don't prefer them.

Agreed - Objectively that may be challenging, i think one of our residents is working on a study. Particularly in our PICU and NICU, as well as with a couple of select floor attendings, I have seen it work as well as described. The PICU and NICU here have been doing it for a couple of years and seem to have some of the kinks worked out.

It seems (informally from speaking with co-residents, not from formal surveys) that the interns who came in with every team doing it seem to prefer it, but they also dont know anything else at this institution. Some of our seniors certainly feel the way you do. I would be interested to read some of the studies you are referring to that describe residents not liking FCR. There was one study I know of out of CHOP's PICU that one of the biggest concerns was residents feeling that families would lose trust in them if they were corrected on rounds during teaching, and when concurrently surveying the families, it was found to be untrue.

 

[shyunj]

My medical school did sort of a hybrid between family-centered and sit rounds, and I thought it worked really well. The team would do walk rounds, but presentations and all discussions about the plan were done outside the patient's room with the door closed so the family could not hear. Then, we would all go into the room as a team, and the attending would present the plan to the parents. This way, there was the opportunity to discuss sensitive subjects and do some teaching without the awkwardness of doing it in front of parents, but the entire team was also present for the conversation between the attending and the parents, keeping everyone on the same page.

 

[oldbearprofessor]

There's often something like 15 people involved from nursing, social work, case management, administration, pharmacy, respiratory, etc so it triples the time involved.

Okay, I genuinely understand why this is annoying. But, from my perspective, having these folks (or a representative subgroup of them) on NICU rounds AND especially having the parents there saves me a lot of time from having to explain all day long to each of these vested interests stuff like when the baby is going home, what home support they'll need, etc, etc. In addition, having these folks AND the parents on rounds saves me from having to defend myself the next day/week from a range of these folks who would otherwise claim that I'm not communicating with them or the family.

The attending does need to control the rounds. Start by telling the family that the doctors are going to talk about their baby and at the end will go over the plan and answer questions. Then, engage the residents in the usual way of rounds and only after that, engage the rest of the folks and their concerns. Often the pharmacist, dietitian, RT, and of course nursing will have very valuable input in the middle of the presentation about relevant parts, but anything extraneous goes after the main medical presentation. Focus on the residents and the others will not control it. Social issues come at the end. Never, ever embarrass the resident with serious pimping in front of the family. Do a sit-down discussion after rounds (or at the bedside of an infant that doesn't have parents there) for any true harassment of the residents about every known cause of metabolic acidosis.

The final trick is the part at the end - the communication with the parents. After summarizing the plan and answering questions, if it's clear the parents have a lot of questions, then tell them you will get back to them in a few minutes. Or, send the team to start on the next baby (the attending isn't THAT important ) and finish talking to the family.

Sure it takes more time and can force you to not talk about mom's drug history or teach about the neonatal effects of maternal syphilis while on rounds, but no one will say you didn't tell them what you were thinking/doing/planning. That itself is worth it from my perspective.

 

[BigNavyPedsGuy]

The final trick is the part at the end - the communication with the parents. After summarizing the plan and answering questions, if it's clear the parents have a lot of questions, then tell them you will get back to them in a few minutes. Or, send the team to start on the next baby (the attending isn't THAT important ) and finish talking to the family.

I wish you were my attending . . .

 

[oompaloompa]

Okay, I genuinely understand why this is annoying. But, from my perspective, having these folks (or a representative subgroup of them) on NICU rounds AND especially having the parents there saves me a lot of time from having to explain all day long to each of these vested interests stuff like when the baby is going home, what home support they'll need, etc, etc. In addition, having these folks AND the parents on rounds saves me from having to defend myself the next day/week from a range of these folks who would otherwise claim that I'm not communicating with them or the family.

The attending does need to control the rounds. Start by telling the family that the doctors are going to talk about their baby and at the end will go over the plan and answer questions. Then, engage the residents in the usual way of rounds and only after that, engage the rest of the folks and their concerns. Often the pharmacist, dietitian, RT, and of course nursing will have very valuable input in the middle of the presentation about relevant parts, but anything extraneous goes after the main medical presentation. Focus on the residents and the others will not control it. Social issues come at the end. Never, ever embarrass the resident with serious pimping in front of the family. Do a sit-down discussion after rounds (or at the bedside of an infant that doesn't have parents there) for any true harassment of the residents about every known cause of metabolic acidosis.

The final trick is the part at the end - the communication with the parents. After summarizing the plan and answering questions, if it's clear the parents have a lot of questions, then tell them you will get back to them in a few minutes. Or, send the team to start on the next baby (the attending isn't THAT important ) and finish talking to the family.

Sure it takes more time and can force you to not talk about mom's drug history or teach about the neonatal effects of maternal syphilis while on rounds, but no one will say you didn't tell them what you were thinking/doing/planning. That itself is worth it from my perspective.

I can totally respect the concept of NICU family-centered rounds where so many aspects of patient care come together and how the long-term nature requires a lot of hand-holding.

However, you must be at very different NICU than the one I trained at if this actually works. 15 babies in each tiny room? We're lucky to get a team of 4-5 through, much less all the ancillary staff. Parents aren't allowed in the area for rounds soley for space/traffic reasons, but I can't imagine many would come anyway. Either they have to work or have transportation issues. It would also be necessary to have dedicated translator for our >95% spanish-only population and all the extra time this entails. Family-centered rounds probably works great at a low-census suburban ICU, but for the 100+ babies at ghetto Parkland, this just isn't feasible. There would be another 60 babies born before you even got through with rounds. (not exaggerating)

To be clear, I'm not at all bashing the concept, just the practical application.

 

[Stitch]

Okay, I genuinely understand why this is annoying. But, from my perspective, having these folks (or a representative subgroup of them) on NICU rounds AND especially having the parents there saves me a lot of time from having to explain all day long to each of these vested interests stuff like when the baby is going home, what home support they'll need, etc, etc. In addition, having these folks AND the parents on rounds saves me from having to defend myself the next day/week from a range of these folks who would otherwise claim that I'm not communicating with them or the family.

So true!

I definitely see what you're saying here, but I'd also argue that the ICU (PICU or NICU) is a very different setting from the floor/general wards, and it's more feasible in a closed unit. Critical care being what it is, you need the input of nursing, social work, pharmacy and nutrition on a daily basis when the patient is critically ill. Honestly most ICU nurses I know are a bit higher caliber than your average floor nurse and often have more insight into what's going on with the patient; as the care can sometimes change drastically on a daily basis or be extended over a longer time period there's more benefit to having everyone along and make sure everyone is on the same page. In fact the studies I've seen supporting family rounding were done only in the ICU setting.

Don't get me wrong: communication is very important, to both families and nurses, and the residents and attendings need to be talking to people. But my experience with this type of thing on the wards for a kid who's admitted for an asthma exacerbation or other less serious illness has not been good, and the contributions made by all the ancillary staff were less useful while actual teaching seemed to decrease.

Of course as everyone has pointed out, it's partly dependent on who's running rounds.