The recent evolution of patient care rounds in pediatric teaching hospitals in the United States and Canada

Introduction: National trends toward empowering and enabling patients and families to take a bigger role in their own medical care and enhanced collaboration between rounding stakeholders have effectuated a new rounding model in the pediatric inpatient setting known as 'Patient- and Family-Centered Rounds/I-PASS,' which has shown to decrease safety events and to improve stakeholders' experience with rounding. Other enhancements to the new model, such as the use of whiteboards, rounding checklists, and facecards, have all been applied to the new model to good effect. Another major enhancement to rounding of late has been the application of a schedule to rounds, which has increased the presence of the nurse and the family during rounds and has improved rounding efficiency without a negative effect on teaching.Objective:  We provide a review of the literature regarding this new rounding model and its effects in the pediatric inpatient setting, as well as a review of the enhancements that have been applied to the new model, the recognized barriers to the implementation of these rounding alterations and the ways in which those barriers have been overcome. Conclusions:  In the pediatric inpatient setting, the 'Patient and Family-Centered Rounds/IPASS' rounding model, as well as enhancements to this new model such as rounding schedules, whiteboards, checklists and facecards, have had a positive effect on stakeholders' experience with rounding, increased patient safety and improved rounding efficiency.  Given these positive effects, these alterations to rounding should be promoted and sustained.PLAIN LANGUAGE SUMMARYRounding is when a medical care provider, or a team of providers, visits patients in the hospital in order to determine a plan of care and discuss that care with the patient and the patient's family. In teaching hospitals, this involves staff physicians, medical trainees and advanced practice providers. Rounding has changed in the recent past as evolving pressures have increasingly led these teams of providers to talk and make decisions about patients outside the patient's room, which lessens the patient's ability to contribute to decision-making. This also lessens the ability of the patient's nurse to contribute. The recognition of this problem has led to big changes in rounding in children's teaching hospitals, the biggest of which is called 'family-centered rounding.' This involves performing the entirety of rounds in the patients' rooms, directing the discussion toward them in language that they understand, with the active participation of everyone present, including the patient's nurse. Other changes in rounding, designed to improve patients' experiences and decrease medical errors, have made this new rounding model even better. Structured communication during rounds, communication aids such as whiteboards and checklists, and planned times for rounding on each patient ('scheduled rounding') have all successfully been used to improve patients' care and experience in the hospital. This article aims to inform the reader about family-centered rounds and other recent rounding transformations that have proven to increase patient safety and improve their experience while in the hospital, also noting barriers to these changes and how they have been overcome.

Microcirculatory perfusion disturbances in septic shock: results from the ProCESS trial

BACKGROUND

We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis.

METHODS

This was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h.

RESULTS

We enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p < 0.003), perfused vascular density (beta = 0.005, p < 0.04), and De Backer score (beta = 0.009, p < 0.01) were higher overall in survivors in a generalized estimating equation model, and this association was significant at the 72-h time point (p < 0.05 for each parameter).

CONCLUSIONS

Microcirculatory perfusion did not differ between three early septic shock treatment arms. We found an association between microcirculatory perfusion parameters of vascular density at 72 h and mortality.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00510835 . Registered on August 2, 2007.

Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis

OBJECTIVE

Sepsis mortality is closely linked to multi-organ failure, and impaired microcirculatory blood flow is thought to be pivotal in the pathogenesis of sepsis-induced organ failure. We hypothesized that changes in microcirculatory flow during resuscitation are associated with changes in organ failure over the first 24 h of sepsis therapy.

DESIGN

Prospective observational study.

SETTING

Emergency Department and Intensive Care Unit.

PARTICIPANTS

Septic patients with systolic blood pressure <90 mmHg despite intravenous fluids or lactate >or=4.0 mM/L treated with early goal-directed therapy (EGDT).

MEASUREMENTS AND RESULTS

We performed Sidestream Dark Field (SDF) videomicroscopy of the sublingual microcirculation <3 h from EGDT initiation and again within a 3-6 h time window after initial. We imaged five sites and determined the mean microcirculatory flow index (MFI) (0 no flow to 3 normal) blinded to all clinical data. We calculated the Sequential Organ Failure Assessment (SOFA) score at 0 and 24 h, and defined improved SOFA a priori as a decrease >or=2 points. Of 33 subjects; 48% improved SOFA over 0-24 h. Age, APACHE II, and global hemodynamics did not differ significantly between organ failure groups. Among SOFA improvers, 88% increased MFI during EGDT, compared to 47% for non-improvers (P = 0.03). Median change in MFI was 0.23 for SOFA improvers versus -0.05 for non-improvers (P = 0.04).

CONCLUSIONS

Increased microcirculatory flow during resuscitation was associated with reduced organ failure at 24 h without substantial differences in global hemodynamics. These data support the hypothesis that targeting the microcirculation distinct from the macrocirculation could potentially improve organ failure in sepsis.

Resuscitating the microcirculation in sepsis: the central role of nitric oxide, emerging concepts for novel therapies, and challenges for clinical trials

Microcirculatory dysfunction is a critical element of the pathogenesis of severe sepsis and septic shock. In this Bench-to-Bedside review, we present: 1) the central role of the microcirculation in the pathophysiology of sepsis; 2) new translational research techniques of in vivo video microscopy for assessment of microcirculatory flow in human subjects; 3) clinical investigations that reported associations between microcirculatory dysfunction and outcome in septic patients; 4) the potential role of novel agents to "rescue" the microcirculation in sepsis; 5) current challenges facing this emerging field of clinical investigation; and 6) a framework for the design of future clinical trials aimed to determine the impact of novel agents on microcirculatory flow and organ failure in patients with sepsis. We specifically focus this review on the central role and vital importance of the nitric oxide (NO) molecule in maintaining microcirculatory homeostasis and patency, especially when the microcirculation sustains an insult (as with sepsis). We also present the scientific rationale for clinical trials of exogenous NO administration to treat microcirculatory dysfunction and augment microcirculatory blood flow in early sepsis therapy.