Bedside doctors and nurses who work on the D-3 transplant and general surgery unit have begun meeting formally every other month as part of a collaborative program launched by the unit's nurse manager with the help of faculty members who practice there.

The goal of the program is to address patient care problems in the context of ongoing issues, including coping with new technologies and tight staffing, said Leitha Springmeyer, D-3's nurse manager. Unlike rounds, the meetings include the active participation of nurses and focus on direct caregivers - attendings, housestaff, transplant fellows and nurses - and the individual patients they serve.

"Even with concerns about the budget, we really did focus on practice issues," said Springmeyer following the unit's first such meeting in March. Topics included D-3's discharge process, ideas for streamlining the volume of orders, and issues related to cardiac monitors and IV blood pressure medication. About 10 to 12 residents, two attending physicians and eight nurses attended the meeting, she said.

"When I came to D-3 in 1995, we had regular meetings, but they weren't working well for our needs, because they only involved attendings," Springmeyer said. "We need to peel through the layers of administration to the bedside where many of the decisions are made and the care becomes reality," she said.

Meetings between nurses and physicians in management roles have been occurring regularly throughout the hospital. Springmeyer sees the latest collaboration as an effort to provide a forum to discuss practice decisions. The metings will not involve broader policy questions that are the responsibility of the attending physicians.

"We have invited the attendings who manage the care to the meetings, but we are really hoping that the nurses and physicians who are in the unit dealing with day-to-day patient care will bring ideas to this forum," said Springmeyer. The attendance at the first meeting seemed to bear this out, she noted.

"There is no other forum that brings together nurses, housestaff and attending physicians - put simply, there is no other forum where these three entities can interact," said Augusto Bastidas, assistant professor of surgery, director of the surgical residency program and a strong backer of the collaborative meetings. "My personal bias is that this sort of interaction has to be face-to-face; you can't do it through nursing management or the chart alone," said Bastidas.

Bastidas noted that D-3 is the highest acuity unit in the hospital that isn't an ICU. "The acuity of the patients leads to a lot of stress for all the caregivers, and I think these meetings will provide a forum to talk about things," he said.

Edward Alfrey Jr., assistant professor of surgery in the multi-organ transplant program, said he welcomed the dialogue not only to "ensure that nurses have adequate support" but also to provide a forum for answering any questions hands-on caregivers may have.

For example, he said, a topic for a future meeting might be the issue of ordering kidney output readings at times when it really is clinically meaningful. He said nurses have pointed out that recording kidney output too frequently or at points in the recovery process when minor fluctuations are not crucial detracts from the caregivers' ability to perform other duties.

"Physicians need to understand the nursing staff's workload and duties when ordering tests and other services," Alfrey said. At meetings, the nurses can learn some of the "whys" behind the physicians' requests, and physicians - particularly newer housestaff members - can gain greater insight into what tests are most useful and when they are best performed, he said. As Springmeyer and Alfrey predicted, the appropriate use of cardiac monitors, which have just been added to the unit, was part of a lively discussion at the first meeting.

"We need to make sure nurses and physicians understand that the monitors are useful for a particular band of patients - an atrial fibrillation patient, for example, who needs monitoring. But the unit is not equipped to offer intensive care or one-on-one nursing," Springmeyer said.

"The only way to resolve these questions is for the nurses and physicians to understand and buy into, in specific detail, the most appropriate point at which a transfer or return to an ICU is necessary," Springmeyer explained.

In addition to Alfrey and Bastidas, several other physicians, including Gregg Adams, chief resident in general surgery, were instrumental in setting up the bi-monthly meetings, Springmeyer said.

"I really want the focus to be collaborative practice," she said. If house- staff and nurses collaborate, we develop trust and open communication. The person who benefits from these efforts is the patient through improved quality of care."

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