Physician and Medical Student Orientation
to Family Centered Rounds at LPCH
The optimal care of the pediatric patient involves a functional and transparent partnership with not only the patient and family, but also multiple other members of the health care team. All must work together to ensure understanding of disease processes and treatment options prior to the creation of a plan of care that will ensure the child’s wellbeing both in the hospital and in the home and community environment.
In line with cultural shifts in the delivery of hospital care, we are shifting towards a more integrated, family-centered approach to the daily rounds that will improve our care of pediatric patients. This process is the result of a multi-disciplinary collaboration between physicians, parents, and other health care providers.
Mission Statement of Family Centered Rounds at LPCH:
To create a family centered culture that improves clinical, safety, and satisfaction outcomes by valuing, respecting, and integrating the voices of the patient, family, and all members of the healthcare team.
Family Centered Rounds Will:
- Implement an innovative interdisciplinary rounding process that optimizes the development and delivery of a comprehensive plan of care.
- Create a standardized efficient process with defined roles.
- Enhance patient and family participation and knowledge by utilizing a shared decision making model.
This new system will eliminate waste by having all stakeholders present for discussion of the patient plan of care. It will move all discussion of the patient to the bedside with real-time input from the family and other care providers.
Important shifts to our current rounding culture will include the requirement of more efficient presentations using more common language and the standardized integration of other opinions prior to the development of the plan of care.
Example of New Presentation Format:
Any sensitive issues such as child abuse, confidential history, etc will be discussed outside the room prior to involving the family.
Introduction: So, we are going to discuss how your child has been doing over the last day, please feel free to interrupt to ask questions or correct anything I say if I don’t get it right.
S: Patient Identification
Pause and ask for input from patient, family, and bedside RN
O: Vital signs, Intake and Output in a summarized format using common language
Description of examination
At this time, the attending and fellow may wish to examine the patient after asking permission of the patient and family. They may also invite the patient, family, or other members of the team to also examine key physical findings.
Description of lab and imaging results
Supervising resident may share these values on rolling computer (COW).
A/P: One line brief summary of medical status and assessment
Presentation of plan by problem, including nutrition and discharge criteria
Ask all other providers and family in the room for their input. These other members (i.e. RT, dietician, bedside RN, pharmacist, social worker) will provide their input in a standardized manner. The senior resident may help with inviting each team member to give their input. The senior and attending may also offer their input on the plan.
P: Presentation of plan with any revisions
Bedside RN will be documenting plan on the white board, and conclude with summary statement of plan. Supervising resident will enter orders and read back all orders for the day.
Conclusion: Thank you for your input. Do you have any questions or concerns about the plan for today?
Presenting a Patient Admitted Overnight
The resident or student will present an abbreviated history and physical focusing on the history of present illness, and pertinent aspects of the past medical history, social history and family history and then proceed to discuss overnight events, objective findings, and assessment and plan for the day as above.
Examples of Change in Rounding Language:
In an effort to make rounds more efficient, the presenter will present data only in family-centered language. If the senior resident or attending would like greater detail, this can be addressed in their comments or reviewed at the bedside on the computer chart.
Family Centered Rounds
“T max was 40.1 at twenty-three thirty”
“I’s and O’s were 650 over 500 with a UOP of 2 ml per kilo per hour.”
“So, for labs, her CBC was WBC 25, H and H 12 over 36, platelets were 350. Diff was 85% neutrophils with 25% bands.”
“So for plan, we’ll switch from IV to PO Clinda.”
Sally had fever overnight; the highest was 40.1 degrees Celsius at 11:30 pm.
Sally had adequate urine output overnight.
The blood test showed an increased white blood cell count, which is a cell that fights infection. Most of the white blood cells were neutrophils, a type of cell that suggests a bacterial infection.
Sally is doing better and we would like to change her antibiotic, Clindamycin, from an IV form to a form that she can take by mouth.
Examples of Ice Breakers
"I'll bet it was a short night. You must be tired"
"Can I tell the rest of the team what you told me about your soccer team?"
"Good morning. We're sorry to
Invitations for Families
"I'm going to review the story so our entire group understands what brought you to the hospital. Please add or correct anything as I go along."
"I'm going to review for the team what happened in the last 24 hours. Your input will be very important."
"The most important thing we do
on rounds is make the plan for the day. While we're the experts on medicine,
you're the expert on your child and family. Together we'll make better
"Rounds is not us talking at you or in front of you. It is us talking together. Please join in at any time."
Addressing a Concerned
Family that Needs More Time
"This discussion usually lasts about 10 to 15 minutes. If we need more time, one or two of us will return after we finish seeing the other patients. Dr. Senior Resident keeps our team organized. She'll / he'll let us know if we need to finish later."
“It sounds like there is a lot more to talk about, why don’t we come back and discuss this issue (i.e. feeding plan, social issue, etc) in more detail after we have finished seeing the other patients.”
Addressing a Concerned
Team Member that is Dominating Conversation
“You bring up a great point. Why don’t we discuss this in more depth after we finish seeing our other patients.”
"The patient is not ready to go home, but for everyone's sake let's talk about what will need to happen here in the hospital for him / her to be ready to go home.”
It is most ideal to have direct,
word for word, interpretation for any interaction with a non English-speaking
family. However, in the interest of time, the interpreter may use summary
statements to convey discussion of past events.
The medical team should still
formally acknowledge the family upon the start of rounds, perhaps with a
statement such as, “I am going to share the story with the team so that everyone
knows what brought your child to the hospital.” If there is any clarification to
the history needed, the family should be asked for their input with word for
For example, when the intern is detailing the history of present illness, the interpreter will be simultaneously telling the parent, in general terms, that the team is discussing what brought their child to the hospital. Nothing specific will be translated, just the fact that the team is speaking about how the child presented.
This will remain the same when the intern moves on to other topics. So when the intern moves on to the past medical history, the interpreter will tell the parents in general terms the topic of past medical history is now being discussed. This will keep the parents in the loop but no time is wasted.
The assessment and plan will be interpreted word for word. This is the most important part of the presentation and family input is critical in devising a plan that everyone can agree on.
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