Patient Care Rounds in the Intensive Care Unit During COVID-19

TO THE EDITOR

Hospital systems face the challenge of protecting patients and health care workers during the coronavirus disease 2019 (COVID-19) pandemic. To minimize exposure to COVID-19, many hospital systems have endorsed a visitor restriction policy. This particularly applies to the ICU, where COVID-19 patients frequently require high-risk aerosol-generating procedures (for example, intubation, endotracheal suction).

The situation has posed a considerable difficulty for patient care rounds in the ICU. Multidisciplinary bedside ICU rounds provide a key stage for providers to review patient conditions and communicate a plan of care. Given the complex nature of ICU patients, who frequently cannot make medical decisions, daily rounds are used to engage family in patient care.^{1 , 2} With a visitor restriction policy, families of critically ill patients feel huge anxiety, guilt, and frustration.³ Families are calling ICU 24 hours a day, crying and wanting information about their loved ones. Another major issue is that families are receiving bits and pieces of information at different times. Sometimes they receive mixed messages, particularly after shift changes or handoffs. The emotional and physical tone of the COVID-19 pandemic is already a huge burden on the staff. On top of that, they believe that the needs of families are not met. A creative solution for ICU rounds is needed in the COVID-19 era.

Evidence has shown success of telemedicine for ICU care.^{4 , 5} Our hospital recently implemented a telemedicine model for ICU rounds that is well received by the ICU team and patient families. First, providers with direct patient care (including an intensivist physician, mid-level provider, nurse, and respiratory therapist) perform bedside patient evaluations separately before rounds. Second, all care team members (including a pharmacist, nutritionist, physical therapist, speech therapist, social worker, charge nurse, and e-ICU) call in to an encrypted videoconference system at a standard time. The patient's preappointed family member is connected into the conference through a different phone line. Third, telerounding is led by a physician following the usual rounding process in which the patient's nurse summarizes overnight events and goes over the ICU checklist, followed by each participant giving his or her recommendation. During virtual rounds, a dedicated staff member is assigned to review electronic medical records for any questions and place new orders. The family member stays on the line for the entire rounds for his or her loved one, which usually takes 10 minutes. For families with limited English proficiency, a real-time interpretation service is used for communication. In the end the physician summarizes key information for the family and answers their questions. If questions remain or other concerns arise, the provider calls the family after rounds. A sample ICU daily rounds scripts is provided in Appendix 1 (available in online article).

As a next step, we plan to engage patients in the rounds as appropriate, using a robotic telepresence system. Another novel use of the ICU rounds being explored by the ICU team is student clerkships, which were canceled during the pandemic.⁶ This is greatly affecting education for medical students. We are exploring the possibility of providing medical student participation during ICU rounds, which would be a huge learning experience in critical care and management of COVID-19 patients. In this challenging time, we hope experience from our center helps the international critical care community to plan for an effective rounding strategy using telemedicine.