key: cord-0986657-ua5d5cy3
authors: Orlov, Nicola M; Mattson, Christopher; Kraft, Antigone; Wagner, Ellen; Mallick, Saleha; Cunningham, Paige; Arora, Vineet M
title: LEAPFROG Rounds: Maximizing the Rounding Experience for the Interprofessional Team During the COVID-19 Pandemic
date: 2021-04-16
journal: Acad Pediatr
DOI: 10.1016/j.acap.2021.04.008
sha: 5227b84aa8038554d0067a9edd0783ecaf976c2d
doc_id: 986657
cord_uid: ua5d5cy3

nan

The coronavirus disease 2019 (COVID-19) pandemic impacted resident education by limiting clinical exposure, available rotations, and didactic learning 1, 2 . Further, it resulted in a disruption of the conventional rounding system used on teaching services 3 

Medicine (PHM) rotation has traditionally been among the most highly rated in the residency program.

The rounding style focuses on optimizing communication and collaboration between nurses and physicians as exemplified by the institution's IGNITE (Improving GME-Nursing Interprofessional Team Experiences) program 5 . The aim of this project was to implement a rounding model that prevents nosocomial spread of COVID-19 while enhancing education, communication and collaboration among interprofessional healthcare teams while respecting the institutional restriction of four providers at the bedside.

Prior to the pandemic, the institution's PHM team conducted family centered rounds (FCR) with 15 interprofessional team members. Initial response to the pandemic resulted in the physician team meeting via Zoom™ to round. Nurses and allied health professionals were not included in "Zoom™ Rounds" due to access difficulty. Residents called individual allied health professionals after rounds for multidisciplinary conversations.

Structure of "LEAPFROG Rounds":

The attending physician and senior resident walk to patient rooms where the resident leads rounds while the attending provides education and supervision. The attending rolls an iPad attached to an IV pole with a speaker. The remaining team including allied health professionals attend virtually on the iPad via Zoom™. At each patient's bedside, the intern or student responsible is physically present to facilitate face-to-face communication with the team and family during rounds. The nurse also joins at the bedside. After presenting, the intern then proceeds to wait outside the room of their next primary patient and watches interim patients via Zoom™. As the team travels to the subsequent room, the intern or student responsible is waiting, having watched the preceding rounds from an iPad or phone.

Technology related limitations involved identifying a speaker that allowed for adequate sound projection. While more costly, a conference-style speaker overcame said challenges. Infection control issues did not arise since the technology did not come in contact with any patients.

Pediatric IGNITE team members met weekly and developed "LEAPFROG rounds" through an iterative process. A twenty-question, retrospective 5-point Likert needs assessment (anchors: 5 = excellent, 1 = poor) was piloted on an interprofessional team. The initial survey was released electronically to all residents and day-shift nurses who cared for PHM patients during the six-week period in which "Zoom™ rounds" was used. "LEAFROG rounds" was implemented in June 2020. A follow-up survey was released electronically 10-weeks later to all residents and day-shift nurses with PHM patients during that period. Surveyed staff were allowed to opt-out of responding. Exempt status was granted by UCM's IRB (IRB20-0724).

Inferential statistics were utilized to compare survey responses for the different rounding processes. That is, two sample t tests were performed to compare pre-COVID to Zoom™ rounds and Zoom™ rounds to "LEAPFROG Rounds".

Response rate for the initial survey was 55% with responses from 18/46 nurses and 16/16 residents.

There was an overall dissatisfaction with "Zoom™ Rounds" compared to pre-pandemic rounding. Both residents and nurses reported worse communication amongst physicians (4.1 to 3.1; p<0.01), between physicians and nurses (3.4 to 2.3; p<0.01), and between the medical team and families (3.5 to 2.1; p<0.01) when compared to pre-pandemic rounding. The educational experience on "Zoom™ Rounds" was also rated with lower satisfaction. Response rate for the follow up survey was 79% with responses from 37/46 nurses and 22/29 residents. Significant improvements were noted overall when comparing "Zoom™ Rounds" to "LEAPFROG Rounds" including communication and nurse understanding of the plan. Residents reported an improved educational experience both during (2.2 to 2.9; p<0.05) and after (2.6 to 3.6; p<0.05) rounds and an overall improved quality of the PHM rotation (2.7 to 4.1; p<0.01). A comparison of the Pre-Pandemic rounding to "LEAPFROG Rounds" confirmed that while the new system is improved when compared to "Zoom™ Rounds", that there is still opportunity to improve (Table 1 ).

"LEAPFROG Rounds" is an innovative proxy for rounds that overcomes barriers imposed by physical distancing. Our study demonstrated improved perception of patient care and education, critical in a year when medical education was upended. Our study has several limitations. First, it was a single institution study and may not be generalizable to other institutions. Next, the seemingly low initial response rate from nurses is deceiving. Nurses were surveyed through a listserv which includes all PHM nurses. During the early pandemic adult surge, the low pediatric patient census necessitated furloughing and paid sick leave of staff. Due to this, the denominator in our response rate reflects the employed compliment rather than the active group of nurses who were working at the time.

Retrospective calculations based on tracking of those who worked suggests that the nurse response rate is closer to 60% bringing the total response rate to 70%. Finally, literature shows that physicians are not good at assessing their own competence; as such the results may be difficult to interpret 6 .

Future steps for this project will include an exploration of how this rounding model effects team and rounding efficiency in addition to the impact on medical student and parental participation on rounds.

While we hope that the pandemic has an endpoint in the near future, opportunities for "LEAPFROG Rounds" live long beyond the end of the pandemic. Namely, future steps include the possibility of creating further accessibility to schedule-based family centered rounds for those not physically present in the hospital 7 Table 1 : The table below reflects results from two surveys. Thirty-four individuals responded to the survey that was disseminated during the Zoom Rounds era. Fifty-nine individuals responded to the second survey which was disseminated during the Leapfrog era. Survey results below compare nurse and resident perceptions of education, communication and clinical experience on rounds prior to the start of the pandemic ("Before COVID") at the start of the COVID-19 pandemic when rounds were conducted exclusively via Zoom ("Zoom Rounds") and the current "LEAPFROG Rounding" method.

Residency in a pandemic: How COVID-19 is affecting trainees

Impact of COVID-19 on neurosurgery resident training and education

Implementing Physical Distancing in the Hospital: A Key Strategy to Prevent Nosocomial Transmission of COVID-19

What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students

Improving Care via Interprofessional Clinical Learning Environments. The Hospitalist

Accuracy of physician self-assessment compared with observed measures of competence: a systematic review

Keeping Time: Implementing Appointment-based Family-centered Rounds, Pediatric Quality and Safety