Medical rounds where provider and care teams gather to discuss and review patient care plans are a staple of the healthcare system. Medical rounds are an important part of daily operations, facilitating collaboration and care planning across multidisciplinary teams. The core group of medical rounds is comprised of an attending provider, registered nurse, pharmacist, and case manager. Other members may include an advanced practice clinician, respiratory therapist, dietician, palliative care specialist, chaplain, and students or trainees.
While laboratory participation in medical rounds is not novel, it is rarely seen beyond larger teaching hospitals or institutions associated with a doctorate program for medical laboratory science, despite the routine and recommended practice of including the lab in other collaborative groups. For example, the lab already participates in facility antimicrobial stewardship programs, infection prevention committees, utilization review committees, quality committees, and more.
“A presence on the patient floor provides the lab with visibility among other care team members and provides an opportunity to discuss clinical matters.”
The delivery of care has been shown to be more effective when an integrated team of professionals participate in medical rounds. Thus, further value can be achieved by incorporating lab personnel into the practice of daily medical rounds.
Getting started with rounding
You may already have a good idea which units could benefit from the addition of lab personnel to daily rounds based on their test ordering patterns, but you should also consider units with complex care patients or extended stays as lab utilization and interpretation similarity becomes more complex.
To get started, reach out to leaders such as unit supervisors, nurse practice specialists, and medical or administrative directors. Getting support from a unit leader will help with the onboarding process, including identifying meeting times, making key team introductions, and learning about department norms.
For example, at Bellin Health, multidisciplinary medical rounds in the ICU are very different than daily rounds in the medical unit. The ICU includes patient family members in their discussions as the care team travels room to room across the unit. By contrast, daily rounds in the medical unit are performed in a classroom setting without family member involvement with multiple providers cycling in and out of the classroom.
Nuances like these highlight the need to be properly prepared by covering introductions and team norms. For example, with a consistent team that rounds by moving around a department, as occurs in our ICU, there is little time to review patient charts during rounds, though there is enhanced team rapport. In contrast, the stationary format of our medical unit has brief reprieves between providers, a benefit for quick scans of the patient chart but lower levels of team engagement.
Who should participate in rounds?
Determining who from your laboratory team should participate in multidisciplinary rounds can be a difficult decision, as the lab is home to laboratorians with diverse skillsets, from generalists to specialists. Focused care units, like a cardiac unit, may benefit more from a laboratory specialist. Similarly, a generalist laboratorian may perform better in a generalized medical care unit. Ultimately, a rotation of generalist and specialist can successfully serve the need of most medical rounds team.
“Key contributions from the lab help build rapport to enhance the impact of a laboratory stewardship program.”
How to prepare for medical rounds
Preparing in advance of medical rounds helps improve the quality of laboratory participation and solidify the value the lab brings to rounds. As patients transition through medical units, the day-to-day caseload can change drastically. Depending on the pace of medical rounds, reviewing cases in real-time can impede a positive contribution. Therefore, the rounding laboratorian must always review the patient list prior to rounding as new patients will require more in-depth chart review and discovery. This preparation and discovery includes reviewing for test ordering patterns, pending culture or referral tests. It also helps prepare the lab member to answer provider questions about completed or pending test results. The review and prep process additionally allows for collaboration with fellow laboratorians in specialty departments.
Where to start asking questions
Preparing in advance often yields early insights into what questions to ask and what answers to listen for. Here are a few key things to look out for in the infancy stages of rounding:
- Standing orders with no end date: Patients are commonly admitted based on protocols specific to a working diagnosis. While the patient diagnosis is updated and becomes clearer over time, standing lab orders are easily overlooked. Value can be found in targeting daily complete blood counts (CBC) with auto differential. Ask if daily labs are still necessary and if the order could be modified to a simpler assay, such as a hemoglobin and hematocrit (H&H).
- Referral tests: There are many instances where the initial workup includes send-out referral tests. However, the value of those referral tests may become nil as care progresses and the clinical picture becomes more evident. Identify referral tests with diminished value to intervene before the referral lab starts testing. This saves the patient and health system unnecessary charges.
- Duplicate tests: Inpatients occasionally have tests collected during admission to the emergency department that are pending. This can result in an inpatient unit provider reordering the same assay—e.g., procalcitonin is one such assay that provides early value in baseline assessment but can be pending during the patient move to inpatient status.
- Lab catalog complexity: Locum coverage providers must navigate the complexities of health systems that have different names for the same tests: Does the “C. Diff Screen” refer to an antigen test, a toxigenic culture, a PCR assay, or some combination? Is that test intended for colonization screening and placement, or CDI detection, treatment, and isolation? By answering questions, the rounding laboratorian can help providers choose the correct test and provide clarity on result interpretations if necessary.
The benefits of participating in medical rounds
Beyond improving patient care, there are several benefits to the lab having a larger presence on care units. A department frequently sequestered to the sublevels of the health system is easily forgotten. A presence on the patient floor provides the lab with visibility among other care team members and provides an opportunity to discuss clinical matters: pharmacy asks questions about culture protocols, new assays, and drug test options; nurses frequently have questions about specimen collection requirements; and healthcare providers often ask about when tests will be completed, test catalog nomenclature, and other in-house testing capabilities. Presence and rapport build further confidence and collaboration.
The laboratory team also benefits by participating in medical rounds. For instance, have you ever wondered why a patient in the ICU has been getting daily triglyceride tests? The answer would likely become apparent during rounds: In the ICU, ventilated and sedated patients may be receiving propofol. Propofol is a lipid-based infusion where prolonged exposure in some patients can cause dangerously high levels of triglycerides.
“Preparing in advance of medical rounds helps improve the quality of laboratory participation and solidify the value the lab brings to rounds.”
Other benefits of rounding include gaining an understanding of which lab tests are utilized per select protocols and having the opportunity to bring patient stories back to other lab staff. Providing other laboratorians with insights to a patient's clinical status and care plan helps reinforce lab staff’s sense of appreciation for their work. This also gives team members who do not round the opportunity to speak up and have a direct impact on select care decisions.
For example, recently, a transfusion services lab member messaged our rounding laboratorian regarding a questionable blood product request. A provider had ordered three units of platelets on a clinically stable patient with a low platelet count. By intervening, the transfusion medicine laboratorian gave the provider pause to question the need and ultimately saved two units of platelets from being transfused unnecessarily.
The lab, full circle
Getting your lab involved in multidisciplinary medical rounds provides your team a chance to explore routine practices, learn provider preferences, understand protocol-based order sets, and increase visibility, while key contributions from the lab help build rapport to enhance the impact of a laboratory stewardship program.
Patient care has been proven to be more effective when an integrated team of professionals participate in medical rounds. Thus, including the laboratory is a logical step in any laboratory stewardship program, improving patient outcomes and reducing waste, as well as boosting the visibility and perceived value of the laboratory, improving interdepartmental communication, and providing learning opportunities for all departments involved.