MD/APP-in-Room

As part of IGNITE (Improving GME Nursing Interprofessional Team Experiences), a multidisciplinary team developed the MD/APP-in-Room button as a novel tool to facilitate socially distanced, face-to-face encounters between physicians and nurses. It facilitates better teamwork and builds trust among physicians, nurses and patients.  How does this build trustworthiness?  The technology increases teams’ competency and reliability and improves communication to better understand and execute patient care plans.

How It Works

Nursing is the most trusted profession in the United States, and nurses are instrumental in caring for patients. Although many medical decisions are made by the patient and provider, nurses ultimately carry out much of this medical care. Safe, effective and efficient care necessitates clear communication between nurses and physicians, and patients must feel that their team works well together in caring for them. The global COVID-19 pandemic has challenged effective communication due to the need for social distancing. To address these challenges, we implemented the MD/APP-in-Room button as a novel tool to facilitate socially distanced, face-to-face touch-bases between providers and nurses. By doing so, we increased teaming within our organization and built trust amongst providers and patients. Each room in our hospital is equipped with a communication console displaying various buttons, which when pressed send a text alert to the phone of the patient’s nurse. We created an “MD/APP-in-Room” that providers press when entering patient rooms to send a text alert to the nurse. The nurse then meets the team outside the patient’s room for a socially distanced touch-base to exchange information, ask questions, and discuss the plan of care for that day. Although touch-bases may not always occur immediately due to time constraints and care of other patients, this text alert still signaled to the nurse that the team had been by to see the patient and could instead encourage a touch base to occur further down the hall or soon after via telephone.

Skills and Competencies

The MD/APP-in-Room button relies on effective communication skills, teamwork, and organizational leadership. When we initially rolled out the button to the organization, we occasionally met with resistance from team members who would ask, “Why did you press the button if you didn’t need anything?” Similarly, some members were slow to adopt usage of the button into their workflow. With continued reframing and support from organizational leadership, we were able to convey that the purpose of this button was not to signal that providers needed something, but rather to allow the opportunity for face-to-face communication and teamwork.

Origins

In response to high bed capacity utilization in our hospital and in preparation for the opening of a level one trauma center, our organization undertook many efforts to reduce length of stay and improve capacity to care for our community. Our organization has an initiative called IGNITE, which stands for “Improving GME-Nursing Interprofessional Team Experiences.” INGITE is made up of teams of nurses, physicians, trainees, administrators, and patient advocates who carry out various quality improvement projects within our institution. Our IGNITE teams hosted a Kaizen quality improvement event focused on reducing patient length of stay. As part of this event, we identified that early communication of patient care plans between providers and nurses was essential to provide effective care and timely discharges. However, discordant work flows made effective communication difficult. The IGNITE teams therefore leveraged existing technology in our institution and created the MD/APP-in-Room button to address this challenge. After successfully piloting this button on our surgical units, the teams then rolled out the initiative to all services and inpatient units within our primary hospital.

Effectiveness

From the outset of our initiative, we tracked various metrics to determine the effectiveness of our intervention. First, we electronically tracked MD/APP-in-Room button utilization to guide where further efforts to encourage adoption were needed. We also surveyed surgical residents to determine their reactions to the MD/APP-in-Room button. We found that 80% felt that speaking to the nurse during morning rounds was beneficial to coordinating patient care and that 68% felt that improving communication would reduce unnecessary discharge delays. As a proxy for increasing face-to-face communication, we tracked paging volume on the pilot services and saw a 22% reduction from the three months prior to after the implementation of the button. We also saw a decrease in length of stay from 6.32 to 5.26 days and increased bed turnover rate from 4.10 to 4.99 during this time. Lastly, we are now tracking patient responses to the question, “How well staff worked together to care for you?” As adoption of the button increased, we began to see a unique change. Nurses were beginning to come to the bedside during rounds even before the button was pressed. This culture change was leading to more effective face-to-face communication and care of our patients.

Scalability

We quickly scaled the MD/APP-in-Room practice from our pilot unit to all units within our main hospital. This required the availability of the communication console within patient rooms. Unfortunately, our children’s hospital and second hospital building do not have this resource. To encourage face-to-face communication in these areas in the absence of the MD/APP-in-Room button, we created a managing daily improvement (MDI) metric across all patient care areas to track patients for whom a touch-base does not occur. This leverages the momentum and culture change of our MD/APP-in-Room button to encourage face-to-face communication throughout our entire organization.