The COVID-19 pandemic has changed many aspects of care delivery and highlighted that in-person care may not always be ideal when attempting to limit the transmission of infectious agents. With the move towards virtual care, we should continue to prioritize family-centred approaches to maintain safe and high quality care.1 This project demonstrates the ability to conduct FCR through a virtual platform and suggests vFCR are an acceptable alternative to in-person FCR in terms of stakeholder satisfaction, perceived effectiveness and perceived usefulness in these unique times.
While other pediatric centres have trialled vFCR,4–8 our process appears to align more closely to FCR best practices in terms of content, scheduling and role clarity.15,19,21 Importantly, our process led to optimizations in timing and overall efficiency; well-known barriers to implementation of successful FCR.3 A virtual rounding process developed in the neonatal intensive care setting reported similar benefits including improved efficiency, shorter rounding times, fewer interruptions, increased safety, and improved physical distancing.7 This evidence of similar processes successfully implemented in different care contexts highlights the utility and adaptability of the virtual rounding approach.
A robust wireless network and access to video-capable tablets with headsets allowed for rapid implementation of our vFCR process. Because vFCR is dependent on technology and technology options vary across organizations, identification of usability requirements and technical factors that would maximize user acceptance22,23 and facilitate implementation and adoption would be important considerations for other organizations implementing a similar process.
Rounding and transition time targets were achieved and were important contributors to securing stakeholder buy-in. Unanticipated benefits of vFCR included increased confidentiality and environmental noise reduction as patients, families and nurses all wore headsets. Furthermore, reducing the number of providers at the bedside was perceived by some patients and families as safer and less intimidating, which is consistent with the literature.13,24
Lessons Learned
To realize the full potential of vFCR, adequate space is required for physicians and trainees to join virtual meetings unmasked. Limited availability of private office space at our hospital meant medical trainees had to remain masked during vFCR, which hindered their ability to maintain non-verbal communication (e.g. understanding and/or support communicated through facial expression), which is particularly important when conveying empathy and compassion during difficult and sensitive conversations.7 To this end, we believe the overall experience with vFCR and perceptions of rapport would have been improved if physician teams could have joined videoconferences unmasked.
In addition, we recognized health care team training on the vFCR process and technology was essential and should be prioritized. While the structure and content of vFCR remained the same as in-person FCR, learning to use vFCR technology was an additional challenge. Moreover, where in-person rounds enabled the use of non-verbal cues (e.g. body position and movement) to support communication, virtual interactions require explicit verbal commands, for example, “…moving on to the next patient”. To support our teams, educational sessions and tip sheets were created, and timely, in-person support from the project team was available.
Similar to other studies,20,25 the creation of a rounding schedule was essential to ensure availability of bedside nurses for vFCR. Given that implementing and adhering to a rounding schedule was a change from our usual in-person process, we initially instituted a simple 10-minute-per-patient schedule for vFCR. We later modified the scheduling system to allow care teams to request longer or shorter rounding times based on predicted patient needs. Unfortunately, we were not resourced to have a rounds coordinator, which has been found to enhance the timeliness of a scheduled rounding process.20
Finally, the ability for patients and families to participate in vFCR is essential. The tablets we used did not support a headset splitter, necessitating removal of the headset so both patient and family could hear. This occasionally impacted privacy and sound quality. Additionally, using a continuous videoconference meeting for all patients facilitated provider workflow but prevented us from inviting offsite family members to join vFCR for security reasons. While the process we developed to allow offsite family members to join by phone was appreciated, ideally, we would have been able to offer participation by videoconference.
Limitations
While the simple project design and iterative improvement process yielded clear results in terms of stakeholder perceptions of vFCR, there was limited evaluation of satisfaction and effectiveness of in-person FCR at our centre against which we could compare. Additionally, certain data were not rigorously captured, which limited our ability to substantiate important observations. For example, staff physicians estimated 90% nursing attendance during vFCR compared to 65% for in-person FCR, however, this was not explicitly tracked by auditors and therefore could not be included in results. The low patient/caregiver sample (n=33) for questionnaire responses is another limitation that could suggest self-selection bias. However, questionnaire responses were corroborated by interviews and qualitative feedback collected by auditors. We attribute the low number of questionnaire responses to low (46%) family participation in vFCR, which may have been, in part, due to COVID-19-related visitor restrictions. In addition, there were only 6 days of questionnaire distribution due to resource limitations, further reducing the potential number of respondents.
While we did not formally analyze cost-effectiveness of the intervention, there were minimal costs associated with the switch from in-person to virtual rounds given our use of existing technology and hardware. Additionally, by adopting a virtual rounding process, we substantially reduced the demand for PPE and estimate PPE cost savings of approximately $36,000 CAD per month ($6.79 CAD per person x 8 members per care team x 11 patients per day x 3 rounding teams x 20 days per month).13
Finally, this project was performed within a single academic tertiary care centre undergoing rapid change in response to the COVID-19 pandemic. The learnings, therefore, may not be generalizable to all contexts.