Stepping Up With Virtual ICU Rounding

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Exchange podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Hassan Khouli, MD:

Hello, everyone, and welcome to the Respiratory Exchange podcast. I'm your guest host today, Hassan Khouli, Chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic.

My guest today is Adi Gerblich. Dr. Gerblich is the Physician Staff in the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic, and he's also the Division Chief for Pulmonary Medicine at Cleveland Clinic Hillcrest Hospital.

Today, we will be talking about virtual ICU rounding. Welcome, Adi, to the program.

Adi Gerblich, MD:

Thanks. Thanks a lot, Hassan.

Hassan Khouli, MD:

So, let's start actually, as we talk to our, you know, audience, who I know they will be intrigued and interested in this interesting topic here, a little bit, frankly, different flavor for what we usually talk about during some of these podcasts. So, I'm looking forward to hear your perspective on ICU rounding there.

So maybe we can start by setting the stage for us of what the ICU environment is like from your perspective and what you encounter.

Adi Gerblich, MD:

ICU environment is dynamic, sort of chaotic many times, interruptions. But you try to give it some structure. Structure by the physician team rounding, having some nursing conglomeration together with the rest of the team, having the family together there if possible. It's a challenging environment. You see life and death all the time, you know, always dealing with very sick people. So, you have to be attuned to the requests of the nurses, the APPs, the different consulting physicians to be on top of the clinical situation at any given time. I think this is key, to be on top of the clinical situation rather than, and foresee what the possible complications are. So that's part of what we do on a daily basis.

Hassan Khouli, MD:

Thank you, Adi. And you know, for many of us who work in the ICU Day in, day out or have spent really many years in that environment, we take things for granted, really. And you know, how you put it there, how important it is to put a structure in place and then, you know, to understand really how, how stressful that environment can be and, you know, how important it is to include the families and then really support them or the patients, you know, certainly during that process there. So that's helpful.

So, as you talked about how important it is to include families and then communicate with them, maybe you can share with us from your perspectives and being, having worked in that environment for a time, what are the different modalities of communications between the ICU team and, and the family?

Adi Gerblich, MD:

So, we have multiple ways to communicate. Obviously, the most natural one is when you communicate in person to the family when they're at the bedside. Very common to have communication via phone. We have the option to communicate via video. We can schedule meeting with the family. We can designate a liaison to the family to communicate with us, say, if there are difficulties. We have interpretive services if the language is not the same. And we have pamphlets and literature and so forth.

So multiple modalities to communicate. And the key thing is that communication is key in any evaluation of a patient, key between the physician and the family and key between the physician and the treatment team. If there is no communication, things are falling apart. So having streamlined communication is essential for good outcomes and good satisfaction by the family.

Hassan Khouli, MD:

I agree. You know in a way, it's a big advantage to have multiple options to communicate, because, you know, we are in different situations. Sometimes, we see patients who or families who are calling us from really a different country, and they do need also to participate in that.

So as maybe confusing sometime to have these different communication modalities, I agree. I think, you know, to be comfortable with them and to pick the right one in the right situation, you know, would make sense there.

Going back to how we do rounding in the ICU, and you stressed out that the team concept of working in the intensive care unit and what we call interdisciplinary team there rounding with the family, maybe you can share with us what is that team like? Who usually rounds in the ICU rounds?

Adi Gerblich, MD:

Yeah. So there has to be intensivists, the physicians specializing in critical care medicine. We include with them also a nurse practitioner or APP that has specialized in critical care medicine and is trained in critical care medicine. And we have also a pharmacist that is concentrating on critical care medicine as well.

And with that, we have additional services like dietary, palliative care, or other consultants in the care of the case. So, this way, you have a conglomerate of people who are all interested in the well-being of the patient, concentrated together with the family, discussing the daily issues of the case.

So that's the idea of the team. And more and more literature suggests that that's probably the most effective way of communicating in the intensive care unit, including the family together with the multidisciplinary team.

Hassan Khouli, MD:

Thank you. And that makes a lot of sense. I mean, we take care of, there's not a single person on their own taking care of a patient in the ICU. It is a team that is caring for them. So, it makes a lot of sense when you're communicating to the family or to the patient about goals of care or other important areas to communicate, is if there's an opportunity to communicate also as a team, as we care for them as a team. I certainly agree with you. This is really a valuable aspect of communication there.

Would you be able to explain to our audience here what is the protocol of a video or a face-to-face communication with the patient family?

Adi Gerblich, MD:

You know, that may change from institution to institution. But in our specific location at Hillcrest Hospital, we don't have fellows and residents in the intensive care unit. So, the presentation of the case, we decided, will be done by the bedside nurse.

To get there, we had to have a lot of training of the bedside nurse, how to present a case in an orderly fashion. And we've trained all the nurses to go through that protocol. It's a protocolized way to present a case, which is similar to, I'm sure, like a resident presenting and a fellow presenting a case.

We come to the bedside. We have all the team together. We have all the family if they're willing to... If the family's at the bedside, we introduce all the team members to the family. The nurse presents the case. She goes through the protocol, so the, all the vital organs and all the problems that happened overnight, all the medication issues, any difficulties she had. Then, we review the medications. We entertain discussion and questions about the lab values and what the tests should be done that day. And we get questions from the pharmacists about medications that should be stopped or added, any complication from medication, any complication from the procedure. We review the X-rays. And we share all this with the family. So, if there's a CT scan, if there's a chest X-ray, we show it to the family to explain to them the medical condition.

And once these discussions are going on, we come to a plan, what will be done today. Will we change the medication that we are giving? Are we going to have a new laboratory test done? We're going to have a procedure, we're going to get a consultant, we're going to get a different opinion, and so forth.

And then after all that is done and said, we summarize in a statement what we are going to do today. And we ask the family do they have any further questions, or they have any more clarifications to the case. And this way, I think I can see a wholesome finalization of the daily rounds.

Hassan Khouli, MD:

That is very, very good description of what takes place. And you're right. You know, including the nurse, like what I learned from what you said, how important it is to include the nurse and other team members in that plans of care discussion, and also reaching out to the family.

Adi Gerblich, MD:

I think that there's an aspect that I didn't think originally about, was that the person who is talking, it depends on the lingo. If a physician would have been describing the case, it would have been different. If a fellow will be describing the case, it would be different, or a resident describing, is they will put in a lot of medical terminology, which the family doesn't understand anything about.

So, I like the fact that the nurse is presenting the case, because she speaks in a less medical way, more in a humanistic way of what exactly happened to the patient, how did they feel, how did they sleep, did they have pain, did they not have pain. So, there's a lot of communication that the family can latch on and understand the clinical condition of the patient, rather than giving summary and medical statements that are a little obscure to them.

So, I think I have, I've learned with time that there's an advantage to that.

Hassan Khouli, MD:

Right. It's the humanistic and structure that the same time, too.

Adi Gerblich, MD:

Yes, yes.

Hassan Khouli, MD:

So, it delivers the points that you want to deliver there. You know, this program that you're describing it, how you do it in the ICU, if you want to take us a little bit through the history, how that thought came about and then how you led us through this creative and innovative way.

Adi Gerblich, MD:

Yeah. Very interesting. So, several years ago, there was a push of the Cleveland Clinic to develop telemedicine.

Hassan Khouli, MD:

Hm.

Adi Gerblich, MD:

And I remember Dr. Wiedemann came to one of the meetings in the ICU. And he told us about this so, you know, this program that the Cleveland Clinic has to have telemedicine and be able to do consultations and outpatients.

And so, I said, "Why not in the ICU?" Because they never thought the ICU should be part of it. So, I said, "I would love to have it in the ICU." That was the inception of the program.

And from that, we developed the protocolized, the nursing protocol and the rounding and so they propagated itself from that.

And lo and behold, we have this program running and collecting you know, server data about the effect of that approach. And suddenly, COVID hit.

Hassan Khouli, MD:

Yeah.

Adi Gerblich, MD:

And it was a phenomenal success in the sense that we were all, you know, trained in that technology and very comfortable with it, being able to share with families who were not able to come to the hospital and be at the bedside and showing them the patient through the window, doors closed, showing them the CT scan, showing them the data.

So that was a great relief for the family. And I cannot tell you how many families have commented about that, that, because in other places, they were totally obscured to what was happening with the family. It was like a black box for them.

Hassan Khouli, MD:

It was. It was. You know, taking us back through these traumatic days and how important it is to have a program like this already set and you know, done and not by necessity, it was already actually mature at the ICUs that you were rounding. That, and how the families and the team really benefit from being in that. It's like a light bulb idea came through and doing that "Why not the ICU?"

Adi Gerblich, MD:

Right.

Hassan Khouli, MD:

So why not the ICU? Then you took it and you carried this to a, to make it a reality, for a, for the ICU rounding and then for the team and beyond there. So, you know, maybe to share with the audience, this is a real-time family member who is joining by video while ICU rounds are taking place, during their set time there, maybe if you can talk a little bit about the details. How do you get the family on the phone, on that video?

Adi Gerblich, MD:

Yeah. So, let's say the family's not at the bedside. So, you make a call to the family, ask them, "Are you willing to participate in a video conference?" and they say, "Yes." And if they say yes, we are using a software program by Amwell, which doesn't need any download. And in the minute that you connect with the patient, you get on the screen, you put the phone number of the patient to their iPhone or to their, any other cellular phone is okay. And then the only thing they get on the screen, they have to put their name and that they accept the call.

And once they do that, they're connected automatically by a video. We see them on the screen. We can have multiple people from multiple locations on the screen at the same time, seeing me, seeing the whole team, seeing the patient. And we do a communication, sort of similar to what would happen if they were physically in the room.

Hassan Khouli, MD:

Yeah. Thank you for sharing that vividly in a picture transferring, you know, to the team. Quite interesting.

Adi Gerblich, MD:

Yeah. Multiple times I had people, the son is in North Carolina, the daughter is in Virginia, and the mother is here.

Hassan Khouli, MD:

Yeah.

Adi Gerblich, MD:

And they want to see her, and they want to communicate. And, and sometimes even when they're out of town and we're finished the rounds, I am leaving the video there for them to discuss the family affairs. So, among each other.

Hassan Khouli, MD:

That's the nature of life and then the family you know some time together and sometime in different places.

Adi Gerblich, MD:

Yeah.

Hassan Khouli, MD:

And when a crisis like this happens, where a loved one is admitted to the ICU to bring them all around the table in the real time with the caring team.

Adi Gerblich, MD:

I even, I had a case of terminally ill woman in the ICU, and the son was in California and wasn't able to come on time. And over the phone, I left them conversing between themselves to decide about goals of care. And over the video, they decided to be DNR comfort care.

So that happened, too. So just the fact that you are able to communicate face to face, you know, even if it's a video, makes a difference in the way that people perceive and make decisions.

Hassan Khouli, MD:

And you shared in that case, you know, information is simultaneously that is relevant for them and from them of that decision making that they came up with then. Thank you. So how does the video conference help the treatment team? You talked about how the family, for example, the way you presented this. How does it help really also the treatment team, Adi?

Adi Gerblich, MD:

I don't know that the video conference is different for the treatment team as far as the in-person, when they're in person or on the video. It's probably similar. I think the fact that the family is observant as to what is happening makes the team more cohesive and more focused on the case. So, they cannot do something else. They have to be attuned to the discussion, because they may be asked a question about the case. And the pharmacist can be asked a question. The APP can ask a question.

So as everybody sees everybody, everybody is concentrated and attuned to the situation.

Hassan Khouli, MD:

Very much so. You know, when you look at the advantages then of this, you described some of them and how it is important to be introduced to the team. Any other advantages you feel for the video communication?

Adi Gerblich, MD:

I think when I look at the statistics of the service that we get, the in-person communication probably scores the best. So, when you're next to the other person, you probably perceive much more information than you are on the video. Although we were not able to clearly show it by the scoring that we got.

But definitely, the in-person and the video communication are very similar statistically as far as the scoring that we have for the different questions that we ask the families. The main difference is between that and the phone conversation, which scores much lower than the video or the in-person interaction.

And that, I think, is the main message, because you are losing the visual quality of the interaction either with the in-person or with the video and you're just relying on hearing. And with the hearing, when you hear the hearing over the phone, the recipient doesn't know what stands behind that physician, in other words, that there was a pharmacist, that there was an APP, that there was a nutritionist and there was a consultant. He just summarizes everything in the phone. So, the receiver, the family does not perceive the whole weight of the message the same way that they perceive it when she sees the whole team by the bedside. I think that's a definite psychological effect.

Hassan Khouli, MD:

I think so, too. And, you know, you studied this scientifically and you collected data, and you analyzed it and compared.

Adi Gerblich, MD:

Yeah.

Hassan Khouli, MD:

And the fact that you can have a video conference modality with a family and then show that it's equivalent to being in person and considering the advantages that you have really outlined here, by itself is a very important observation. Thank you for sharing it with our audience here.

Are there any shortcomings, any disadvantages that you see for this modality?

Adi Gerblich, MD:

Well, technology is technology. It's only good when it works. So, some deficiencies. One is that you have to have an internet connection. I mean, you can do it on a 5G or a 4G network, but it's not as good. So, I think internet connection is, is a key.

So sometimes, elderly patients, the spouse is elderly, doesn't know how to fiddle around with the iPhone. That may be a difficulty. Most of the time, we overcome it with the granddaughter or the children coming and helping them out. So, I think that's a very small number of cases. Nowadays, even that population is okay.

The other problem is it takes about a minute or minute and half sometimes to make the connection after you click the phone. So that's sort of dead time. But short of that, it works very well.

Hassan Khouli, MD:

And, you know, the more you practice doing that, too, certainly so you can overcome some of these technical difficulties.

Adi Gerblich, MD:

Yeah. It becomes secondhand.

Hassan Khouli, MD:

Yeah.

Adi Gerblich, MD:

It's like waiting for the phone to, phone call to respond. So similarly, here, you wait for the video to respond.

Hassan Khouli, MD:

Right. And the flow of rounds really are not much interrupted.

Adi Gerblich, MD:

Yeah. And I must say the video quality and the voice quality are exceptional. We didn't really have major problems either with the voice or with the video. Even if it was transcontinental, I mean, like I spoke to Europe or South Africa or whatever, you know, I'll just say there was never a problem. So here in Cleveland, for sure not.

Hassan Khouli, MD:

So how do you ensure that all the family members or the family members that are key stakeholders in this are who want to participate also are participating, are involved?

Adi Gerblich, MD:

Well, I leave it to the POA. He decides who he wants to have on the call for us. I mean, if he wants one person, two-person, five person, it's same for me. So, I'm not the one deciding who is going to be in the conference. I mean, the POA has to decide that. So that's a family function and they know the pecking order in the family, who should talk, who should not talk, who's more aggressive, who's less aggressive, and so forth.

So, I don't know the family. I just meet them the first time. I let them decide. I don't decide. The only decision is the POA. When there's no POA, then it's becoming more complicated. So, you have to go by the Ohio rule, the majority of the kids, and so forth. I mean, there's a pecking order of how we go through that. So, we do that. But usually, the POA decides.

Hassan Khouli, MD:

Right. And the POA is, just for our audience, is the power of attorney that we are referred to. Here in Ohio, it may have, I know, a different reference of who that person would be than in some different parts of the country here in the United States, too.

So how does family that are, you know, family involvement in the discussion impact the decision making process from your experience?

Adi Gerblich, MD:

I think we have both the family and the treatment team, we have the same goal. The goal is to get the patient into a better shape if possible.

So that's similar. The problem is to explain to the family the difficulty of getting there and what are the hurdles and the complications in my encounter and what in our judgment is the best way to do that. And that's the education piece that has to be involved in the round to explain to them. Is the bronchoscopy worth it? Is the central line worth it? Is the X-ray worth it? Should we, do it? Should we not do it?

So, I'm very careful describing the cons and pros of the procedure, of the next step that I am going to do. How is it going to work? What are the possible complications? So, I'm trying to be as open-minded in whatever I do so they see the whole spectrum of what can happen to the patient.

And I think that helps them understand the disease process and the complexity of it and come to a decision which will lead to the goals of care that they will direct me as to what they think is the best for the patient. I can tell them my opinion, but I'm listening for them to have guidance as to how to behave myself.

Hassan Khouli, MD:

Right. You're recreating a sense of alignment between the you know, the family, the patient's wishes, and the care team with the information they have.

Adi Gerblich, MD:

I mean, the main thing is that they should perceive that my only agenda is the patient and his wellbeing.

Hassan Khouli, MD:

Yeah.

Adi Gerblich, MD:

Once they perceive that that's my central agenda, that I am unbiased about it, I think you get confidence from the family.

Hassan Khouli, MD:

And you're using this unique platform of communication to that may not be able sometime because of, you know, lack of ability to bring people together to really reach that alignment, you know, there.

So, what strategies do you usually use to make communications compassionate and effective, you know, in an environment as stressful as the ICU environment?

Adi Gerblich, MD:

Yeah. I think one of the key things is, first of all, to listen to what the family wants. Listening is important. I mean, it reduces the fear of the family that tells them what the problems are. You can learn from it information that you otherwise don't, have not seen or is not on the chart. I always find it fascinating how much more information you can get from the family on every critical case.

And then I think you have to come across that you are unbiased and honest, and you are transparent with whatever information is. In other words, in my book, there are no unknowns or hidden agenda. Whatever is in the chart, whatever information is, I give it to the patient and to the family. And I tell them my opinion about it. And they will ask me questions about it.

So, I think I come across as you need to have honesty and a sense of unbiased-ness and benevolence and willing to do good. And if you show that as part of your strategy, I think they will accept it.

Hassan Khouli, MD:

I think so, too. You know, thank you for sharing that, Dr. Gerblich with us. Are there any resources or training that you provide the ICU staff to ensure that way of effective communication?

Adi Gerblich, MD:

Yeah. So, we have ongoing reviews of the nurses' performance in the presentations. So, if the nurse forgets, we have the protocolized presentation on the card. So, if she forgets something, it can show her, "Here's what you have to do," and so forth. This is the main activity as far as updating, because nurses are changing all the time. We have turnover of nurses and not all nurses have a lot of years of experience. So, this is our main mode of updating the team.

Hassan Khouli, MD:

Wonderful. So, my last question to you is based on your experience and being really a pioneer in this area, what are the preferred modes of communication with family that you think?

Adi Gerblich, MD:

No question, the best is in-person. I think a video is a substitute. Video conferencing is a substitute. In my opinion, phone conversations should be only done as follow-up, not as primary explanation to the family of what the condition of the patient is or what the wanting was about.

The problem with the phone is, A, it's post factum and you don't have the whole team together. You cannot show data. So, it's much more limited type of information packaged that you are sending to the family. So, I think it's most suited for a follow-up conversation.

So, let's say you had in the morning, you have a meeting with the family on the video, and then something else happened during the day that needs an update to the family, I think phone is perfectly okay. You don't need to have another video conference. They're already soiled and oiled and know the plan and so forth.

But to put it the other way around and have the phone as the primary communication mode with the family, I think that probably will cause reduction in satisfaction, reduction in understanding of the family, reduction in the confidence that the family has in the team, and on and on and on. It can go in the scoring system, and you see it very clearly that the score's fallen the minute you put the phone conversation as the primary mode of communication.

Hassan Khouli, MD:

Thank you. I'm so intrigued really by what you shared with us earlier, about that how close it, the effectiveness of, you know, virtual video communication to the in-person and to have that as an invention, advantage and bring the family and different people together that they may not be able to do. In an ideal situation, they may be, you know, being there, it's great, but how that really provides that valuable option to different family there, too.

Thank you, Dr. Gerblich, and thank you, everyone, for listening to our podcast today. I'm your guest host Hassan Khouli, Chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. And my guest today was Adi Gerblich. Dr. Gerblich is a staff physician in the Respiratory Institute in the Department of Critical Care Medicine at the Cleveland Clinic and a Division Chief for Pulmonary at Cleveland Clinic Hillcrest Hospital.

With that, we conclude our podcast. Thank you.

Raed Dweik:

Thank you for listening to this episode of the Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at Raed Dweik MD.