R&R Rounds help ICU staff process challenging patient care situations

At Brigham and Women’s Faulkner Hospital, staff have long had access to Ethics Consults, Schwartz Rounds, Social Work and Spiritual Care Services to help cope with the stresses of their work. Now, a new program in the ICU is offering a unique approach to support staff when faced with challenging patient care situations.

The idea was suggested by attending physician Thiago Oliveira, MD, MPH, while the team was working through a very emotionally challenging case. Their patient had been in BWFH’s ICU for quite some time, so many members of the staff had been part of their care. As the patient became increasingly ill, Dr. Oliveira recognized the need to debrief with his colleagues. “During my critical care fellowship training at the Brigham, I did a palliative care elective rotation. I was introduced to Remembrance Rounds, which are held weekly and are intended to bring staff together to honor their patients who had passed, centering on their humanity and allowing their clinical presentations to fade into the background," says Dr. Oliveira. “I hoped a similar venue could be useful to our staff, helping us tap into gratitude for the special moments and relationships we experience amidst the hardships of caring for our patients during their critical illness.”

Together with ICU Medical Director Hassan Sajjad, MD, Nurse Director for the ICU, Dialysis and Respiratory Estier Sayegh, MBA, BSN, RN, CCRN, PCCN, CNRN, ICU, Clinical Leader Ellen McCarthy, DNP, MSN, RN, CCRN, and Social Work Manager Maxine Klenicki, MSW, LICSW, Dr. Oliveira was able to quickly bring the multidisciplinary care team together. A meeting was arranged with an option to join either in person or virtually. Staff were invited to reflect on the care they provided the patient and share their experiences and concerns.

“These meetings don’t replace an Ethics Consult or formal Schwartz Rounds, but give space in an informal, social format in the ICU to share work stories, emotional well-being and perhaps coffee and cookies,” explains Klenicki. “The hope is to bring together our colleagues from all disciplines sharing patients in the ICU to connect over the work and share the emotions, including humor and sadness, that may arise as we reflect on patients we are or have cared for together in our ICU.”

Sayegh adds, “It’s also a way to help staff understand their patients’ cultural and religious differences and ensure our own beliefs don’t get in the way of our patients’ beliefs.”

At the first session, ICU leadership was impressed by the level of participation from staff. “With very little notice, we had quite a few people in the room and on Zoom. That really speaks to the need for something like this,” says McCarthy. “Several staff members expressed interest in doing these rounds more often going forward. Particularly when a patient dies, you don’t always get to process it. We may debrief after a code, but not after every patient who dies. Typically you have to pull yourself together and move to the next patient’s room so the processing of that death gets lost. These rounds provide that forum to be able to go back and debrief.”

What was most impactful during the first session was the understanding gained of each other’s work. “It allowed us to appreciate the work of all the disciplines,” explains McCarthy. “To hear what the different disciplines were going through when they were caring for the patient was very impactful.”

Dr. Sajjad agrees, “In the ICU, we have a multidisciplinary approach to care. Sometimes, when we are reflecting back on difficult cases, we get bogged down asking what we did wrong and get too focused on the medical aspects. Being able to hear from members of the care team from other disciplines helped me see the whole patient.”

The concept has been named R&R Rounds. Depending on the day and the staff’s needs, the Rs can stand for Restoration, Reflection or Remembrance.

“Initially our plan was for the staff to get together to debrief on this one particular case,” explains Dr. Sajjad. “However, given the excellent participation and strong interest from nursing, respiratory therapy, dietary and providers, we have introduced quarterly R&R Rounds. Going forward, R&R Rounds will be informal with a goal of providing staff with an opportunity to reflect on challenging cases and celebrate memories of our patients. I do think that opportunities like this help reduce stress and burn out in the ICU. As I reflect on the COVID-19 pandemic and how many patients we lost, I wish we had something like this then. It would have helped a lot.”

Published 12/16/22