كيفية إجراء جولة سريرية فعّالة وآمنة في وحدة العناية المركزة

[00:00:03]Peace be upon you again. I welcome Dr. Hassan Hawwa, who always enriches us with insightful additions and depth in his research during his lectures.

[00:00:21]I attend each lecture beforehand because I learn something new, like how to conduct rounds more effectively in the ICU.

[00:00:35]Dr. Hassan has been a friend for over 10-15 years. I can't remember when I first came to King Faisal Hospital; he congratulated me and said, "Hassan, may God reward you." We worked together at King Faisal Hospital and continued working together after I left in 2018. He moved from Riyadh to Jeddah. His background is in England, which motivates me to always tease him and compare America and England. But to be honest, I learned a lot from Hassan, especially in the depth of hemodynamics and management. He had a complete, very in-depth course in hemodynamics, which we covered in part of our work in Damascus, Latakia, Idlib, and Aleppo. The second one is also distinguished in it; he has another course in Medical Emergencies. God willing, the opportunity will arise to include it in the curriculum of the Intensive Care Unit.

[00:01:49]Hassan, thank you for your time and for being here with us. You can take the time required by the students. Please, thank you, brother Mazen. I mean, it's actually an honor for me to meet you, and I'll tell them the story of how we met. Okay, today's topic is that I will need a lot of your help today because part of it is not purely medical research, but rather a kind of chat. But honestly, it's one of those important chats that one can realize the importance of after starting, if they are not practicing as a senior in the ICU. When they reach the level of leading ICU rounds, they will realize that many of the points we will mention today are fundamental facts and are relied upon by experts in the field of intensive care.

[00:02:42]I was confused about what to call the title. I would call it effective, but I also want it to be safe and secure.

[00:02:49]Effective, if we want it to be a safe and effective care tour, but it's not safe to give, rather it helps in patient safety. So, the title was a challenge from the beginning, but we'll see what God grants us today. Okay, we'll talk a little about the aviation industry and the world of aviation in general, because many doctors and the health sector have benefited greatly from colleagues, or rather, experts in the world of aviation. Because in the world of aviation, when a real disaster happens, it's a compound disaster. The first loss is the loss of passengers, and the second loss is the loss of the crew. So, it's like comparing the loss of patients, God forbid, with the loss of medical staff. Add to that the enormous cost that results from any loss when a plane crash occurs, and plane crashes are usually—no joke—usually, most, if not all, of the passengers and crew die. So, what did the Florida plane crash that happened in January 1982 teach us? In truth, there are many lessons we have learned from it, and we still practice them daily without realizing it. Its beginnings were from this incident, which we'll tell you about in a bit.

[00:04:20]This is the plane whose picture I was able to get through the EA, or rather, color it with the EA. It's the Boeing A-299 long-range bomber from the 1940s. It also played a huge role in giving the Allies the advantage in the battles of World War II. There was also a very profound lesson from its first flight. Here is the plane. The third lesson we will learn today from the Delta 1141 flight is that the plane didn't even get to fly. So what was the lesson learned? What did the doctors and the health sector learn from this incident? Now, there are industrial sectors where mistakes are unacceptable, including aviation, nuclear industries, and chemical industries. These are the things that absolutely cannot tolerate mistakes. So, we must first ask ourselves why we conduct medical rounds, visiting patients every day and tiring ourselves out. The truth is, this represents a fundamental pillar in patient care, whether inside the ICU or even outside of it. During our rounds, when we visit patients, we brainstorm treatment plans.

[00:06:00]If the diagnosis isn't clear, we try to determine the most accurate diagnosis and develop the appropriate treatment plan. This also includes consulting with other specialists and adjusting patient care and support based on their needs. We then plan the patient's discharge from the ICU or even from the general ward. Another goal is to communicate the treatment plan to all members of the medical team involved in the patient's care. This team isn't just doctors; it includes nurses, physical therapists, clinical pharmacists, and other teams that may be involved in the patient's care. In our intensive care unit, when patients arrive, they find that the treatment plan and diagnosis from the care team or the team supervising the patient are clearly documented. In addition, anything that happens to the patient must be immediately recorded as an incident, sometimes called an event note. For example, if a nurse suddenly calls me and says, " Doctor, your patient has a rapid heartbeat or a sudden drop in blood pressure," the first thing you do when you treat the patient is immediately write this down and document it in the patient's file. This allows the next team to know what happened, thus ensuring continuity of treatment. Furthermore, especially in countries with advanced medical systems, these patient files are used as legally valid documents in courts.

[00:08:15]This can sometimes be a lifeline for the doctor.

[00:08:21]Imagine if someone came in, saw a patient, gave them the correct treatment, and left without writing anything down in their notes, months later, or even after that. For example, if someone files a lawsuit against a doctor, the doctor won't remember every patient. But if there's a written record of, "I arrived at such and such an hour on such and such a date and found the patient in such and such a critical condition and treated him," it proves that he fulfilled his duty towards the patient. However, if there's nothing written down, it says "not recorded," not "not assumed," so you can't prove that you fulfilled your duty towards the patient. Consequently, you could be accused of negligence if there's no documentation of what you did for the patient. In addition, clinical rotations are an opportunity for trainees to learn the craft of medicine from their supervisors. In fact, most of what we share or what we've gained in our clinical lives comes from our supervisors.

[00:09:25]Dr. Nabil, may God reward him, calls it "by osmosis learning." By osmosis, or infiltration, the trainee hears and sees how the supervisor dealt with different cases, and thus, subconsciously, the method of treating or approaching different medical conditions begins to become ingrained in him. And I always encourage the trainee They don't get stuck with just one supervisor, and they don't try to see what's best with each supervisor, learn from them, and acquire skills.

[00:10:06]If we look at what we've discussed, communication is the fundamental element in clinical rounds. This is where the Joint Commission International (JCI) found that communication failures are the root cause of up to 85% of serious incidents in hospitals. Many of the serious incidents that patients experienced, and in 85% of cases, the problem was a failure in communication. Therefore, anything that improves communication will definitely improve the outcome for patients. There are key things we need to remember: the unique environment of the intensive care unit (ICU).

[00:11:10]There are also tools that have now been accepted as tools to enhance the efficiency of clinical rounds.

[00:11:21]Studies have shown us that some things facilitate clinical rounds, while others are real obstacles.

[00:11:34]This is a model for an ICU room. The ICU played a major role in this picture. You'll notice that we might have significant distractions in the ICU.

[00:11:47]Where else would you find them? For example, the constant alarms from monitors, ventilators, or pumps. Or, the patient themselves might need your attention; you need to deal with them quickly before they harm themselves. Or, a patient's health might be deteriorating rapidly, requiring immediate intervention. Or, the surgical team might come and tell you, "Doctor, the patient in bed so-and-so has this problem, and we need to take him to surgery."

[00:12:25]You might be focusing on the patient, and suddenly someone comes and distracts you from where you were taking the patient. This issue of distraction is very serious during clinical rounds. In fact, in Britain, the system is much stricter than in America; nurses administering medication to patients in the wards and units wear full protective suits. Don't interrupt me, don't interrupt, because she needs the utmost concentration to administer her medications to patients.

[00:13:03]Another possible problem is that the trainees and students accompanying you on rounds are all eager to know what they want, ask questions, and seek clarification. This can also distract you from providing optimal patient care if you don't know how to lead the rounds. Furthermore, you start with the first patient feeling refreshed and enthusiastic, but by the time you reach the sixth or seventh patient, you might start to feel somewhat exhausted, even bored, and your concentration might decrease. You might start to feel hypoglycemic and think about your next cup of coffee. All of this also affects your focus on the patients. All these factors, and others of course, make the ICU environment unique and require careful handling.

[00:13:58]We've talked about medical errors. The truly astonishing statistics on medical errors in the United States show that 200,000 patients die as a result.

[00:14:11]Medical errors occur annually. If you were to try to address them like this, it would be equivalent to a giant plane crash every day.

[00:14:18]Imagine if every day a plane crashed, killing everyone on board, including the crew.

[00:14:24]What would happen? This would undoubtedly cause a huge uproar from all segments of society, politicians, and decision-makers.

[00:14:39]Unfortunately, we still don't see this level of attention given to medical errors, as if a plane crash were a real tragedy. And this is n't just happening in America. Even in Britain, when they conducted a study on medication errors, they found that one in ten patients admitted to a hospital in Britain experiences a medication error. So, these things really exist, and we see them daily. If you look closely, you'll find them. Notice for yourselves. If you haven't witnessed it yourself, you've surely noticed it with one of your colleagues who made a mistake or whose actions led to an error with the patient.

[00:15:25]What are the main reasons for these errors? For medical errors, you have communication gaps or breakdowns due to misunderstandings. This means either the sender of the message was unclear in what they wanted to convey, or the problem was with the recipient who didn't understand what the speaker or the person requesting the information meant. Either what the recipient understood wasn't intended by the sender, or what the sender intended wasn't correctly understood by the recipient. I liked this phrase; I once heard it from a sheikh: "Understudied but not intended, and intended but not understood." This is the root of the problem—a real problem in medical professionals.

[00:16:15]Therefore, since the problem is one of communication, if we improve communication, we will definitely have better medical consultations.

[00:16:26]As we said, the aviation industry is the safest. As we mentioned, a disaster isn't just about losing passengers, but also the crew members on board, and also the huge financial loss. Therefore, they must learn from any mistake that occurs. And there are many things that I admire and that attract my attention... The aviation accidents and investigations we sometimes see on a channel like National Geographic are not an advertisement for National Geographic, but I really like this program.

[00:17:02]Okay, let's go back to the Floridan plane crash that we talked about at the beginning in 1982.

[00:17:12]What was the problem? They found that the problem was the hierarchical barrier or functional chain of command between the captain and his co-pilot. The captain made a mistake, and the co-pilot didn't dare to point it out.

[00:17:38]This led to the plane crash, the loss of passengers, and the injury of the crew. From this came the idea that the solution to this problem is to encourage co- pilots and empower them to express their concerns. How can we apply this to our reality in the intensive care unit? We should encourage trainees, nurses, and anyone on the team helping us care for patients to speak up when they notice a mistake, without fear. In Britain, they've even reached a point where our break room is the same as the doctors' and consultants', and the same as the nurses', including those who clean the ICU. They found that this way, you're removing all the barriers. In Britain, if you say... I tell him, "Dr. Hassan, Dr. Hawa, this is your job. You're doing it with such formality.

[00:18:43]Nobody knows me except Hassan. I'm in Britain, not because they don't want to respect me, but because they found that if we remove this hierarchy, we remove the barriers between members of the same team. It becomes easier for the nurse who's used to calling him Hassan, Dr. Hawa, by his first name, Hassan, to tell him if she sees him or someone else making a mistake. She doesn't fear his position; he's a consultant, after all. I've noticed with some nurses, maybe Mazen has also noticed, the Indian ones here in Saudi Arabia. I'll be walking down the corridor, and she'll be sitting at a computer, and I won't see her until she stops, as if she wants to give me a special greeting.

[00:19:26]So I've often emphasized to them, 'If you see this, stop and tell her, "No, you can't do that at all. You stay seated. I'm just passing by."'

[00:19:34]So this is the problem in our world of excellence; you find that the prestige and the... They put it, and the aura that is placed around consultants is sometimes the reason for disasters to occur with patients. No one dares to talk to them. This is the lesson learned from aviation. The Florida plane crash. Now let's talk about the accident that happened with the long-range model A299. In fact, it is one of the best planes made by the American industries. In 1935, they brought in the best and most skilled pilots to conduct flight tests on this four-engine plane. But unfortunately, the plane took off, then suddenly lost thrust and crashed. The matter ended with the death of this professional pilot, his co-pilot, and one of his assistants.

[00:20:45]After they did a long analysis and investigation into what happened, they found that there was no problem with this plane, but they discovered that the plane was so good that it was very complex because one person, one pilot, could operate it. They found that the problem was just a human error that led to this problem. So how do we solve this issue? Because they didn't change anything about the airplane, they just added one simple thing that allowed it to fly over two million miles without a single accident. This was simply because they introduced something called a checklist, which Atul Gawande discussed extensively in one of his scientific publications. Atul Gawande is a renowned American surgeon and author on patient safety issues. He used this model because he says that medicine has become incredibly complex, and no one person can handle it all.

[00:22:03]Information is multiplying daily, and new things are constantly being introduced. So, it's a long time since doctors could perform all tasks themselves. This is why we benefit from the checklist in our medical rounds.

[00:22:21]Who says that flying is more complex than seeing patients?

[00:22:29]Once, I counted over 200 variables that you have to review and evaluate until you reach a genuine conclusion that allows you to make the right decision for your patient. Imagine, sometimes you have to review 200 variables for each patient! Until you reach a decision that will hopefully be closer to the truth, imagine how many obstacles we might face on this path, obstacles you might easily forget. This is where something called a checklist comes in. The checklist, or checklist, is a review list, depending on what you call it.

[00:23:11]You give me a checklist, a verification list, a checklist—wow, I like it! So, the question is, could the checklist really be the answer?

[00:23:26]As I mentioned, this teacher, Atul Gawande, said that medicine has become very complicated because we rely solely on memory and experience. He suggested that using a checklist doesn't indicate weakness in the doctor, but rather it's a way to address the complexities we face in treating patients. Are there any examples of checklist use that show it's actually beneficial? We have the famous success story of the magician at Michigan Champion Hospital when they tried to reduce central catheter infections and created a checklist [laughter].

[00:24:18]As you can see, you must ensure that he used chlorhexidine to sterilize the catheter insertion site.

[00:24:31]Maximum precautions were taken: the doctor wore a cap, a mask, and a goggle over gloves. He also covered the entire patient, not just the half-meter area around the central catheter insertion site.

[00:24:50]They emphasized avoiding the femoral route, for example. Finally, the doctor applied a sterile dressing to the central catheter insertion site.

[00:25:02]You'll notice that these things might seem simple in themselves, but when they're included in a checklist, the doctor can't proceed without having checked and performed all of them.

[00:25:16]Professor Brunovst published the results of his research in the New England Journal of Medicine, and you'll see the results here. The truly astonishing thing they achieved is that they started at a level that, for many of our care facilities in the developing world, might seem insignificant. For example, the infection rate was 2.7 per 1000 days of catheterization, and they reduced it to zero within the first three months. It started to drop to zero after being... 2.7 Followed every 1000 days, any day a catheterization, so if only, excuse me, someone is talking, poor Hassan, Dr. Proponst, died two days ago from a central catheterization, no, don't say that, really, or you're killing me [laughs], you sometimes surprise me [laughs], I swear I met him, he came to King Faisal Specialist Hospital, I met him, it was a real scientific meeting, he was going crazy with him, okay, so if this is the first example or checklist, it led to a truly great success in reducing central catheterization infections and thus reducing harm to patients, there is a second checklist, which is the surgical safety checklist adopted by the World Health Organization, and they also found that just by following strict steps before you start the surgical operation, including that you first make sure of the patient's identity, because it happened that the operation was performed on patients other than the patients who needed the operation, or that they performed the operation on the wrong side of the patient, imagine a patient who has kidney cancer, for example, on the right, and they removed the healthy left kidney and left him These events occurred repeatedly, not just once or twice.

[00:27:23]They discovered that applying a surgical safety checklist, if its strict steps are followed, can indeed lead to excellent results, reducing problems for patients. Through this checklist, they found that it reduces mortality rates for patients undergoing surgery, and they have implemented it in multiple countries worldwide. The truth is, the checklist doesn't have to be a long, detailed list. This is an example from one of the most famous children's hospitals, perhaps in the world, Great Ormond Street Hospital in London. They introduced something called the default. The default is an initial letter of the checklist they used. You always begin by asking, "What is the resuscitation status of this patient? Is it clear?" Then there's the D4D,... The fluid plan for this child and the feeding plan that we will agree on, which is for analgesia, what are the painkillers and sedatives that we will use for the patient, that we make sure that we are indeed giving the patient profluxes to prevent stomach ulcers, and also that we move the child to prevent skin ulcers, and for lines out, that the patient does not need a central catheter, we must remove it so as not to cause infections, and the titer volume should be, according to this study, less than 8 ml per kilogram, and look at the result since they entered this simple checklist, they found that cases of, for example, self-acceptance, or that means that the child pulls out the tube by mistake, dropped to zero, even though he used to have several cases per month, sometimes reaching three cases per month, it reached zero only through the application of the checklist, this simple checklist, but it is a fact, the matter does not go away from the challenges of the checklist, or why? Because sometimes when we're making a checklist, we just tick the box indicating that something has been done without actually checking what the question is asking. This is a common mistake, especially if the checklist is long. This is where the story of the Delta Airlines crash in 1988 comes from. The pilot, captain, and first officer were working on a pre-flight checklist when the pilot said, "The flaps are in the correct position." The first officer ticked it without verifying that the flaps were indeed in their correct position and functioning properly.

[00:31:01]Unfortunately, when the plane took off, it crashed because the flaps weren't in their correct position. There was another mistake he didn't notice. The most important thing is that on the checklist, he wrote that the flaps were in their correct position without actually checking. So, from this, we can see that one of the important tools in patient checkups is using a checklist. And I mean, it's one of the things that can Let me tell you about this.

[00:31:44]Once, I was chatting with someone named Mazen Khairallah, and he told me that everyone definitely needs a checklist in their head. And that's absolutely true.

[00:31:54]Because without a checklist—and it doesn't have to be a written checklist, guys, or a computer checklist—each of us has to have it in our minds. When you're going through a patient, you have to go through it one by one. You're listening to the trainees with you, for example, as they present the case to you. You have to have a checklist running. He told me about the breathing, about the ventilator, he told me about the catheters, he told me... He told me that you don't have to check every single point on the checklist that needs to be engraved in our minds when we approach patients.

[00:32:33]This is one of the things I remember perfectly from Dr. Mazen, may God bless him, the professor of critical care. There's another checklist or tool that helps us a lot during rounds, the kind that goes through patients. It's called a daily goal. The goal sheet, which is the daily goal sheet, is that right? Is it a sheet of paper, or what else could we call it?

[00:33:01]Yes, that's right, yes, it's the daily goal sheet. Thank you so much for your encouragement, Dr. Reem. Okay, so we're going back to our brother, Pronovost, whose mother has a central venous catheter.

[00:33:16]He actually published an article about a list, meaning the daily goal sheet, and he gave an example of this model. He's telling you, in this model that he proposed, that we need to think about what we need for this patient to leave the ICU, what the biggest risk is for this patient that we need to avoid. This is the list that he proposed: what the patient needs in terms of pain control and sedation, what the patient's condition is in terms of heart and circulation, and the patient's volumetric status. These are things that we need to define our goal in this regard. It's part of managing the disease.

[00:33:57]The patient needs to be sedated to a head-down position, for example, or they need to be very sedated. Deep or we say no, we need to revive the dead, so all of this is goals you must define on this model he set up. He told you that you should do this three times a day. The suggestion was to do it in the morning, setting goals between 7:00 AM and 3:00 PM: from 3:00 PM to 11:00 AM, and from 11:00 AM to the next morning. So, set the rest of the goals that he thought were necessary to use. He found, through using this daily goal sheet, that the percentage of nurses and resident trainees who understood and knew what the daily goals were for each patient increased from less than 10% to almost 100% simply because we used this tool, which is the daily goal sheet for patients.

[00:35:00]Not only that, as long as the entire medical team understanding the patient's daily treatment goals was reflected positively on the length of stay in the intensive care unit.

[00:35:18]Now, I was a mother who inherited from Dr. Mazen Khairallah, which department?

[00:35:27]Quality in the adult intensive care unit at King Faisal Specialist Hospital in Riyadh.

[00:35:35]I tried to combine two tools and implemented a system called the Daily ICU Gold Sheet and World Round Checklist. I combined the checklist with the Gold Sheet, and with any change you want to implement, I faced significant challenges. I conducted an audit before implementing this system. It's rare to find a senior doctor. Imagine, a senior doctor at King Faisal Specialist Hospital—the number of those who actually checked everything, the things they should have said during patient rounds, was very small. Unfortunately, most doctors were missing many important things, including, for example, whether a catheterization is needed today. They might have thought about it, but there's no evidence. When we audited and reviewed their work, we found nothing to prove that the doctor had considered it.

[00:36:37]Dr. Magz, Dr. Nabil, or anyone else, didn't mention this to us. He was a model of how to bring 100% always, God bless him. This growth, this daily goal sheet in front of you, includes setting goals for the nervous system, the target pressure, the desired intracranial pressure for the patient, whether we will give the patient sedation leave today or not. If the patient has an ACP monitor, we state the target ACP pressure, the intracranial pressure we want it to be. If the patient has a PEST monitor to determine the depth of the lesion, we set the required reading. We also set, for example, the acceptable pH for the patient in the respiratory system, the target PIO2, the target PIO2, or target set. If you have a country-specific record, we used to write these things by hand in British ICUs. They use paper; they don't have electronic medical records. We used to write them daily, saying, "The target is..." 2. For example, if the oxygen saturation ( BO2) is between 50 and 60, it should be, for example, 55 millimercury daily. We write this on the large sheet you see in the ICU so that anyone who comes to see the patient knows that the consultant decided today that this is the acceptable oxygen level for this patient.

[00:38:11]We then move on to the cardiology department: what is the target map? What is the target CVP ( CVB) if you have one and are concerned about it? Or the ventricular oxygen saturation (VOS) and central oxygen saturation (COS)?

[00:38:24]What is the target VIS rate required for the renal department? It is very important to give guidance and instructions to the nurses and doctors working with us. We need to get the patient to have a urine output today, or if they are on dialysis, we need to achieve a negative load balance the next day. So we give our instructions to the nurse or the person supervising the dialysis procedure, and to tell them how much ultrafiltration to do for the patient. So, as you can see, some of these things are... Targets, but some of them were a kind of checklist. Did you think about the patient's code status? Because it's one of the things I need to think about every day. I mean, the patient came in, we gave him a chance the first day, we gave him another chance the second day, so he was definitely full code. But then, on the third day, the patient was severely dehydrated and on high doses of vasoconstrictors. We had to make this decision. It's true that when he first came in, I would have called him full code, but now it's time to think about this issue and discuss it with the family and the medical team. Have we achieved this hand hygiene thing? Hand hygiene, in its simplicity, if we adhere to it, we can eliminate the infections that occur inside hospitals: catheterization, central catheterization, polyurethane catheterization, skin infections— all of this is possible just through hand sanitization. It's reached the point where, in Britain, they've started putting cameras on every door of one of the units—I don't know if anyone heard this story from me—cameras. The camera is connected to a very large screen in the hospital director's office, so if he catches anyone not sanitizing their hands, they summon them to the director's office to reprimand them.

[00:40:30]He asks him why he entered the patient's room or the room where he was receiving treatment without sanitizing his hands.

[00:40:35]We've reached this point because MRSA and CdA ( cluster extinguishers, what do you call them?) were widespread at one point. Anyway, hand hygiene is very important, and it's one of the things you can consider a checklist we must pay attention to. Now we've reached the last part of our discussion today. Are there any studies on this topic? Are there things that help make clinical rounds safe and effective for patients, and are there any obstacles we must avoid? I found a Systematic Review from 2013, and they reviewed 43 studies on this topic. 35 of them, I call them active studies ( quantitative studies), meaning they contain numbers, and eight of them are qualitative studies ( qualitative studies), which don't focus as much on numbers but rather on comparisons, sometimes non-numerical.

[00:41:46]They came up with a long list of things that can act as facilitators and aids to... For clinical rounds, or sometimes they might be barriers, so he's telling you that, for example, clinical rounds, if they're at the patient's bedside, can be easier and more helpful because the round is more effective. But they can also have problems, as we'll see shortly. They came up with a list of things we can benefit from during clinical rounds in the ICU, and they showed us the strength of the evidence behind each one. For example, the multidisciplinary approach means that the round should always be with the doctor, not just the doctor alone, but a multidisciplinary approach involving multiple specialties. The doctor should be accompanied by a nurse, even better if they have a clinical pharmacist, and even better if they have a physical therapist. It's even more effective if they also have a nutritionist, in addition to the trainees. If these five specialties are present, we can create a multidisciplinary approach. Of course, a multidisciplinary approach can work with two, but they found that if all these specialties are present, the evidence is very strong, and this helps to make the round more effective. Clinical patient care is effective and contributes to patient safety. One of the things that strongly supports our rounds is that patient visits are conducted in a clear and organized manner. There's a specific time and place for each round, and we know who the team members are who will be making the rounds.

[00:43:47]Every team member must know their role during the rounds, and all team members should be encouraged to contribute. For example, after you've listened to the patient's history from your trainee, you should encourage the patient to share their concerns and worries. You should ask the clinical pharmacist if there are any drug interactions with the medications they're currently taking. This is because the issue is more complex than just one person being aware of all drug interactions, determining the correct dosage, and ensuring the dosage is appropriate for kidney function. For instance, a patient might enter the day with good kidney function, and you prescribe the correct dosage, but then two days later, they might experience kidney problems. Acute kidney injury might cause you to forget, while round the patient, that you need to adjust antibiotic dosages.

[00:44:45]Clinical pharmacy professionals are very helpful in this regard. There's a lot of encouragement, and strong evidence suggests that using helpful tools during rounds, like the checklist and daily goal sheet, is beneficial.

[00:45:00]You should try to avoid distractions and non-essential activities that could waste your time while rounding patients. For example, you can focus on teaching, as we discussed, but avoid arguing or debating with trainees about minute details that won't change the patient's condition. Anything that doesn't seem to affect the patient's condition, but rather focuses on improving it—a learning aspect that can be postponed until after the rounds are over—is enough to explain things like, " Dr. Mohammed, you asked me about using a certain antibiotic, so I'll explain it to you in detail." The purpose of all this is to avoid prolonging the rounds and, consequently, becoming exhausted. Fatigue and boredom can lead to decreased focus during patient rounds.

[00:46:00]We try as much as possible, and there is strong evidence to support this, to minimize distractions, such as someone interrupting us during patient rounds, because this disrupts our focus. We always try to discuss the daily treatment goals for each patient and ensure these are clearly documented in the patient's file.

[00:46:24]Now, one of the things being said is that Conduct is one of the things we care about, that all our work should be focused on the patient. So, it's said that making rounds next to patients' beds can help you focus on the patient, but what's the problem? It might make you susceptible to distractions, or someone might come from the right or the left asking about the other patient, thus interrupting you. They found that some might say, "No, you conducted a discussion about the patient away from the patient's bed. You sit in a meeting room with your team members, for example, especially if it's on a computer. It's very easy on the big screen, and you review the patient's file step by step and suggest a treatment plan." They found in some studies that this also helps improve the quality of patient rounds. In fact, I believe combining the two is best. I believe that I conduct online patient rounds, which are remote, to get an initial idea of ​​the patient's treatment plan, and then I go and confirm this if I'm at the patient's bedside.

[00:47:44]Okay, we're almost done, God willing. The most important thing is to distribute the medical team in a circle, not in a separate area, because a circle encourages communication and interaction among team members so they don't feel marginalized. And always encourage team members to talk. The Royal College of Physicians (RCP) also gave suggestions for what we should do while round patients.

[00:48:24]Things we talked about, this applies both inside and outside the ICU.

[00:48:30]This is a model I tried to apply to my artificial intelligence skills.

[00:48:34]I told him to create a system where all team members are integrated, so they all look at the screen in a semi- circle. Therefore, everyone can see each other and easily interact with the consultant overseeing the case. If they all walk in a line, there won't be any effective communication with the consultant. These are simple things, but believe it or not, they've been studied, and it was found that the way you stand with your team can help improve communication. Finally, I'll conclude with a list of things we should do and things we should avoid, summarizing this systemic review we've discussed. I believe we should do... A hybrid approach, if possible, is used when reviewing patient files. We start by reviewing the patient's file remotely in the meeting room on the computer, and then we go to the patient's bedside and continue the rounds.

[00:49:40]This is the best approach if it's feasible. I know it might not be possible in intensive care cases where the patient's file is in a very large file format, for example, and labels are written on it. Try to remove hierarchical barriers with team members. Encourage the team to communicate with you easily without the fear of being reprimanded or having a dismissive reaction from a consultant.

[00:50:11]Unfortunately, we see this from time to time, and we've seen it before. Always encourage the team to speak up because we are all human and may overlook some simple things. One of the things we did when I was the quality manager in Riyadh was to emphasize to the nurses the importance of asking the attending physician: " Do we need a central venous catheter today, or can we?" We removed it when we assigned this task to the nurses. It became impossible for any doctor to pass by a patient without making a decision regarding central catheterization. Thanks to God, we succeeded for two consecutive years when I was in Riyadh in the surgical intensive care unit. We had zero central catheterization infections, and we won the Patient Rounds Award in Saudi Arabia, praise be to God. This means having a structured round and a specific timeframe for patient rounds. The place and time are never suitable for a long round. This doesn't indicate depth of the round, but unfortunately, it might indicate a lack of focus. As we said, the longer the round, the more it leads to boredom, distraction, and exhaustion. We had a doctor from the old system in Britain, and we had to take a coffee break during our rounds with him. He would say, "Oh, it's time for a coffee break!"

[00:51:43]because it was clear that we had only three hours and still had n't finished. Some were repenting, others were starting to lean, so we had to take a break. Coffee breaks during power outages are something I don't think one should ever reach.

[00:51:54]This is supported by studies I have.

[00:51:59]We try to use checklists and daily gold sheets because they help make patient rounds more effective. We also consider special configurations: how to arrange the team around the patient's bed in a way that encourages interaction. These are things I haven't written down or included because I haven't found any evidence for them in the study, but I find them useful. I learned this from one of the great teachers I worked with in Britain: every day I start with a different bed number. So one day I started with bed number 1 and went to bed number 12, for example. The next day I started with bed number 12 and went in reverse.

[00:52:39]Why? Because if you start every day with number 1 and end with bed number 12, poor patient, you keep coming to bed number 12 every day, and you're already exhausted, your blood sugar is dropping, and you're starting to think you need to leave. Oh, your cup is finished! Yes, empty his cup. In this case, if you start with him the next day, you will have been fair in distributing your activity among the patients.

[00:53:10]The things we must avoid, contrary to what we said, are that firstly, having a background and a background is something you absolutely must avoid. Don't waste your time on non- essential activities while rounding patients. Be careful not to create a discouraging atmosphere for other team members who are participating in patient treatment. Also, don't have a clear method for rounding patients, don't use the tools we talked about, and don't have the medical team positioned in a straight line or one behind the other without any communication. I reached the supervising sensor, and with that, we have finished the rounds. I hope it was a safe round, and I am ready to answer any questions.

[00:53:59]Wonderful, Hassan! I've heard it from you several times. The lecture is amazing, each time with additions, variety, and clear objectives. Yes, it's easy. I arrived late, and the internet connection was poor.

[00:54:17]Or look, several times I've seen several people who experienced this. This last slide summarized all the things we need to address. I have some small comments, Hassan, and we'll see the comments of the young people in Syria. Of course, removing the hierarchical structure is great; it's the first thing. This requires a change in culture. So my question to the people in Syria is, how easy or difficult is it for the doctor to be on the same level as the nurse, the therapist, the respiratory therapist, and so on? What we saw on our tours was always at a higher level than the others, and everyone else followed the doctor, who was the leader, the one moving forward, the one who knew everything, and no one could make a move or do anything except by order of this doctor. No one could even discuss this with him. Now, Abdul Hasib, answer me on this point. The second point, Hassan, you mentioned, is improving communication. I was trying to find the Arabic translation for "close-up communication." If anyone has it, how did you translate it into Arabic?

[00:55:38]But the close loop is a reality, and as Hassan said, 85% of errors are a result of a lack of communication.

[00:55:46]Now they've taken it to a second level as well. For example, I tell him to give the patient 1/2 nitrate, and the patient tells me, " I gave the patient 1/2 nitrate." The doctor replies, "Excellent, you gave the patient 1/2 nitrate." There was a medical error in the ICU.

[00:56:00]The doctor gave 20 mg of it. His language is American, but he's Black, so their language is always fast, so she understood 2 mg and gave 2 mg. She said, "I gave 2 mg of it," and the patient was agitated. But the doctor didn't tell her, he didn't pay attention to what she said. This thing is that it creates a close loop. The source of the words I used is good. The intended meaning is understood, and the understood meaning is not intended. So we always try to do this process to make sure that what I said is understood correctly.

[00:56:50]Of course. In America, we have another problem, which is accents. We pay close attention to them because we have a multicultural system that doesn't exist in Syria. For example, an Indian accent is different from an Egyptian accent, and a Syrian accent is different from an Indian accent. You'll find everyone speaking differently, and the poor patients... these Americans, by the way, don't understand accents like we do. Anyone who speaks English with a different accent, we understand them. But for an American, it's very difficult to understand our accent. The third thing is, I'm mentioning the same points Hassan mentioned, with a small comment: including a checklist that is agreed upon by the team. I mean, we all know what's right, not that I have it in my head, but I want everyone on the team to have it. It might change from one person to another, from week to week, each person contributing, but it's a basic set of elements that are already in the ICU.

[00:57:45]I put it in a list. What Hassan mentioned is excellent. I combined the goals with the checklist and put them in. If you noticed, the system is better. I took all the systems in the body and put them in I set a goal for each task within these devices, and I included it in a checklist. This way, I achieved everything I could to cover regarding the patient's condition that day. What I want to say is that the goal sheet is dynamic. It's true that it's set in the morning, but the patient's condition can change throughout the day, and consequently, the goal can change as well. It's not like I just set it in the morning and forget about the patient's condition. Regarding multidisciplinary rounds, we asked about their importance. Perhaps the best thing is that they include several specialties together, specifying the time and place, clearly defining roles, and giving everyone the opportunity to participate. It seems the truth is, you'll conclude that you'll learn more from others than if you act like you're in charge and just going with the flow. This is how I truly developed and enriched myself with knowledge and the ability to improve patient outcomes. So let's open the discussion and ask questions. See if we have any questions in the chat first. I don't like to ask questions, but anyone who wants to can turn on their mic and ask any question. Or give us any comment. Please, Abdul Rahman.

[00:59:24]Peace be upon you. Thank you very much, Dr. Hassan, for the lecture. I really liked how you combined your hobby of aviation accidents and following aviation accidents with this topic. I have two questions. The first question is, approximately how long does a round take on average? And the second question is, is the round educational? I mean, do resident doctors learn during it, for example, or is it exclusively about what is happening with the patient?

[01:00:04]Thank you.

[01:00:06]Beautiful words. Thank you, brother Abdul Rahman. Actually, there is no specific time for the round, but it is common to say that if it exceeds two hours, it means that the focus starts to decrease, and it definitely does not exceed three hours. You will find that even on Twitter, some famous people in the ICU tell you to be careful not to exceed three hours in the round.

[01:00:32]Of course, you also [clears throat] depend on the team, its energy, and the situation you are in. I mean, I am saying it is true not to make the round too long, but brothers, surely you have experienced it with COVID. Many of you would enter the patients' rooms at 8 in the morning and not leave. The care was until 3:00 because, especially at the beginning of the pandemic, we didn't have the luxury of changing masks, and the number of masks was limited. So we had to go in and check one at a time. Of course, the number of patients was huge, so sometimes it took us six continuous hours just to make rounds. It was an exceptional situation, so I want to tell him that this situation depends on the patients and the dynamism of the team you have. But in general, I know that if you have a specific number, I would say two hours is the ideal time. But if it exceeds two hours, then perhaps that's where the issue arises. You need to think about something like taking a break to recharge your team. The second thing is about education. Try to pay attention to education. Some people, God bless them, have a great passion for education, but this passion shouldn't affect patient care or affect the rest of the team.

[01:01:40]So, I give something focused. For example, I notice something on the ventilator, like a Dicron sample, and I take the opportunity to bring it. The trainees were next to the ventilator. I explained the point to them for a minute or two, and then we left. If they still had questions, I told them I'd continue after the round because if you want to bring up the topic of dyschronization, it won't be finished in an hour. The other team members who aren't involved with the ventilator might feel excluded, and that's a mistake. You must always maintain the entire team's interest by ensuring they are fully engaged during the rounds with the patients. I don't know what you have, Hassan. Yes, hello Abdul Rahman. You actually raised a real problem in implementing multiplayer rounds, which is combining the training of the head nurse with the process of getting input or involving all team members. And if we're talking about the practical side, you'll have a problem with this.

[01:02:57]If you bring in the nurse, the anesthesiologist, the physical therapist, and the respiratory therapist, and tell them to stand with me for two or three hours, there are problems related to the roles of these members.

[01:03:07]For example... Respit Therapy only has two patients from your team with them, and they don't deal with the rest. There's another one besides them. There are several issues now. Most hospitals have implemented two different rounds.

[01:03:28]One is quick. Here at Sampford, we do something called an MDR IDT (Sorry, Inter-Assembly Team Round) or MDR Multi-Decimer Round. We adopted the A2F Bundle, which is part of the Emancipation Defeat. We added two letters to it, one of which is "home," but there's another one.

[01:04:00]Each Discline gives its input within this element. This happens after we finish the Teach Round. So, the Teach Round used to include, or currently includes, the nurse, the pharmacist, the doctor, and the president.

[01:04:21]After finishing the Teach Round, we do a quick round with each patient for two minutes, so that all the other team members get the gist and give their opinions. And it's possible to exceed the plan, of course, it's tiring and annoying sometimes, but the problems of having all the team members on long rounds are what made us resort to this. Regarding the round duration, I agree with you. I mean, I try for an hour and a half, really, depending on the number of patients, but when you have 10 or 12 patients, an hour and a half isn't enough. Yes, but you said something really good, Hassan, that every day I start with a different patient, sometimes one, sometimes six, sometimes twelve, to give everyone their due. And I do that too. In the morning, the first patient I see is the diabetic patient, the sixth one, because that's the one who needs to be treated. I don't want to leave them for last and then be surprised that they don't need potassium or something that required a quick intervention. So I do a quick round in the morning to see who's coming first. Before I arrive, I drink my coffee, and then I see them going to the ICU. I run to them there alone, and then the patient tells you, the patient tells you There's a problem here. You know which patient needs the most attention, right?

[01:05:43]So when we start a round, let's start with this patient. Please, no, you're supporting us, Dr. Abdul Rahman.

[01:05:55]Any other comments?

[01:05:58]Yes, Abdul, you have this problem.

[01:06:01]When I was with Faisal, they were all part of the team [clears throat]. There was nothing separate. Did you face a problem with this? And it's still just one round?

[01:06:11]No, it's still just one round, Mazen.

[01:06:14]But like I said, Mazen, I'm from Beaver in the hybrid system, and you're studying, Mazen. Our system is very good. You know, the details about the patient are already on the computer.

[01:06:26]I mean, you can even do three- quarters of the rounds from home. You still have the part about the secret check, which you do in a liquid form. So I try to combine the two so that when I come to the patient, I already have a plan for all the patients in the ICU, a preliminary plan. Yes, he wanted to say, yes, of course, he had to. We need to know, and what's the point? Thank you, our dear Dr. Hossam. Now, regarding the fear, the fear of the leader, I'm speaking personally. I mean, as soon as the resident starts their rounds with me, and even the nurses, I tell them, "Don't be afraid, sit with me, let's joke and laugh, and you talk more." I don't just talk, there are others who are terrifying. And you said about us in Syria, this thing needs to diminish a little, it needs to diminish a little. Okay, now, the problem of learning from the supervisor, I mean, in Syria, I do n't recommend it because, for example, in my hospital... uh, uh, I know what I'm saying, right? That's how you get carried away, Dr. Abdul Hassan. But, I mean, to fill the time, when a resident wants to learn from a doctor, from an orthopedic doctor, for example, in one of the government hospitals, he puts amphotericin with ceftriaxone in all the orthopedic surgeries he performs for all the patients, all their procedures. So, if the resident learns from the supervisor, we've entered a maze. I mean, I always ask for... He accompanies me on the tour, and I tell them, as soon as they enter, to turn off their phones. When I get a ringtone, one is to the tune of a certain singer, another to the tune of the liberation anthem, and the third and fourth, I tell them to turn it off. But should I, as the head of the round, turn off my phone?

[01:08:25]Why am I the one who tells others to turn it off and not me? I mean, am I special? My personal conviction is that we shouldn't bring our phones with us, even if we put them on silent. If you have them in your pocket, they'll distract you. That's my personal conviction. Yes, the plane crash, Doctor. In our country, I think, only the passengers were affected, but the captain and crew... I mean, nothing is happening to them, neither the captain nor the assistant. We don't even learn from our mistakes. That's the problem.

[01:08:54]Yes, these are my comments. Does anyone want to comment?

[01:09:00]Thank you very much. I'll take the blame. And truly, you learn the best you'll find with the supervisors. This guy, the one with the ceftriaxone and ampicillin, maybe he has other qualifications. He benefits from the trainee, he learns from him, but he doesn't learn the wrong thing. He sees, and I swear, I pass by the doctor. Another one tells him, "I swear." We want to give Amsin Straxson that one to fix. I tell him, "No, my son, this combination is wrong," and he learns that it's correct. That doctor does it, so he starts doing a kind of evaluation, even for the sciences. And this is a fundamental thing. We were talking about it yesterday, that the evaluation of trainers by trainees is one of the important things to know, especially the supervisors of education, the specialties board, who the good trainers are and who the bad trainers are, and what feedback is being given to the trainers so that we don't allow incompetent trainers to train our doctors, the doctors of the future. Am I being too strict, Doctor? I mean, until this period passes, Amen. Go ahead. I mean, change takes years. No change can happen in two years, by the way. You know that when a protocol or evidence best is released, it takes 10 years to be implemented. It doesn't change that it comes out in the study today. You find colleges that take years. I'm talking about developed countries, so what about us? What about a whole system, really? It's not wrong for things to change, and in my opinion, it will take generations for things to change. But they won't change without the "pump," which is these lectures and what we're doing and working together in our meetings in Syria. Every word spoken is a "pump" for future change. God knows how it might happen. I was saying, "I want something from you, from me.

[01:11:09]Where's your phone?

[01:11:12]Why isn't it working?"

[01:11:20]First, the sound was cutting out. "Mazen, did you take something from us or from you?" Then, "Yes, he has it.

[01:11:29]You hear me?" "Yes, I'm saying it's not just me. I can't hear." "No, no, no."

[01:11:33][Laughter] "The internet in America is bad. He'll say I'm talking to them. We should get them a line for Syriatel or MTN. He's always talking about us. I see, by God, and God knows best, the effects of the war on them are evident." I wanted to say something, Dr. Abdul Hussein, about the issue of mobile phones. I jokingly tell the trainees that anyone who takes out their phone, for example, or I see them playing games... On his phone, he wants to invite us all for coffee after the rounds. Some of us are joking, of course. "Sure, you're exempt, sir." What does that mean? Wow, what a generous people we are! You know how it is. This creates a kind of joke, but at the same time, I immediately convey to him that we are indeed in a critical time for patient care.

[01:12:26]Mazen, it seems we need to connect you to a Syriatel or MTN line. The electricity will be cut off for us, right? [Laughs] Go ahead. You were talking about mobile phones. So, I'll say that the first thing here is that the EMR is now available on mobile phones, so all orders are placed via mobile. You access the electronic medical record (EMR), the medical file. Yes, that's the first point. But the second thing is that you use the resources available on the internet, including the EMR.

[01:12:59]Yes, you use it to answer anything you need during your rounds. Therefore, honestly, I mean, our emphasis to every resident is to try to find the information as quickly as possible. Knowledge has become so vast that it's impossible to encompass everything. Something, and therefore it's best that we use it to develop our skills in accessing information. You know, there's something called Ambiance Script. It's something you put in place to attend the discussion with the patient. It's like I logged in from the computer again, let it look at it [clears throat]. So you put it in place. Actually, a couple of days ago I looked at some studies that greatly improve the on-screen interaction or interview with the patient, as it intervenes in the way you ask the patient questions. We might not have much of this in the ICU because, thank God, all our patients are on propofol and dexamethasone, but it's essential to integrate technology into patient care to improve the overall experience. For example, a very simple example is if you're talking to a patient who has a sick bone and you forget to ask about the dosage of the sick bone, then this tool will come in and tell you if you can ask him about something, and he'll ask a question. So yes, the second thing is protocols. It puts the algorithm in place and gives it to you. Kamal tells you what to do: one, two, three. In my opinion, the phone is fine if it's used for calls and messages unrelated to the patient.

[01:14:50]This is definitely distracting and should be prohibited. However, it should be used to improve the level of service provided to the patient. Of course, this requires internet access, and it must be available within the ICU. This is essential. God willing, in the next phase, it will develop and improve further in Syria.

[01:15:19]Any other input?

[01:15:25]Okay, no comments. Thank you all.

[01:15:29]Hassan, may God give you strength.

[01:15:33]Your range was excellent and truly wonderful.

[01:15:36]Yes, thank you, thank you. May God bless you. I see that your Arabic has improved a lot, my brother. May God reward you. Dr. Reem, we're talking. We're listening to Dr. Hassan's Arabic. Did he bring it from outer space or what? No, look, no, excuse me, Dr. Hassan, your speech is wonderful, no doubt about it, but the writing, yes, that's what's being talked about. Stop here, may God be pleased with you. May God keep you safe. Of course, I'm here to attend, but Hassan studied medicine, all of it in Yeah.