Part of the Essential DNS Toolbox: Effective Daily Clinical Rounds

The director of nursing services (DNS) has many issues to prioritize each day, such as resident falls, staffing, and grievances. Unfortunately, the DNS may be tempted to relegate clinical rounds to “later,” considering them a low priority due to time constraints, which can prove to be a costly mistake. Daily clinical rounds are an essential part of the DNS’s toolbox. They can serve as a preemptive strike to address impending issues and may even forestall problems before they occur. Clinical rounds can help the DNS identify resident safety or quality-of-life concerns and set the priorities for the day. This article reviews the purpose of daily clinical rounds, how to prepare for them, and areas to focus on during rounds to ensure they are as effective as possible.

The Purpose of Daily Clinical Rounds

As a nurse leader, conducting daily clinical rounds is an opportunity for the DNS to connect with staff and residents, gain valuable information, reinforce consistency of standards, and model clinical leadership behaviors and skills. They are also an excellent tool for survey preparedness and a great way to ensure that safety and quality are maintained. Ideally, the DNS will schedule clinical rounds at the beginning and end of the day. The second round should also include follow-up on any items of concern noted earlier.

Preparing to Conduct Rounds

It is impossible to look at every aspect of care and services in a single clinical round. Instead, we recommend two approaches. The first focuses on clinical areas where the facility has struggled, such as concerns cited during the survey or where the DNS knows from monthly mock survey reports that the facility is falling behind. Examples of these problematic areas are falls, pressure ulcers, or weight loss. The second approach concentrates on one clinical system each day of the week, such as falls or pressure injuries. The clinical round may involve all residents or a sample of residents, depending on expectations and facility policy.

When conducting rounds with survey readiness in mind, select a mock survey sample, composed of 20% of the resident census (but no more than 35 residents) who would likely be included in the annual survey sample. It can be done monthly or more frequently, depending on the readiness of the facility. Information from these sources will inform the selection of the resident sample each month:

a. Triggers from the MDS 3.0 Facility and Resident Level Quality Measure Report
b. CMS 802-Matrix for Providers
c. Facility reported incidents (FRIs)
d. New admissions within the last 30 days
e. Vulnerable residents, such as a resident who has Alzheimer’s, depends on staff for care, or is quadriplegic
f. Identified concerns included in the previous survey sample with the same trigger still present, other state agency involved with a resident’s case, or other situations or dynamics that pose a concern or risk
g. Clinical conditions: pressure ulcers, dialysis, hospice, low-risk bowel and bladder conditions, ADL decline, unplanned hospitalizations, change of condition, use of high-risk medications, level II screening, clinically complex care needs
h. Other: smoker, elopement, resident representative or resident has expressed concerns with the facility’s services

The monthly mock sample of residents is useful to conduct rounds, ensuring that specific needs identified in the care plan and compliance with high-risk services are met, such as infection control practices. Be sure to check resident satisfaction with care and services. By doing this, issues of potential noncompliance or problematic patterns can be addressed timely during rounds.

The DNS can also use rounds to praise and reinforce care that meets expectations of compliance and provides clinical leadership to ensure the staff are meeting the needs of the residents. This reinforcement is equally as important as addressing problematic patterns timely during rounds.

The DNS can also delegate clinical rounds to other nurse managers as an additional check. However, the person must know how to conduct them and be fully engaged.

Areas of Focus

Clinical rounds can be daunting, especially for those new to the DNS role. Many times, it is difficult to know what to focus on when there are so many areas from which to choose. Here are suggestions to help guide the DNS in conducting clinical rounds:

Area	Items to Review
Resident dignity	Is privacy being provided during care? Do urinary catheters have dignity bag covers? Are residents well groomed? Are resident choices included in the plan of care?
Falls	Are preventive devices in place? Are there any apparent tripping hazards? Are staff using gait belts? Are staff using lifts properly?
Pressure injuries	Are preventive devices in place? Are residents being turned and repositioned per the plan of care? Are dressings dry and intact, and current per physician orders?
Respiratory	Is oxygen being delivered per correct flow? Is tubing being changed per policy and off the floor? Are concentrators clean? Are humidifiers full? Is filter being changed per policy? Do any residents appear to be in respiratory distress? Are tracheostomy sites clean? Is there an extra inner cannula visible?
Pain and mood	Do residents appear comfortable? Are residents positioned correctly? Do residents appear to have their psychosocial needs met?
Urinary/Incontinency	Do residents appear to be dry? Are catheter bags hung correctly? Is urine flowing in tubing of catheter bags? Does urine appear normal for the resident? Is there an odor around a resident with a catheter or incontinence? Are residents being toileted according to the plan of care?
Alternative nutrition/Intravenous therapy	Is the resident receiving nutrition/IV per physician order? Is the tube feeding/IV pump and pole clean? Is the dressing at the tube site clean? Are tubing, syringe, and bag being changed per facility policy? Is stoma/IV site free from infection?
Infection control	Are staff washing hands per facility policy? Is linen being handled correctly? Are transmission-based precautions (TBPs) being followed? Is personal protective equipment used properly? Are isolation precautions being followed?
Environment and safety	Are hallways clutter free? Are call bells within resident reach? Are there any odors? Does any broken equipment need to be removed? Are medication carts clean? Are medication carts and rooms locked when unoccupied? Are oxygen tanks stored correctly? Is the nursing station clean? Are computer screens in sleep mode when unoccupied? Are resident charts closed when not being reviewed?
Staff	Do staff appear engaged? Do staff have the resources they need to do their job today? Are staff concerns being followed up? Does any process appear not to be working well? Are there any staff members who can receive praise for a job well done? Do any procedures need reinforcement?
Miscellaneous	Are splints and devices in place per physician order? Do residents have their glasses on per care plan? Do residents appear happy? Are staff interacting with residents and each other respectfully?

In closing, although daily clinical rounds can be time consuming, be sure to prioritize them. Daily clinical rounds lead to better processes, more content residents and staff, and improved quality of care.

For further assistance, see AAPACN’s Daily Clinical Rounds Tool.

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