Abstract
Interdisciplinary rounding has been shown to improve patient safety and provider engagement. Many models for interdisciplinary rounding have been proposed but few focus on preserving bedside medical education. The authors changed the interdisciplinary bedside rounding model to accommodate more time for medical education. The objective was to assess perceptions of communication, care coordination, and teamwork surrounding this change. Resident and attending physicians and unit-based nursing staff completed an anonymous online survey prior to and following the rounding intervention. Length of stay on medical units also was monitored prior to and following the rounding intervention. Following the intervention, there were perceived improvements in interdisciplinary communication, care coordination, and teamwork, and there were no significant changes in length of stay.
Integration of interdisciplinary rounding into patient care has been shown to improve patient safety and provider engagement.1,2 Likewise, introduction of a nursing safety checklist into interdisciplinary rounds has improved patient safety indicators. 3 Although many interdisciplinary rounding models exist, preserving bedside medical education for interdisciplinary rounds has not been a primary emphasis.1-6 Some published rounding models exclude bedside teaching to facilitate the interdisciplinary structure. 7 Interdisciplinary rounds are largely supported in the medical literature to improve communication and patient care, but concerns regarding impact on medical education have been raised. 8
Although providing excellent patient care is a common goal, there are several competing demands between hospital administration, nursing staff, and clinician educators at academic medical institutions. Delivery of efficient, effective, and safe patient care must be balanced with educating medical trainees. O’Mahony et al showed that multidisciplinary rounding could improve patient safety and decrease length of stay while enhancing resident medical education, 7 but studies incorporating medical education into bedside interdisciplinary rounds are lacking.
The research team sought to provide high-quality patient care, improve communication between team members, and improve interdisciplinary bedside rounding to allow for increased time and flexibility for medical education. This evaluation aimed to explore the impact on interdisciplinary communication, care coordination, teamwork, and length of stay.
Methods
Setting and Study Design
This pilot study was conducted at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, a 957-bed academic medical center. Prior to implementation of this pilot, hospital medical units conducted Structured Interdisciplinary Bedside Rounding (SIBR), which has been described in the literature. 9 SIBR rounds were conducted with the medical teams, nursing staff, and case managers on geographic units each weekday morning. Two medical units, one telemetry unit (40 beds) and one med-surg unit (36 beds), were targeted in this pilot study. Both pilot units served as the geographic unit for 2 internal medicine resident teams. Resident teams consisted of 1 to 3 medical students, 1 to 2 interns, 1 senior resident, and 1 attending physician caring for 14 patients, with up to 3 of those patients located off the geographic unit. Nursing staff included the patient’s bedside nurse and a nurse facilitator (charge nurse, clinical nurse specialist, or trained staff nurse). The nurse facilitator coordinated SIBR and had no clinical responsibilities during rounds. SIBR was scripted for each patient encounter, limiting the amount of time spent in a patient’s room.
Although medical and nursing staff were satisfied with the study institution’s nursing safety checklist (Figure 1), declining emphasis on bedside teaching and brief patient interactions led to medical staff dissatisfaction and a sense of decreased quality of medical education. In an attempt to solve this problem, SIBR was moved to the early afternoon to allow for traditional morning rounds, which was not well received by either nursing staff or physicians. As a result, SIBR was suspended until further consensus of rounding structure and goals could be developed.
Nursing safety checklist completed by all bedside nurses on each patient during IPR.
Development and Implementation of the Intervention
Meetings involving key nursing, physician, and hospital stakeholders identified a need to allow for greater flexibility for medical education while providing high-quality patient care and fostering interprofessional collaboration. Two separate processes were developed: Care Management Rounds (CMR) and Interdisciplinary Patient Rounds (IPR). CMR and IPR occur each day, excluding weekends and holidays. Unit leadership, hospitalists, and residency program representatives designed the new rounding model, which focused on integrating teaching into interdisciplinary rounds, completing a nursing safety checklist, and setting discharge milestones. Prior to launching CMR and IPR on the pilot units, education about the new rounding model, including objectives and logistics, was provided to resident and attending physicians and nursing staff on each unit.
CMR occurred early in the day and was designed to efficiently enlighten and involve other disciplines in the care plan, identify actions needed to move patient care forward, and inform that day’s IPR schedule. On the geographic unit, medical residents, nurse facilitators, case managers, and unit physical therapists met each morning to participate in CMR, which lasted approximately 10 minutes per resident team. The medical resident was encouraged to use Situation-Background-Assessment-Recommendation communication, 10 and a discharge planning checklist (Figure 2) identified needs for the interdisciplinary team.
Care management rounds discussion points and discharge checklist.
IPR began midmorning, with the goal to complete rounds within 90 minutes. The purpose of IPR was to foster patient-centered medical decision making and increase communication of care goals between team members caring for the patient. This communication allowed the interdisciplinary team to identify barriers to reaching the patient’s care goals, to apply standards of quality and safety to achieve care milestones and discharge, and to formulate and implement a plan of care that involves the patient and an interdisciplinary team. Case managers did not participate in IPR routinely given their presence during CMR and their recognized time constraints with clinical demands.
Rounds began with each resident team on opposite ends of the units. The nurse facilitator for each team ensured a patient’s bedside nurse was available for rounds prior to IPR for a particular patient. Occurring inside the patient’s room or in the hallway, depending on team preference, the bedside nurse completed the nursing safety checklist aloud (Figure 1), followed by the medical team presentation. The attending physician identified discharge milestones for each patient. If a patient’s bedside nurse was unavailable for rounds, the medical team continued with rounds and the nursing facilitator reported back to the bedside nurse with information discussed. This process was continued until rounds were complete for all patients on the geographic unit (Figure 3).
Interdisciplinary patient rounds (IPR) workflow. Progression through IPR coordinated by nurse facilitator.
Instrument and Data Analysis
An online Research Electronic Data Capture survey was developed based on surveys previously published in the literature.4,11 To establish face validity, survey content was reviewed by nursing staff and internal medicine physicians prior to initial surveying. Participation in the survey was anonymous, optional, and participation implied consent. Survey questions are listed in Table 1. Nursing staff on general medicine units and the attending and resident physicians who worked on the geographic-based units in the 3 months prior to and following the launch of the new IPR model were surveyed.
Comparison of Pre- and Postintervention Nursing and Physician Responses.
P < .05 value used for statistical significance using the Kruskal-Wallis test and SAS for analysis.
Survey responses were dichotomized from a 5-point Likert-type scale. Strongly disagree, disagree, and neither agree nor disagree were dichotomized as unfavorable, and strongly agree and agree were dichotomized as favorable. Pre- and postintervention responses for physicians and nurses were compared using the Kruskal-Wallis test.
The institutional goal of conducting SIBR was to reduce length of stay. The research team assessed length of stay as a primary outcome measure prior to and following the rounding intervention. Length of stay was generated by unit from data from the electronic medical record. The team used an XmR control chart to assess for special cause variation in length of stay prior to and following the intervention on the 2 pilot units. Control charts were created using Microsoft Excel (Microsoft Corporation, Redmond, Washington).
The study was approved by the Thomas Jefferson University Institutional Review Board and found to be Human Subjects Research Determination Exempt (IRB #19E.581).
Results
The overall response rate was 58% (n = 99) for the preintervention survey and 74% (n = 102) for the postintervention survey. Comparison of pre- and postintervention nursing and physician responses can be seen in its entirety in Table 1, with the following results highlighted.
Both physicians (P < .05) and nurses (P < .001) agree there was more clarity in the patient’s daily care plan post intervention. Likewise, both groups had an increased perception that physicians make an active effort to discuss care plans with the bedside nurse, that nursing input is encouraged on rounds, and that physicians and nurses work together as a well-coordinated team.
Compared with preintervention surveys, physicians were more likely to agree that nurse–physician rounding will improve patient safety (P < .05), that communication between nurses and physicians is efficient (P < .05) and effective (P < .05), and that discharges occur promptly following the intervention (P < .05). Nursing perceptions in these areas did not change significantly following the intervention.
Length of stay analysis for the 2 medical units involved in this pilot can be seen in Figure 4. No special cause variation was detected following the intervention.
Length of stay analysis of the 2 pilot units (36 med-surg beds, 40 telemetry beds) utilizing an XmR control chart with labels noting changes in interdisciplinary rounding format. No special cause variation was detected for either unit.
Discussion
Implementation of the new IPR format demonstrated a statistically significant improvement in most survey responses regarding perceptions of communication, care coordination, and teamwork. This indicates a potential for improvement in provider satisfaction and interdisciplinary communication and teamwork. Comparing pre- and postintervention survey questions, there was a significant difference in more of the physician responses than nursing responses, perhaps because of increased time allowed for bedside medical education.
There is wide variation in physician rounding preferences and bedside teaching practices. 12 A rounding structure that increased time available for medical team presentations and direct patient care, while allowing flexibility for attending physician rounding and bedside teaching styles, was unsurprisingly popular among physicians. The improved physician perceptions of all aspects of communication surveyed after the change in rounding structure suggested that IPR was effective in teaching trainees the importance of interdisciplinary communication and teamwork. Giving the attending physician autonomy to partake in bedside medical education within the constraints of the IPR framework allowed for continued medical education for trainees without a decrease in interdisciplinary communication and quality patient care.
For physicians and nurses, implementation of IPR did not demonstrate a significant impact on communication with nurses after rounds, alerting physicians in a timely manner, and reducing calls or texts. Despite improved communication in many aspects, there was no significant improvement in perceived support from clinicians. However, preintervention practice also included an interdisciplinary rounding structure designed specifically to target these measures, so it is encouraging that a redesign to support medical education did not have an adverse effect on these elements of teamwork.
Nurse survey responses differed from physician responses in a few key areas. In contrast to physicians, nurses did not perceive a statistically significant increase in nursing input being positively received, the quality of care on the unit, efficient or effective communication, and care coordination. Results show nurses do not perceive difficulty in raising concerns about patient care issues, suggesting a high degree of psychological safety on the 2 medical units. The increased time allotted for IPR to accommodate medical education could possibly affect nursing perceptions regarding efficient communication.
Nursing staff have competing demands during morning rounds, and higher patient ratios and acuity can lead to decreased nursing interaction on rounds. 13 A dedicated nursing facilitator free of clinical responsibilities was paramount to the success of IPR and is something others should consider if adopting this model. This rounding allowed patients to participate in their care plans, respected attending physician preference in rounding style, and allowed for bedside teaching and observation.
Length of stay analysis showed no special cause variation related to the interdisciplinary rounding process, as multiple changes in rounding time and structure did not increase variation in length of stay. Although IPR did not significantly decrease length of stay, the research team hopes to see a sustained decrease in length of stay following implementation of the IPR model similar to other published descriptions of rounding models. 7 Additionally, allowing more time for medical education during IPR did not increase length of stay significantly.
Limitations
This project had several limitations. It was carried out at one institution on only 2 nursing units, thus limiting generalizability of study findings. Survey responses were not matched given physician rotations prior to and following the intervention, and there was an insufficient sample size to isolate resident and attending physician responses for subanalysis. Additionally, there were no measurements prior to the initial institutional SIBR implementation, so provider baseline perceptions are not known. IPR was suspended for a period of time during a holiday block with high seasonal censuses, which may or may not have increased length of stay during the study period.
Future Studies
Future directions of study include assessing resident and attending perceptions of the educational value of IPR and assessing ongoing relationships between length of stay, discharge time, readmissions, and patient satisfaction. Conducting time-motion studies on components of IPR will be helpful to quantify time spent on medical education, direct patient care, and interdisciplinary communication.
Conclusions
Implementation of a new interdisciplinary rounding structure demonstrated improvements in perceptions of interdisciplinary communication, care coordination, and teamwork. Implementation of longer interdisciplinary bedside rounding focusing on medical education did not have a negative impact on unit length of stay or any measure of perceived teamwork and communication effectiveness.
Footnotes
Acknowledgements
We acknowledge the assistance of Agapi Somwaru, PhD, and from leadership of the medical units, including John R. Stewart, MD, Luis Taboada, MD, Gabrielle Mangan, RN, and Kristine Meagher, RN.
Authors’ Note
Preliminary results of this study were presented at the Society of Hospital Medicine National Meeting, National Harbor, Maryland, in March 2019.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
