All together now: Impact of a regionalization and bedside rounding initiative on the efficiency and inclusiveness of clinical rounds
BACKGROUND
Attending rounds at academic medical centers are often disconnected from patients and team members who are not physicians. Regionalization of care teams may facilitate bedside rounding and more frequent interactions among doctors, nurses, and patients.
OBJECTIVE
We used time–motion analysis to investigate how regionalization of medical teams and encouragement of bedside rounds affect participants on rounds and rounding time.
DESIGN AND SETTING
We used pre–post analysis to study the effects of care redesign on teams’ daily rounds on a general medicine service at an academic medical center.
PARTICIPANTS
Four general medical teams were evaluated before the intervention and 5 teams afterward.
INTERVENTIONS
General medical teams were regionalized to specific units, the admitting structure was changed to facilitate regionalization, and teams were encouraged to round bedside.
MEASUREMENTS
Primary outcomes included proportion of time each team member was present on rounds and proportion of bedside rounding time. Secondary outcomes included round duration and non-patient time during rounds.
RESULTS
Proportion of time the nurse was present on rounds increased from 24.1% to 67.8% (P < 0.001), and proportion of total bedside rounding time increased from 39.9% to 55.8% (P < 0.001). Mean total rounding time decreased from 3.0 hours to 2.4 hours (P = 0.01), despite a higher patient census.
CONCLUSIONS
Creating regionalized care teams and encouraging interdisciplinary bedside rounds increased the proportion of bedside rounding time and the presence of nurses on rounds while decreasing total rounding time. Journal of Hospital Medicine 2017;12:150-156. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Attending rounds at academic medical centers are often disconnected from patients and non-physician care team members. Time spent bedside is consistently less than one third of total rounding time, with observational studies reporting a range of 9% to 33% over the past several decades.1-8 Rounds are often conducted outside patient rooms, denying patients, families, and nurses the opportunity to participate and offer valuable insights. Lack of bedside rounds thus limits patient and family engagement, patient input into the care plan, teaching of the physical examination, and communication and collaboration with nurses. In one study, physicians and nurses on rounds engaged in interprofessional communication in only 12% of patient cases.1 Studies have found interdisciplinary bedside rounds have several benefits, including subjectively improved communication and teamwork between physicians and nurses; increased patient satisfaction, including feeling more cared for by the medical team; and decreased length of stay and costs of care.2-10
However, there are many barriers to conducting interdisciplinary bedside rounds at large academic medical centers. Patients cared for by a single medical team are often geographically dispersed to several nursing units, and nurses are unable to predict when physicians will round on their patients. This situation limits nursing involvement on rounds and keeps doctors and nurses isolated from each other.2 Regionalization of care teams reduces this fragmentation by facilitating more interaction among doctors, patients, families, and nursing staff.
There are few data on how regionalized patients and interdisciplinary bedside rounds affect rounding time and the nature of rounds. This information is needed to understand how these structural changes mediate their effects, whether other steps are required to optimize outcomes, and how to maximize efficiency. We used time-motion analysis (TMA) to investigate how regionalization of medical teams, encouragement of bedside rounding, and systematic inclusion of nurses on ward rounds affect amount of time spent with patients, nursing presence on rounds, and total rounding time.
METHODS
Setting
This prospective interventional study, approved by the Institutional Review Board of Partners HealthCare, was conducted on the general medical wards at Brigham and Women’s Hospital, an academic 793-bed tertiary-care center in Boston, Massachusetts. Housestaff teams consist of 1 attending, 1 resident, and 2 interns with or without a medical student. Before June 20, 2013, daily rounds on medical inpatients were conducted largely on the patient unit but outside patient rooms. After completing most of a rounding discussion outside a patient’s room, the team might walk in to examine or speak with the patient. A typical medical team had patients dispersed over 7 medical units on average, and over as many as 13. As nurses were unit based, they did not consistently participate in rounds.
