The impact of bedside interdisciplinary rounds on length of stay and complications

The care of hospitalized patients requires practitioners from multiple disciplines to assess and communicate the patient’s status in a dynamic manner during hospitalization. Although optimal teamwork is needed for patient care to be delivered reliably and efficiently, care within hospitals is typically delivered in a fragmented manner.¹ A bedside model for daily interdisciplinary rounds (IDR) has been proposed as a method to provide a structured process and engage all team members in a patient-centered, system-of-care delivery.² Specific advantages of convening rounds in the presence of the patient include the ability to directly assess care (eg, presence of a potentially unnecessary urinary catheter), patient engagement in key aspects of their care and disposition, and an increased opportunity for team members to develop a shared understanding of the patient’s views and needs.

Implementing dramatic changes to the workflow of multiple disciplines will require rigorous evidence to support a concerted effort from leadership and buy-in from stakeholders at the front line of patient care. Despite the urgency for evidence, there has been little investigation of this strategy. A systematic review³ identified 30 studies published between 1998 and 2013 addressing interdisciplinary interventions on medical wards, none of which examined a bedside IDR model. In a study performed after the period assessed by the systematic review, Stein et al⁴ described the restructuring of a medical ward as an accountable care unit (ACU), which included a bedside model for rounds by the interdisciplinary team. The change was associated with decreased mortality and length of stay (LOS), although the study did not isolate the impact of rounds or use a concurrent control group and presented aggregate rather than patient-level outcomes. The lack of convincing data may be a reason bedside rounds are not widely employed by hospitals. To provide high-quality evidence, we performed a large, prospective controlled trial comparing a structured bedside model (mobile interdisciplinary care rounds [MICRO]) with standard rounds.

This study took place at the Mount Sinai Hospital, which is a 1171-bed tertiary care academic medical center in New York City, New York. A nonteaching unit offered the ability to use a prospective controlled design. Patients were assigned to the north and the south wings of the unit in a quasi-randomized manner, rather than based on diagnosis or acuity. We transformed IDR to a bedside model on the north side of the unit (MICRO group), while the south side of the unit continued using standard conference room-based IDR (control group). The north and south sides of the unit contain 17 and 14 beds, respectively. During the study period, nurses and hospitalists cared for patients on both sides of the study unit, although on any given day were assigned only patients on 1 side of the unit. The unit uses a clinical microsystem model, which has been defined as “a group of clinicians and staff working together with a shared clinical purpose to provide care for a population of patients,” and has a defined set of characteristics associated with high performance.^5,6 Our microsystem model has incorporated features as described by Stein’s ACU model,⁴ including co-leadership by a hospitalist and a nurse manager, geographic assignment of patients to teams, and unit-level data reports. One hospitalist is assigned geographically to each area of the unit in a 2- to 4-week rotation. Coverage of the unit does not include house staff; patients are primarily assigned to hospitalists working with nurse practitioners. Patients were enrolled prospectively during their initial IDR by a research coordinator. Patient-level data and outcomes were collected prospectively by a research coordinator who attended IDR on the intervention and the control sides of the study unit daily.