Standardized attending rounds to improve the patient experience: A pragmatic cluster randomized controlled trial

RESULTS

We observed 241 AR involving 1855 patient rounding encounters in the intervention arm and 264 AR involving 1903 patient rounding encounters in the control arm (response rates shown in Figure 1).

Intervention teams adopted each of the recommended AR practices at significantly higher rates compared to control teams, with the largest difference occurring for AR occurring at the bedside (52.9% vs. 5.4%; Figure 2).

Teams in the intervention arm demonstrated highest adherence to the pre-rounds huddle (78.1%) and lowest adherence to whiteboard use (29.9%).

Patient Satisfaction and Clinical Outcomes

Five hundred ninety-five patients were allocated to the intervention arm and 605 were allocated to the control arm (Figure 1). Mean age, gender, race, marital status, primary language, and insurance provider did not differ between intervention and control arms (Table 1).

One hundred forty-six (24.5%) and 141 (23.3%) patients completed surveys in the intervention and control arms, respectively. Patients who completed surveys in each arm were younger and more likely to have commercial insurance (Appendix).

Patients in the intervention arm reported significantly higher satisfaction with AR and felt more cared for by their medicine team (Table 2).

Patient-perceived quality of communication and shared decision-making did not differ between arms.

Actual and Perceived Duration of Attending Rounds

The intervention shortened the total duration of AR by 8 minutes on average (143 vs. 151 minutes, P = 0.052) and the time spent per patient by 4 minutes on average (19 vs. 23 minutes, P < 0.001). Despite this, trainees in the intervention arm perceived AR to last longer (mean estimated time: 167 min vs. 152 min, P < 0.001).

Healthcare Provider Outcomes

We observed 79 attending physicians and trainees in the intervention arm and 78 in the control arm, with survey response rates shown in Figure 1. Attending physicians in the intervention and the control arms reported high levels of satisfaction with the quality of AR (Table 2). Attending physicians in the intervention arm were more likely to report an appropriate level of patient involvement and nurse involvement.

Although trainees in the intervention and control arms reported high levels of satisfaction with the quality of AR, trainees in the intervention arm reported lower satisfaction with AR compared with control arm trainees (Table 2). Trainees in the intervention arm reported that AR involved less autonomy, efficiency, and teaching. Trainees in the intervention arm also scored patient involvement more towards the “far too much” end of the scale compared with “about right” in the control arm. However, trainees in the intervention arm perceived nurse involvement closer to “about right,” as opposed to “far too little” in the control arm.

CONCLUSION/DISCUSSION

Training internal medicine teams to adhere to 5 recommended AR practices increased patient satisfaction with AR and the perception that patients were more cared for by their medicine team. Despite the intervention potentially shortening the duration of AR, attending physicians and trainees perceived AR to last longer, and trainee satisfaction with AR decreased.

Teams in the intervention arm adhered to all recommended rounding practices at higher rates than the control teams. Although intervention teams rounded at the bedside 53% of the time, they were encouraged to bedside round only on patients who desired to participate in rounds, were not altered, and for whom the clinical discussion was not too sensitive to occur at the bedside. Of the recommended rounding behaviors, the lowest adherence was seen with whiteboard use.

A major component of the intervention was to move the clinical presentation to the patient’s bedside. Most patients prefer being included in rounds and partaking in trainee education.^{12-19,28,29,31-33} Patients may also perceive that more time is spent with them during bedside case presentations,^14,28 and exposure to providers conferring on their care may enhance patient confidence in the care being delivered.¹² Although a recent study of patient-centered bedside rounding on a nonteaching service did not result in increased patient satisfaction,²⁴ teaching services may offer more opportunities for improvement in care coordination and communication.⁴

Other aspects of the intervention may have contributed to increased patient satisfaction with AR. The pre-rounds huddle may have helped teams prioritize which patients required more time or would benefit most from bedside rounds. The involvement of nurses in AR may have bolstered communication and team dynamics, enhancing the patient’s perception of interprofessional collaboration. Real-time order entry might have led to more efficient implementation of the care plan, and whiteboard use may have helped to keep patients abreast of the care plan.

Patients in the intervention arm felt more cared for by their medicine teams but did not report improvements in communication or in shared decision-making. Prior work highlights that limited patient engagement, activation, and shared decision-making may occur during AR.^24,34 Patient-physician communication during AR is challenged by time pressures and competing priorities, including the “need” for trainees to demonstrate their medical knowledge and clinical skills. Efforts that encourage bedside rounding should include communication training with respect to patient engagement and shared decision-making.

Attending physicians reported positive attitudes toward bedside rounding, consistent with prior studies.^13,21,31 However, trainees in the intervention arm expressed decreased satisfaction with AR, estimating that AR took longer and reporting too much patient involvement. Prior studies reflect similar bedside-rounding concerns, including perceived workflow inefficiencies, infringement on teaching opportunities, and time constraints.^12,20,35 Trainees are under intense time pressures to complete their work, attend educational conferences, and leave the hospital to attend afternoon clinic or to comply with duty-hour restrictions. Trainees value succinctness,^12,35,36 so the perception that intervention AR lasted longer likely contributed to trainee dissatisfaction.

Reduced trainee satisfaction with intervention AR may have also stemmed from the perception of decreased autonomy and less teaching, both valued by trainees.^20,35,36 The intervention itself reduced trainee autonomy because usual practice at our hospital involves residents deciding where and how to round. Attending physician presence at the bedside during rounds may have further infringed on trainee autonomy if the patient looked to the attending for answers, or if the attending was seen as the AR leader. Attending physicians may mitigate the risk of compromising trainee autonomy by allowing the trainee to speak first, ensuring the trainee is positioned closer to, and at eye level with, the patient, and redirecting patient questions to the trainee as appropriate. Optimizing trainee experience with bedside AR requires preparation and training of attending physicians, who may feel inadequately prepared to lead bedside rounds and conduct bedside teaching.³⁷ Faculty must learn how to preserve team efficiency, create a safe, nonpunitive bedside environment that fosters the trainee-patient relationship, and ensure rounds remain educational.^36,38,39

The intervention reduced the average time spent on AR and time spent per patient. Studies examining the relationship between bedside rounding and duration of rounds have yielded mixed results: some have demonstrated no effect of bedside rounds on rounding time,^28,40 while others report longer rounding times.³⁷ The pre-rounds huddle and real-time order writing may have enhanced workflow efficiency.

Our study has several limitations. These results reflect the experience of a single large academic medical center and may not be generalizable to other settings. Although overall patient response to the survey was low and may not be representative of the entire patient population, response rates in the intervention and control arms were equivalent. Non-English speaking patients may have preferences that were not reflected in our survey results, and we did not otherwise quantify individual reasons for survey noncompletion. The presence of auditors on AR may have introduced observer bias. There may have been crossover effect; however, observed prevalence of individual practices remained low in the control arm. The 1.5-hour workshop may have inadequately equipped trainees with the complex skills required to lead and participate in bedside rounding, and more training, experience, and feedback may have yielded different results. For instance, residents with more exposure to bedside rounding express greater appreciation of its role in education and patient care.²⁰ While adherence to some of the recommended practices remained low, we did not employ a full range of change-management techniques. Instead, we opted for a “low intensity” intervention (eg, single workshop, handouts) that relied on voluntary adoption by medicine teams and that we hoped other institutions could reproduce. Finally, we did not assess the relative impact of individual rounding behaviors on the measured outcomes.

In conclusion, training medicine teams to adhere to a standardized bedside AR model increased patient satisfaction with rounds. Concomitant trainee dissatisfaction may require further experience and training of attending physicians and trainees to ensure successful adoption.

Acknowledgements