All together now: Impact of a regionalization and bedside rounding initiative on the efficiency and inclusiveness of clinical rounds

In June 2013, as part of a general medical service care redesign initiative, the general medical teams were regionalized to specific inpatient units. The goal was to have teams admit patients predominantly to the team’s designated unit and to have all patients on a unit be cared for by the unit’s assigned team as often as possible, with an 85% goal for both. Toward those ends, the admitting structure was changed from a traditional 4-day call cycle to daily admitting for all teams, based on each unit’s bed availability.¹¹

Teams were also expected to conduct rounds with nurses, and a system for facilitating these rounds was established. As physician and nurse care teams were now geographically co-located, it became possible for residents and nurses to check a rounding sheet for the planned patient rounding order, which had been set by the resident and nurse-in-charge before rounds. No more than about 5 minutes was needed to prepare each day’s order. The rounding sheet prioritized sick patients, newly admitted patients, and planned morning discharges, but patients were also always grouped by nurse. For example, the physician team rounded with the first nurse on all 3 of a nurse’s patients, and then proceeded to the next group of 3 patients with the next nurse, until all patients were seen.

Teams were encouraged to conduct patient- and family-centered rounds exclusively at bedside, except when bedside rounding was thought to be detrimental to a patient (eg, one with delirium). After an intern’s bedside presentation, which included a brief summary and details about overnight events and vital signs, the concerns of the patient, family, and nurse were shared, a focused physical examination performed, relevant data (eg, laboratory test results and imaging studies) reviewed, and the day’s plan formulated. The entire team, including the attending, was expected to have read new patients’ admission notes before rounds. Bedside rounds could thus be focused more on patient assessment and patient/family engagement and less on data transfer.

Several actions were taken to facilitate these changes. Residents, attendings, nurses, and other interdisciplinary team members participated in a series of focus groups and conferences to define workflows and share best practices for patient- and family-centered bedside rounds. Tips on bedside rounding were included in a general medicine rotation guidebook made available to residents and attendings. At the beginning of each post-intervention general medicine rotation, attendings and residents attended brief orientation sessions to review the new daily schedule, have interdisciplinary huddles, and share expectations for patient- and family-centered bedside rounds. On the general medicine units, new medical directors were hired to partner with existing nursing directors to support adoption of the workflows. Last, an interdisciplinary leadership team was formed to support the care redesign efforts. This team started meeting every 2 weeks.

Study Design

We used a pre–post analysis to study the effects of care redesign. Analysis was performed at the same time of year for 2 consecutive years to control for the stage of training and experience of the housestaff. TMA was performed by trained medical students using computer tablets linked to a customized Microsoft Access database form (Redmond, Washington). The form and the database were designed with specific buttons that, when pressed, recorded the time of particular events, such as the coming and going of each participant, the location of rounds, and the beginning and the end of rounding encounters with a patient. One research assistant using an Access entry form was able to dynamically track all events in real time, as they occurred. We collected data on 4 teams at baseline and 5 teams after the intervention. Each of the 4 baseline teams was followed for 4 consecutive weekdays—16 rounds total, April-June 2013—to capture the 4-day call cycle. Each of the 5 post-intervention teams was followed for 5 consecutive weekdays—25 rounds total, April–June 2014—to capture the 5-day cycle. (Because of technical difficulties, data from 1 rounding session were not captured.) For inclusion in the statistical analyses, TMA captured 166 on-service patients before the intervention and 304 afterward. Off-service patients, those with an attending other than the team attending, were excluded because their rounds were conducted separately.

We examined 2 primary outcomes, the proportion of time each clinical team member was present on rounds and the proportion of bedside rounding time. Secondary outcomes were round duration, rounding time per patient, and total non-patient time per rounding session (total rounding time minus total patient time).

Statistical Analysis

TMA data were organized in an Access database and analyzed with SAS Version 9.3 (SAS Institute, Cary, North Carolina). We analyzed the data by round session as well as by patient.