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

Inclusion Criteria

All patients admitted to the medicine service on the study unit were eligible. Patients were greater than 18 years and admitted for an acute medical condition. Patients admitted to another unit and later transferred to the study unit were enrolled at the time of transfer. Patients could be included more than once if hospitalized on the study unit on more than 1 occasion. Most patients were covered by hospitalists, although patients covered by private physicians were included. Patients from other departments, including family medicine, are uncommonly admitted to the unit and were excluded. Patients were also excluded if they were admitted and discharged over the same weekend, because the MICRO rounds occur during weekdays and there was no opportunity to offer the intervention on Saturdays and Sundays.

MICRO Intervention

Interdisciplinary rounds occurred daily at 10:00 am for the control group and at 10:30 am for the MICRO group, and were attended by the hospitalist caring for the majority of patients on the unit, staff nurses, and the unit medical director, nurse manager, social worker, and case manager. Rounds on the control unit focused on the plan of care and disposition but did not follow any set structure and were typically 25 to 30 minutes in duration.

The MICRO rounds occurred at the bedside and followed a structured script (Appendix 1) that was designed to limit discussion of each patient to 3 minutes or less, and included speaking roles for the hospitalist, nurse, and social worker. For private physicians, the nurse practitioner assigned to the patient performed the role of the hospitalist. Rounds were expected to be approximately 50 minutes in duration. Patients were further engaged by asking for their main goal for the day. A patient safety checklist was reviewed. Initially, this task was performed by the nurse manager, who did not verbalize the items unless a deficiency was noted. After 6 months’ experience, this responsibility was given to the staff nurse, who reviewed the checklist verbally as part of the bedside script. Patients were seen daily, including those being discharged later that same day.

Staff and Clinician Education

We developed and implemented a curriculum based on a modified version of the Agency for Healthcare Research and Quality’s TeamStepps^® program to ensure that all team members were provided with the basic principles of communication within the healthcare setting. The curriculum consisted of interactive didactics on essential elements of teamwork, including team structure, communication, situation monitoring, and mutual support, as well as the purpose and structure of the MICRO model. The curriculum was delivered to nurses at 3 monthly staff meetings on the study unit and to hospitalists during 3 hospital medicine grand rounds over a 3-month period. Nurses and physicians providing care on both geographic areas of the study unit received the education program because no group of practitioners was designated to only 1 geographic area.

Outcomes

Primary and Secondary Outcomes

The primary outcomes were clinical deterioration (CD) and length of stay. Clinical deterioration was a composite outcome defined a priori as death; escalation of care (ie, transfer to an intensive care unit, intermediate care unit, or teaching unit); or a hospital-acquired complication (ie, venous thromboembolism, fall, stage III-IV pressure ulcer, catheter-associated urinary tract infection, central-line associated bloodstream infection, or Clostridium difficile-associated diarrhea). The LOS was calculated as the mean LOS with outliers excluded (outliers defined as having a LOS 100 days or longer or 2.5 or more standard deviations from the expected LOS).

Process metrics on IDR, such as the duration of rounds, attendance by members of the interdisciplinary team, the percentage of patients discussed, or the effectiveness of communication, were not collected. We assessed patient satisfaction based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Patient Safety Culture Survey

To assess the impact on the perceptions of patient safety, we administered the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture to all staff and clinicians working on both sides of the study unit immediately before and 12 months after implementation of the MICRO model. Results are reported for the AHRQ dimensions that were most relevant to the MICRO intervention: “teamwork within units,” “overall perceptions of safety,” “communication,” “openness,” “overall patient safety grade,” and “handoffs and transitions.” The survey represents pre- and post-comparison. All nurses and hospitalists on both the MICRO and control sides of the study unit had received the TeamStepps curriculum and participated in MICRO rounds by the time of the postintervention survey. We added 3 questions specifically assessing the perception of the efficiency and effectiveness of IDR. Postintervention respondents reflected on their overall impression of IDR, which included their experiences on both sides of the unit, because no group of nurses or hospitalists was exposed only to the MICRO side or the control side of the unit. Responses to survey questions were recorded on a 5-point Likert scale (from “strongly disagree” to “strongly agree” for opinion questions; and “never,” rarely,” sometimes,” “most of the time,” and “always” for frequency questions) and given a score from 1 to 5. The question asking for an overall grade for patient safety was scored from 1 to 5 points corresponding to letter grade choices F, D, C, B, A.