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

We found that the MICRO intervention significantly decreased LOS compared to the control group for patients transferred to the study unit. This analysis was exploratory and the finding was unexpected. Patients were transferred to the study unit from units of higher acuity, and were more likely to have Medicaid or no insurance and be discharged to facilities rather than home, suggesting that these patients had substantial disposition challenges. It is plausible that this is the population for which bedside IDRs may have the greatest impact. This was a secondary analysis, however, and should be considered as hypothesis-generating for future investigations.

Although the impact on outcomes of bedside IDRs is uncertain, potential benefits and practical barriers have been examined. Gonzalo et al.¹¹ surveyed inpatient physicians and nurses at a hospital employing bedside IDRs and found that the benefits ranked the highest were communication, coordination, and teamwork, and the lowest-ranked benefits were related to efficiency and outcomes. The 6 greatest barriers concerned the time required to complete bedside IDR. These results indicate that the time investiture by staff may be a barrier to widespread adoption. More modest changes, such as increasing the structure of standard conference room rounds, may improve care, although the data are mixed. O’Leary et al.¹² assessed the value of a structured approach in a conference room setting, which primarily entailed implementing a checklist for newly admitted patients, and found no difference in LOS. Follow-up studies by these investigators found mixed results on the ability of structured IDR to decrease the incidence of adverse events.^13,14

The results of our AHRQ survey of patient safety culture found that several important aspects of teamwork and safety were perceived as improved by the intervention, including the “overall grade on patient safety.” Other studies have similarly shown increases in teamwork and safety ratings through redesign of IDR. O’Leary et al.¹² surveyed residents and nurses on a unit that implemented a structured, conference room-based IDR and found that providers on the intervention unit rated the teamwork climate higher than providers on the control unit. Our finding that hospitalists and nurses gave higher ratings for IDR being “efficient” and “a good use of my time” on the postintervention survey than the pre-intervention survey suggests that initial concerns about the additional time commitment may be offset by gains in overall efficiency and in development of an environment of enhanced communication, teamwork, and safety.

This study has several limitations. First, the trial may have been underpowered to find small differences between the groups. The trends for decreased LOS and clinical deterioration in the MICRO group may suggest that bedside IDR can provide a small but clinically significant benefit that would be statistically significant only in a larger trial. Second, patients were not randomized to the 2 groups. The impact is diminished, however, because the routine hospital process for assigning patients to the 2 areas in which the groups were located is random and based solely on bed availability. Third, nurses and hospitalists caring for patients in the control group likely experienced improved communication practices from the unit-wide TeamStepps education and from participating in the MICRO protocol when caring for patients on the intervention side of the unit. Fourth, we did not collect data on the effectiveness of communication and are unable to assess the fidelity with which the structured protocol was followed or whether interprofessional communication was fostered or hindered. Lastly, the study was implemented on a nonteaching unit at a single academic medical center. The protocol and the results may not be generalizable to other hospitals or units that include house staff.

In conclusion, transforming IDR from a conference room model to a bedside model did not reduce overall LOS or clinical deterioration on a unit using features of an ACU structure. Although several beneficial effects were noted, including a reduction in LOS for patients transferred to the study unit and higher ratings of the patient safety climate and efficiency of IDR, implementing bedside IDR in this setting has marginal benefit. Future studies should assess whether a comprehensive transformation of the inpatient model of care, including patient-centered bedside IDR, geographic cohorting of teams, and co-leadership, improves outcomes compared to models without these features.

Disclosures

This trial was funded by Medline’s Prevention Above All Discoveries Grant Program. The authors report no financial conflicts of interest.