Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation
BACKGROUND: Previous research has shown that interdisciplinary ward rounds have the potential to improve team functioning and patient outcomes.
DESIGN: A convergent parallel multimethod approach to evaluate a hospital interdisciplinary ward round intervention and ward restructure.
SETTING: An acute medical unit in a large tertiary care hospital in regional Australia.
PARTICIPANTS: Thirty-two clinicians and inpatients aged 15 years and above, with acute episode of care, discharged during the year prior and the year of the intervention.
INTERVENTION: A daily structured interdisciplinary bedside round combined with a ward restructure.
MEASUREMENTS: Qualitative measures included contextual factors and measures of change and experiences of clinicians. Quantitative measures included length of stay (LOS), monthly “calls for clinical review,’” and cost of care delivery.
RESULTS: Clinicians reported improved teamwork, communication, and understanding between and within the clinical professions, and between clinicians and patients, after the intervention implementation. There was no statistically significant difference between the intervention and control wards in the change in LOS over time (Wald χ2 = 1.05; degrees of freedom [df] = 1; P = .31), but a statistically significant interaction for cost of stay, with a drop in cost over time, was observed in the intervention group, and an increase was observed in the control wards (Wald χ2 = 6.34; df = 1; P = .012). The medical wards and control wards differed significantly in how the number of monthly “calls for clinical review” changed from prestructured interdisciplinary bedside round (SIBR) to during SIBR (F (1,44) = 12.18; P = .001).
CONCLUSIONS: Multimethod evaluations are necessary to provide insight into the contextual factors that contribute to a successful intervention and improved clinical outcomes.
© 2018 Society of Hospital Medicine
Evidence has emerged over the last decade of the importance of the front line patient care team in improving quality and safety of patient care.1-3 Improving collaboration and workflow is thought to increase reliability of care delivery.1 One promising method to improve collaboration is the interdisciplinary ward round (IDR), whereby medical, nursing, and allied health staff attend ward rounds together. IDRs have been shown to reduce the average cost and length of hospital stay,4,5 although a recent systematic review found inconsistent improvements across studies.6 Using the term “interdisciplinary,” however, does not necessarily imply the inclusion of all disciplines necessary for patient care. The challenge of conducting interdisciplinary rounds is considerable in today’s busy clinical environment: health professionals who are spread across multiple locations within the hospital, and who have competing hospital responsibilities and priorities, must come together at the same time and for a set period each day. A survey with respondents from Australia, the United States, and Canada found that only 65% of rounds labelled “interdisciplinary” included a physician.7
While IDRs are not new, structured IDRs involve the purposeful inclusion of all disciplinary groups relevant to a patient’s care, alongside a checklist tool to aid comprehensive but concise daily assessment of progress and treatment planning. Novel, structured IDR interventions have been tested recently in various settings, resulting in improved teamwork, hospital performance, and patient outcomes in the US, including the Structured Interdisciplinary Bedside Round (SIBR) model.8-12
The aim of this study was to assess the impact of the new structure and the associated practice changes on interprofessional working and a set of key patient and hospital outcome measures. As part of the intervention, the hospital established an Acute Medical Unit (AMU) based on the Accountable Care Unit model.13
METHODS
Description of the Intervention
The AMU brought together 2 existing medical wards, a general medical ward and a 48-hour turnaround Medical Assessment Unit (MAU), into 1 geographical location with 26 beds. Prior to the merger, the MAU and general medical ward had separate and distinct cultures and workflows. The MAU was staffed with experienced nurses; nurses worked within a patient allocation model, the workload was shared, and relationships were collegial. In contrast, the medical ward was more typical of the remainder of the hospital: nurses had a heavy workload, managed a large group of longer-term complex patients, and they used a team-based nursing model of care in which senior nurses supervised junior staff. It was decided that because of the seniority of the MAU staff, they should be in charge of the combined AMU, and the patient allocation model of care would be used to facilitate SIBR.
Consultants, junior doctors, nurses, and allied health professionals (including a pharmacist, physiotherapist, occupational therapist, and social worker) were geographically aligned to the new ward, allowing them to participate as a team in daily structured ward rounds. Rounds are scheduled at the same time each day to enable family participation. The ward round is coordinated by a registrar or intern, with input from patient, family, nursing staff, pharmacy, allied health, and other doctors (intern, registrar, and consultant) based on the unit. The patient load is distributed between 2 rounds: 1 scheduled for 10
Data Collection Strategy
The study was set in an AMU in a large tertiary care hospital in regional Australia and used a convergent parallel multimethod approach14 to evaluate the implementation and effect of SIBR in the AMU. The study population consisted of 32 clinicians employed at the study hospital: (1) the leadership team involved in the development and implementation of the intervention and (2) members of clinical staff who were part of the AMU team.
