Rounding's not just for clinicians

Hospitalists work to make rounds more patient-centered.

About 5 years ago, Northwestern Memorial Hospital in Chicago launched a successful interdisciplinary rounding program that involved nurses, hospitalists, and care coordinators meeting regularly to collaborate and discuss patient care plans. Seeking to build on that success, the clinicians decided to move their daily confabs from the conference room to the bedside—but the results weren't quite what they expected.

Photo by Thinkstock
Photo by Thinkstock

“We anticipated that bedside rounding would improve patient involvement in decision making and increase satisfaction with their care,” says Kevin J. O’Leary, MD, FACP, chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “However, we were surprised to find it didn't make a significant impact on patient perceptions.”

For the pilot study, Dr. O’Leary and his team implemented bedside rounding on 2 hospitalist service units at Northwestern Memorial, relying on input from the hospital's patient and family advisory council to determine the optimal format and timing for rounds.

After analyzing patient interviews and satisfaction survey data, they found no significant differences in patients' perceptions of shared decision-making or satisfaction with care in the intervention units compared with 2 control units that continued with usual care.

The results, published in the Dec. 15, 2015, BMJ Quality and Safety, suggest that while interdisciplinary rounds improve teamwork, bringing them to the bedside does not necessarily make care more patient-centered, said Dr. O’Leary. However, it can still be part of a broader patient engagement strategy.

“Rounds should really be part of a set of interventions,” he said. “Improving patient-centeredness may be less about rounds and more about improving patients' knowledge and comprehension of their care.”

Forming the bedside team

One challenge when implementing bedside rounding is figuring out how to engage patients without overwhelming them. That could mean limiting the bedside team to a physician and nurse; however, there may also be advantages to having more team members present, such as social workers, case managers, physical therapists, and pharmacists.

“We were concerned about overwhelming patients with our full team at the bedside, which sometimes includes a dozen people,” said Luci Leykum, MD, FACP, professor in the division of hospital medicine at the University of Texas Health Science Center at San Antonio. “But many patients have told us it's reassuring to realize that a whole team of professionals knows what's going on with their care.”

The hospital has procedures in place to make sure patients aren't caught off guard by a large rounding group, she said. Patients are prepped by the bedside nurse before meeting the team for the first time, and the team leader always asks the patient if it's OK to enter before bringing everyone in.

Franciscan Healthcare in LaCrosse, Wis., part of Mayo Clinic Health System, tried using a large team at the bedside but eventually narrowed it to include only a hospitalist and the nurse caring for that patient, said Umesh Sharma, MD, FACP, chair of hospital medicine. The smaller group seems to put patients at ease and makes it more likely that they will participate in the discussion, he said.

The team spends about 10 minutes with patients and families going over the care plan, said Dr. Sharma, who led a study, published in the Journal of Interprofessional Care in 2014, showing that the team-based rounding model improved workflow and communication between nurses and physicians.

Although he has not directly studied the impact on patient engagement, the hospital has seen its patient satisfaction scores increase since bedside rounding was implemented.

“The bottom line is that we changed a process that was very physician-centered to one that is more about the patient,” he said. “It's created a very positive collaborative relationship among nurses and physicians, and that seems to make patients feel more confident about their care.”

Getting the patient involved

Ideally, bedside rounds would leave ample time for explanations, questions, and answers, but that doesn't always happen in reality. Teams spent an average of only 8 minutes at the bedside in a study at Penn State Hershey Medical Center, published in the July 2014 Journal of General Internal Medicine.

However, even short sessions can be beneficial if the interaction is patient-centered, said the study's lead author, Jed D. Gonzalo, MD, MSc, assistant professor of medicine at Penn State College of Medicine in Hershey, Pa. For some patients, the value might be in simply staying informed.

Patients feel reassured when they see the care plan being put into action, he added. For example, they might see team members tracking down test results, making calls to specialists, or discussing details related to their discharge.

“Patients can find satisfaction and assurance in seeing the nursing staff talk to and collaborate with the physicians,” he said. “The very fact that we're there fosters a feeling that there are providers who care for them and are making efforts to provide the best care.”

The way information is delivered can also make a difference, he said. For example, one of his colleagues carries a stool with him on rounds so he can sit next to the patient at eye level.

“That sets the agenda for the encounter and gives the perception that we are here for you at this time,” he said. “These are things that might seem simple but that enhance communication.”

Similarly, Dr. Sharma counsels clinicians to use nontechnical language and allow patients to interrupt with questions. He encourages them to ask patients before leaving the room what they understood from the discussion to make sure there was no miscommunication.

Some patients may not want to contribute to the discussion but still appreciate being informed about what to look for or when they should contact the team, said Dr. Leykum. The most important thing is to keep the patient's perspective in mind, something that may not have been explicitly considered in the past.

“We often talk a lot about the diagnosis and treatment plan,” she said. “But what we really need to consider are the concrete things that patients may be worried about.”

Patient-centeredness starts before the team even enters the room, she said. In a recent study, Dr. Leykum and her colleagues shadowed 11 inpatient medicine teams on rounds to assess the association between “sensemaking”—how clinicians made sense of what was happening with their patients in real time—and patient outcomes.

Rounding based on patient-driven needs, as opposed to a predetermined order, was significantly associated with shorter length of stay and lower complication rates, found the study in the December 2015 Journal of General Internal Medicine. For example, a team working in a patient-centered manner might decide to start with a patient whose condition had worsened overnight or who was scheduled to be discharged later that day, rather than proceed unit by unit.

Building on those findings, the hospital recently implemented a collaborative care initiative designed to actively involve patients and families during rounds.

“We've restructured the whole conversation on rounds so that it's not a medical conversation per se but an interprofessional dialogue with patients and families at the bedside,” she said. “We want it to be more of a roundtable discussion than a presentation.”

Another key element of the model is using a whiteboard to outline the care plan and the responsibilities of individual team members, she said. The board provides an easy reference for patients and families and keeps the care team on the same page.

“The patient sees the plan of care evolving and has a level of comfort with the team,” said Dr. Leykum. “It also helps patients see what's being planned in terms of discharge, what it will look like, and what they can expect to happen.”

To really help patients understand their care, hospitals should also focus on what happens outside of rounds and improve patient access to information at all times, through patient portals or other methods, according to Dr. O’Leary. “During rounds we present a lot of complicated information in a short time but we don't give patients any memory aides to help them retain and process that information after we leave,” he said.