Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis.

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.

Impact of Bedside Rounding on Attending Teaching Evaluations.

OBJECTIVE: To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics. METHODS: Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites. RESULTS: A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain. CONCLUSIONS: Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

Teleconferencing for Virtual Visiting Professors and Virtual Grand Rounds.

SUMMARY: The 2020 global pandemic related to the coronavirus has led to unprecedented interruptions in typical patient care and resident education. Teleconferencing software was deployed by many institutions to comply with quarantine and social-distancing regulations. To supplement the loss of clinical experience for trainees, the authors implemented a novel virtual-educational programming using virtual visiting professors and virtual grand rounds. The authors describe the two different formats and advantages such as access to multiple speakers on diverse, innovative topics and decreased financial burdens to the host program. However, the authors do acknowledge some disadvantages from lack of face-to-face social interaction/networking and the need to consider time-zone differences. Both new programs were embraced by trainees at the authors' own institution and residents/medical students across the United States and Canada and around the world. The authors believe teleconferencing should be permanently incorporated into future educational opportunities for plastic surgeons, as it provides easy access to high-quality information.

Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study.

BACKGROUND: We examined whether a context and process-sensitive 'intelligent' checklist increases compliance with best practice compared with a paper checklist during intensive care ward rounds. METHODS: We conducted a single-centre prospective before-and-after mixed-method trial in a 35 bed medical and surgical ICU. Daily ICU ward rounds were observed during two periods of 8 weeks. We compared paper checklists (control) with a dynamic (digital) clinical checklist (DCC, intervention). The primary outcome was compliance with best clinical practice, measured as the percentages of checked items and unchecked critical items. Secondary outcomes included ICU stay and the usability of digital checklists. Data are presented as median (interquartile range). RESULTS: Clinical characteristics and severity of critical illness were similar during both control and intervention periods of study. A total of 36 clinicians visited 197 patients during 352 ward rounds using the paper checklist, compared with 211 patients during 366 ward rounds using the DCC. Per ICU round, a median of 100% of items (94.4-100.0) were completed by DCC, compared with 75.1% (66.7-86.4) by paper checklist (P=0.03). No critical items remained unchecked by the DCC, compared with 15.4% (8.3-27.3) by the paper checklist (P=0.01). The DCC was associated with reduced ICU stay (1 day [1-3]), compared with the paper checklist (2 days [1-4]; P=0.05). Usability of the DCC was judged by clinicians to require further improvement. CONCLUSIONS: A digital checklist improved compliance with best clinical practice, compared with a paper checklist, during ward rounds on a mixed ICU. CLINICAL TRIAL REGISTRATION: NCT03599856.

Experiential learning of overnight home care by medical trainees for professional development: an exploratory study.

OBJECTIVES: In an ageing society, community-based medical education in a home care setting needs to be developed. Drawing on Kolb's experiential learning theory, this study aimed to explore the learning processes in overnight home care by medical trainees in terms of their understanding of terminally ill patients and their conceptualization of themselves as future physicians. METHODS: An overnight home care program in which a trainee had to take care of terminally ill patients on his/her own under the supervision of a healthcare team was conducted. Nineteen trainees, including eight medical students and 11 residents, participated in this study. Text data of reflective reports written after the overnight care were collected and thematically analyzed. RESULTS: The trainees' learning experiences in the program were categorized into four stages: predeparture, concrete experience, reflective observation and abstract conceptualization. Although they had mixed feelings, including anxiety, fear and expectations, at the predeparture stage, they could be actively involved in providing medical care and daily life support and in taking care of dying patients at the patients' homes overnight. By reflecting on their experiences, they gained a sense of achievement and identified the aspects upon which they should improve as future physicians. Subsequently, based on their reflective observation, they conceptualized their approaches to home care and the roles/responsibilities of physicians as healers, which led to professional identity formation. CONCLUSIONS: Overnight home care by medical trainees has the potential as an educational strategy to promote their realistic understanding of home care and facilitate professional identity formation.

Analysis of patient safety messages delivered and received during clinical rounds.

BACKGROUND: Multiple modalities are available to introduce patient safety training to healthcare professionals. In internal medicine, clinical rounds have always played an important role in education; however, the patient safety content taught at the point of care is not well studied. We studied, both quantitatively and qualitatively, the number and nature of patient safety messages delivered by attending physicians to determine what is taught at the point of care and how well this is recognised and recalled by attending physicians, residents and medical students. METHODS: This prospective mixed methods study was conducted on the medicine teaching service. Clinical rounds were audio-recorded. Immediately after rounds, attending physicians, residents and students completed a short survey card identifying the number and type of educational messages they immediately recalled teaching or hearing. Independent t-test was used to compare differences in the number of messages delivered by attendings and recalled by trainees. One-way analysis of variance was used to compare differences in messages delivered by attending physicians compared with trainees. Recordings were transcribed and analysed qualitatively for patient safety content. RESULTS: Trainees recalled more educational messages than attendings recalled teaching in all educational domains. Safety messages comprised 17.5% of educational messages. The average number of patient safety messages recalled per session was 1.08 per attending physicians, 1.84 per resident and 2.50 per student. Residents recalled 56.4% of safety messages delivered; students recalled 76.7% of safety messages. CONCLUSION: Patient safety is a focus of teaching during clinical rounds and provides meaningful opportunities to train students and residents to practice safe patient care.

Call Bell Usage: Tracking the Effect of Hourly Staff Rounding.

Hourly rounding by nursing staff helps to proactively manage patient needs and minimize the number of unscheduled calls from patients. The focus of this study was to determine if an increased emphasis on hourly rounding had an effect on call bell usage on an oncology unit. Patient call bell usage requests, such as asking for water or repositioning, and the total number of all alarms, such as bed exit alarms and lavatory assist alarms, decreased. Subsequent patient satisfaction surveys showed an increase in patient perception of how quickly help was received.

Pre-registration nursing students' perceptions and experience of intentional rounding: A cross-sectional study.

This paper examines pre-registration nursing students' perceptions of the practice of intentional rounding and perceived benefits for nurses and patients. Intentional rounding was developed to ensure nursing staff regularly check on patients to ensure that all care needs are met. It has been linked to a reduction in falls and call bell use, and an increase in patient safety. No previous studies have examined pre-registration nursing students' role in the practice of intentional rounding during clinical placements nor the perceptions of rounding practices, important from a future workforce perspective. A cross-sectional multisite study was undertaken, and pre-registration nursing students completed the Nurses' Perceptions of Patient Rounding Scale between August 2017- June 2018, distributed using online education platforms and email. Strobe reporting guidelines were used to report findings. Participants perceived positive benefits in intentional rounding for nurses and patients. Mixed opinions surrounded the sufficiency of education received around the intervention. Previous nursing experience was linked to opposing opinions of intentional rounding, depending on education levels. Participants had a positive perception of intentional rounding practices overall. Education surrounding intentional rounding needs to be consistent, and introduced before students are expected to actively participate in the practice of rounding on clinical placement.

Mixed methods quality evaluation of structured interprofessional medical ward rounds.

BACKGROUND: Standardised structure and content of interdisciplinary medical ward rounds can promote patient safety and patient-centred teamwork. AIMS: To evaluate interdisciplinary ward rounds using a Structured Interdisciplinary Bedside Rounding (SIBR) intervention. METHODS: The study involved multi-method, repeat measures with a non-equivalent control group. Non-participant observations were collected at: 1 and 6 months, on an intervention ward that introduced SIBR; and a control ward that continued traditional rounds. Focus group and survey data were also collected on the intervention ward. Participants were clinicians (medicine, nursing and allied health) working in two general medicine wards at a tertiary hospital in Melbourne, Australia. RESULTS: Seventy-eight patient rounds were observed at Time 1, and 239 at Time 2. The SIBR ward rounds had all clinician disciplines represented, whereas allied health and nurses were present for less than 20% of non-SIBR rounds. Interdisciplinary participation and frequency of desired clinician behaviours increased, and variability in duration of time per patient decreased, on the SIBR rounds. Longitudinal data reflected decreased performance of some SIBR behaviours in the intervention ward, while some desired behaviours increased in the control ward. Qualitative survey and focus group data indicated many positive views, but fit with broader ward routines impacted SIBR implementation. CONCLUSIONS: The overall recommendation by staff was that SIBR should continue. The results provide insights into the adoption of SIBR behaviours and illustrated diffusion of behaviours across wards. Highlighting successes and identifying barriers can help meet challenges for ongoing improvement.

Standardizing Multidisciplinary Rounds: Creation of an Efficient and Effective Process to Care for the Critically Ill.

OBJECTIVE: To describe the impact of a standardized rounding process on rounding time and multidisciplinary member attendance. BACKGROUND: Rounding efficiency and effectiveness are often compromised by lack of standardization of important elements including start time and location, the attendance of multidisciplinary representatives, patient presentation highlights, and physician workflow. In 2017, the study authors noted inefficiencies and process failures in multidisciplinary rounds within our ICU. METHODS: We conducted a retrospective review of rounding data before and after the implementation of a simplified and streamlined rounding template for ICU nurses and measures to standardize rounding processes and attendance. RESULTS: Rounding time was decreased by 25% in postimplementation phase. Additionally, attendance of respiratory therapists, clinical dietitians, and case managers improved. CONCLUSIONS: We suggest the piloting of these strategies in other ICUs that experience similar inefficiencies and process failures during multidisciplinary rounds.

Improving physicians' surgical ward round competence through simulation-based training.

OBJECTIVE: Ward rounds are an essential part of physicians' daily routine. Existing studies suggest that their practical implementation is inconsistent. Therefore, developing interventions to train ward round competence and assessing if they are effective educational tools are crucial goals for research. METHODS: We analysed a simulation-based tutorial dedicated to fourth-year medical students, including casework and ward round simulation. We investigated the effectiveness of this intervention regarding ward round competence through a randomized controlled trial. Performance was assessed with the modified/validated surgical ward round assessment tool by two blinded and trained raters. Supplementary, motivation during the ward round tutorial was assessed for all students at different time points. RESULTS: Analysis of the ratings show that, in contrast to the control group (pre: 66.1 vs. post: 64.8 points, p =  0.72), the ward round competence of the intervention group (pre: 62.6 vs. post: 69.6 points, p =  0.0169) improved significantly after participating in the ward round tutorial. CONCLUSION: The results show that our simulation-based training is an effective way to improve competence of medical students in conducting surgical ward rounds. PRACTICE IMPLICATIONS: Participation in ward round trainings is a valuable tool to prepare students for their future professional practise.

An international perspective on the frequency, perception of utility, and quality of interprofessional rounds practices in intensive care units.

PURPOSE: To describe international variation in interprofessional rounds in intensive care units (ICUs). MATERIALS AND METHODS: Survey of ICU clinicians on their practices and perceptions of rounds using societal mailing lists and social media. RESULTS: Out of 2402 respondents, 1752 (72.8%) use rounds. Teams are mostly composed of intensivists, nurses and medical trainees. The majority of rounds (57.5%) last >2 h, and North Americans report the highest rates of rounds allowing family attendance (92.4%). Shorter rounds (1-2 h, OR 0.67, 0.52-0.86, p < 0.01; <1 h, OR 0.72, 0.53-0.97, p = 0.03), and strategies such as designating a person for writing (OR 0.73, 0.57-0.95, p = 0.01), and designating a person to assist other patients (OR 0.75, 0.57-0.98, p = 0.04) are associated with a lower perception of negative outcomes. Using daily goals during rounds is associated with a higher perception of positive outcomes (OR 1.85, 1.17-2.90, p < 0.01). CONCLUSIONS: Three-quarters of respondents perform rounds, and models of rounds are heterogeneous, creating challenges for future studies on improving rounds. Respondents reporting better outcomes also experience shorter rounds, and adopt strategies such as discussion of daily goals, and designation individuals for writing or assisting other patients during rounds.

[The application of checklist in ward rounds on the prognosis of critically ill patients].

The study was to investigate whether the application of checklist during ward rounds could improve the prognosis of critical ill patients.The results suggested that the checklist used during ward rounds could not improve the inhospital mortality of critically ill patients, but it increased the proportion of deep vein thrombosis prophylaxis, and shortened prophylaxis treatment of gastric stress ulcer.

The Power of Family Engagement in Rounds: An Exemplar With Global Outcomes.

Family engagement in rounds has been recommended to improve communication, but its impact on patient outcomes is unknown. At the authors' institution, nurses encouraged family presence at rounds as part of a larger project to enhance communication during rounding. In the case reported here, family engagement resulted in a critical care patient's wife suggesting bacteriophage therapy, which led to her husband's survival. The wife's involvement provided unique insight into the patient's response to treatments and valuable suggestions regarding the treatment plan. Real-time communication among the nurse, family, and physician improved the accuracy and quality of shared information as well as the plan of care. This exemplar demonstrates how family engagement in rounds can not only optimize the outcomes of individual patients but also lead to medical and scientific advances. More research is needed to further elucidate the impact of families on treatment plans and outcomes.

"Getting Everyone on the Same Page": Interprofessional Team Training to Develop Shared Mental Models on Interprofessional Rounds.

AIM: This study aimed to evaluate the effect of a team training program to support shared mental model (SMM) development in interprofessional rounds. DESIGN AND PARTICIPANTS: A three-arm randomized controlled trial study was conducted for interprofessional teams of 207 health profession learners who were randomized into three groups. PROGRAM DESCRIPTION: The full team training program included a didactic training part on cognitive tools and a virtual simulation to support clinical teamwork in interprofessional round. Group 1 was assigned to the full program, group 2 to the didactic part, and group 3 (control group) with no intervention. The main outcome measure was team performance in full scale simulation. Secondary outcome was interprofessional attitudes. PROGRAM EVALUATION: Teamwork performance and interprofessional attitude scores of the full intervention group were significantly higher (P < 0.05) than those of the control group. The two intervention groups had significantly higher (P < 0.05) attitude scores on interprofessional teamwork compared with the control group. DISCUSSION: Our study indicates the need of both cognitive tools and experiential learning modalities to foster SMM development for the delivery of optimal clinical teamwork performances. Given its scalability and practicality, we anticipate a greater role for virtual simulations to support interprofessional team training.

Development and Testing of an Electronic Multidisciplinary Rounding Tool.

Patients hospitalized with neurologic and medical issues in the neuroscience critical care unit have widely varying and complex disease states that can change rapidly. The large amount of data that must be reviewed regularly by medical staff members presents a challenge to the provision of high-quality care to these patients. In an effort to lessen the burden, the authors' team implemented an electronic multidisciplinary rounding tool, which facilitates team communication by allowing accurate and concise review of patient information. The rounding tool is part of an ongoing quality improvement project and has been in use for 4 years. Nurses have reported that the tool provides a comprehensive summary of the patient's hospital stay that facilitates handoff during shift changes. A survey of nursing staff members demonstrated high levels of satisfaction with the tool during both multidisciplinary rounds and handoffs.