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Systematic review
Implementing bedside rounds to improve patient-centred outcomes: a systematic review
  1. John T Ratelle1,
  2. Adam P Sawatsky2,
  3. Deanne T Kashiwagi1,
  4. Will M Schouten1,
  5. Patricia J Erwin3,
  6. Jed D Gonzalo4,
  7. Thomas J Beckman2,
  8. Colin P West2,5
  1. 1 Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  3. 3 Medical Library, Mayo Clinic, Rochester, Minnesota, USA
  4. 4 General Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
  5. 5 Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr John T Ratelle, Hospital Internal Medicine, Mayo Clinic, Rochester, MN 5072559225, USA; ratelle.john{at}mayo.edu

Abstract

Background Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes.

Methods Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains.

Results Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a ‘bundle’. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen’s d=0.09, 95% CI 0.04 to 0.14, p<0.001, I2=56%), but no significant association between BR and patient knowledge (Cohen’s d=0.21, 95% CI −0.004 to –0.43, p=0.054, I2=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data.

Conclusions BR have been implemented in a variety of hospital settings, often ‘bundled’ with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

  • health services research
  • hospital medicine
  • patient-centred care
  • patient satisfaction

https://doi.org/10.1136/bmjqs-2017-007778

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    Introduction

    Patient-centred care (PCC) is the dominant paradigm in modern healthcare, and leads to improved healthcare outcomes.1–3 At its core, PCC is ‘the active engagement of patients when … healthcare decisions must be made’, and involves specific activities such as demonstrating respect for patient values, effective communication and education, and involving patients and their caregivers in the decision-making process.1 4 Successful PCC requires a close relationship between the myriad of healthcare providers, including nurses, physicians, pharmacists, etc, and the patient as they work together to achieve the patient’s healthcare goals.5

    In hospital-based settings, ward rounds are ‘the time when the team meets to discuss each patient and makes clinical decisions’6 and often comprise the largest portion of direct patient care activities.6 7 These rounds, however, infrequently occur at the patient’s bedside, and more often take place in a location separated from the patient, limiting the opportunity for PCC.8–11

    Bedside rounds (BR), the process where care review and decision-making among healthcare providers take place in the presence of the patient and his/her family caregivers, may be an ideal approach to promote PCC in the hospital.12 13 BR bring patients, their caregivers and clinicians together to allow for information sharing and relationship building.14 15 This process can promote deliberation about care decisions and ultimately lead to shared decision-making (SDM), arguably the cornerstone of PCC.4 Additionally, BR may involve the necessary interprofessional collaboration to ensure the patient is meeting his/her healthcare goals and to promote patient safety.14 16 17 For these reasons, BR are currently endorsed by multiple professional societies.18–20

    Despite the enthusiasm for BR, empiric evidence to support their use as an intervention to promote PCC is inconclusive. A cross-over trial by Landry et al found that parents of paediatric patients were more satisfied when rounds took place at the bedside versus the conference room.21 However, a randomised trial by Lehmann et al found that patients who participated in BR felt their physicians spent more time with them, but this did not translate into greater satisfaction compared with patients whose rounds took place away from the bedside.22 More recently, O’Leary and colleagues found that patients who were exposed to BR were no more likely to participate in SDM than patients who participated in traditional rounds, even when adjusting for patient preference.23 These results have led some to question the practical value of BR in the promotion of PCC.24 However, the definition and implementation of BR has varied greatly between studies, and may explain the inconsistent results.25–28

    Given the conflicting results of studies of BR, a synthesis of the evidence is needed to explore the variation in implementation of BR and to more fully define the actual effect of BR on PCC. Therefore, we conducted a systematic review to describe the implementation of BR and determine the effect of BR on patient-reported and objectively measured clinical outcomes.

    Methods

    This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement.29

    Data sources and searches

    With the aid of an experienced medical librarian (PJE), we created a search strategy using terms for setting/context (eg, hospital, hospital medicine, inpatients), activity (eg, rounds, ward rounds, bedside rounds, medical history taking) and participants (eg, attending, resident, intern, medical student). We searched Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception (see online supplementary appendix for complete search strategy). Additionally, we reviewed reference lists for relevant titles.

    Study selection

    Given that bedside rounding is an expansive construct, broad inclusion criteria were used to ensure a comprehensive review. Specifically, we used the following operational definition of BR, which was adapted from the work of Gonzalo et al 16:

    A minimum of 2 health care professionals, one of whom is a physician, discussing the patient’s history, condition, and daily plan of care in the presence of the patient and/or the patient’s family caregivers.

    We included studies that: (1) described an intervention involving BR, (2) included a quantitative comparison with an alternative form of ward rounds, and (3) used an experimental study design (ie, randomised controlled trials (RCT) or non-randomised cohort studies).

    To ensure a comprehensive evaluation of the effect of BR on PCC, we intentionally chose broad outcomes. However, synthesising the results of patient-centred interventions can be challenging, particularly given the large heterogeneity of measures.30 Therefore, to categorise patient outcomes for quantitative analysis we used the framework described by Coulter and Ellins,31 which identifies four categories of outcomes of interest regarding patient-centred interventions:

    1. Patient knowledge (eg, comprehension, understanding of information, knowledge of condition and treatment options).

    2. Patient experience (eg, satisfaction, clinician–patient communication, SDM, psychological well-being).

    3. Use of services and costs (eg, hospital length of stay (LOS), readmission rates, cost).

    4. Health behaviour and health status (eg, mortality, adherence to treatment, sentinel event rates).

    Studies were included if they contained a patient outcome that could be categorised within this framework, regardless of language or date of publication.

    Abstract and full-text review were conducted independently and in duplicate by study investigators, with disagreements resolved by consensus. If there was insufficient information to clearly include or exclude a study, the authors of that study were contacted for clarification. Subsequently, final decisions on inclusion were made through consensus among study investigators.

    Data extraction and quality assessment

    A data extraction instrument was created based on related research on hospital ward interventions.30 32 To capture variability across BR interventions, we fully described each intervention and categorised interventions as ‘bundled’ or ‘not bundled’. An intervention was considered ‘bundled’ if it had components other than BR (eg, audit and feedback of the rounding process).

    As noted previously, we categorised outcomes according to the Coulter-Ellins framework to facilitate comparison and meta-analysis across studies. In cases where a single instrument was used to measure several patient outcomes (eg, satisfaction and understanding of care), we categorised survey subscales and/or individual survey items according to our framework.

    Risk of bias for included studies was assessed using tools adapted from the Risk of Bias in Non-Randomized Interventions tool for non-randomised studies33 and the Cochrane risk of bias assessment tool for randomised studies.34 All steps in data extraction and risk of bias assessment requiring subjective judgement were conducted independently and in duplicate, with disagreements resolved by consensus.

    Data synthesis and analysis

    Data analysis began with a summarisation of study setting, design and participants. We qualitatively synthesised the implementation of BR among the included studies, focusing on the activities defining BR as well as any cointerventions that were included as part of a bundle. We summarised risk of bias across studies and in cases where an individual study was deemed to be at high risk of bias in one or more categories, we qualitatively analysed the methodological limitations contributing to the high risk of bias.

    When outcomes within a study could be thematically grouped to allow quantitative pooling, a standardised mean difference and SE were calculated for each outcome measure using either the mean and SD (in the case of continuous or ordinal outcomes) or OR (in the case of dichotomous outcomes). For studies reporting multiple outcomes within a single domain (eg, item-level analysis of a survey instrument without a summary score), we calculated a mean domain-specific summary outcome for each study with a pooled variance based on a between-item correlation of 0.44 (from results for a previously validated instrument reported in an included study).23 Authors were contacted for missing data. In cases where mean scores were reported without a measure of variance or p value and data were not available from authors, we used the average SD from all other studies reporting that outcome. We calculated a pooled Cohen’s d effect size estimate for each outcome domain using the generic inverse variance method and random effects models given the heterogeneity of study designs and outcome measures.

    We measured heterogeneity using I2. To explore sources of heterogeneity, we performed the following prespecified subgroup analyses: bundled versus non-bundled BR, uniprofessional (ie, only physicians) versus interprofessional BR, randomised versus non-randomised study design and paediatrics versus non-paediatrics study setting. Results from intensive care units (ICU) versus non-ICU settings and from general medical wards versus other settings were compared in post hoc subgroup analyses. We used Review Manager V.5.3 software for all analyses.

    Results

    Our database search was last updated on 28 July 2017. This yielded 3751 unique abstracts, 396 of which met criteria for full-text review. Of these, 29 met full inclusion criteria (figure 1).21–23 25–28 35–55 Chance-adjusted inter-rater agreement for study inclusion between reviewers was moderate (κ=0.48), and absolute agreement was high (89.4%). Outcomes in the patient knowledge and patient experience domains were deemed amenable to meta-analysis. However, outcomes in use of services and costs, and health behaviour and health status, domains were more diverse and not felt amenable to quantitative pooling. For example, outcomes in the use of services and costs domain ranged from 30-day readmission to the proportion of patients discharged during the first nursing shift.

    Figure 1
    Figure 1

    Summary of literature search. *Total exceeds the number excluded due to some articles being excluded for more than one reason.

    Characteristics of included studies and participants

    Of the 29 included articles, eight were RCTs and 21 were cohort studies. Study characteristics and details of the interventions are summarised in online supplementary table 1.

    Supplemental material

    The majority of studies (n=23, 79.3%) were conducted in the USA, and no studies involved more than one institution. General medical wards were the most frequent study setting (n=10, 34.5%), followed by the ICU (n=7, 24.1%), general paediatric wards (n=3, 10.3%) and the emergency department (n=2, 6.9%). BR were most often interprofessional (n=22, 75.9%) and included medical trainees (residents (n=16, 55.2%), medical students (n=15, 51.7%), fellows (n=3, 10.3%), nursing students (n=2, 6.9%), physician assistant students (n=1, 3.4%), pharmacy students (n=1, 3.4%)).

    Description and implementation of BR

    Descriptions of BR varied widely, both in terms of the level of detail regarding the intervention and the specific activities that constituted BR (online supplementary table 1). For example, Ramirez and Gonzalo both described BR as an activity involving a bedside case presentation by a trainee, followed by review of the patient’s physical exam and discussion/formulation of the patient’s plan of care.25 46 On the other hand, Dunn and Stein described BR as a structured dialogue between the physician, nurse and patient to review team member roles, safety checklists, the patient’s current status and care plan.28 39 In these latter studies, BR were designed to be 3 min in duration and take place after an independent patient assessment by the physician and nurse.

    Family-centred rounds (FCR) were commonly described in studies conducted on paediatric wards, as well as paediatric and neonatal ICUs. While an explicit definition of FCR was rarely provided, common elements were described. These elements included a bedside case presentation by a physician-learner in the presence of the patient’s family caregiver with opportunities for interprofessional and family participation by asking questions and/or providing input on the plan of care. While frameworks for FCR were outlined among the included studies, the implementation of FCR was often unstructured and did not involve cointerventions such as communication scripts or checklists.

    Thirteen (44.8%) studies were categorised as bundled interventions.23 25–27 39–41 44 45 47 48 51 52 Cointerventions varied widely, but most often included staff education, structured communication tools/checklists and observation and feedback of rounding practices.

    Bundled interventions were most frequently implemented on non-ICU adult units, and the majority of studies (n=6, 60%) conducted in this setting were considered bundled. Several studies on adult medical units included similar types of cointerventions such as interprofessional leadership/teamwork training, unit-based teams with geographic colocating of patients, structured communication during BR and unit or physician-level performance feedback.17 28 39 48

    Risk of bias and common methodological limitations

    Risk of bias among the included studies is outlined in the online supplementary tables 2 and 3. None of the included studies were deemed to be at low risk of bias overall, and the majority of both the cohort studies (n=12, 57.1%) and RCTs (n=4, 50%) were at high risk of bias in at least one category.

    Common methodological limitations leading to high risk of bias are outlined in figure 2. Selective reporting was most often manifested by reporting only select items from a larger survey measuring a patient-reported outcome. Adherence rates to BR were only reported in 15 (51.7%) studies, and only five studies reported an adherence rate of >90%. Two studies attempted to mitigate the limitation of low adherence rates by reporting both per-protocol and intention-to-treat analyses.22 23

    Figure 2
    Figure 2

    Common methodological limitations leading to high risk of bias (n=16 studies).

    Effectiveness of BR

    Patient knowledge

    Ten studies (34.5%, 4 RCTs) reported an outcome within the domain of patient knowledge.21 22 26 27 35 41 46 47 49 54 Outcomes in this domain were most often survey items measuring patient-reported understanding of care and/or satisfaction with the amount of information received. Only one study reported an objective measure of patient understanding of care.35 The summary Cohen’s d estimate was small at 0.21 (95% CI −0.004 to –0.43, p=0.054, I2=92%) (figure 3). None of the subgroup analyses (study design, uniprofessional vs interprofessional, bundled vs non-bundled, paediatrics vs non-paediatrics, ICU vs non-ICU, general medical vs non-general medical) yielded statistically significant differences (online supplementary figures 1–6). Post hoc sensitivity analyses excluding the most extreme results (Lewis et al 27 and/or Allen et al 35) yielded smaller statistically non-significant effect size estimates and reduced heterogeneity, with similar summary interpretations (data not shown).

    Figure 3
    Figure 3

    Effect of bedside rounds on patient knowledge.

    Patient experience

    Twenty-four studies (82.7%, 8 RCTs) reported an outcome within the domain of patient experience.21–23 25–27 35–39 41 42 44–47 49–55 Outcomes in this domain varied greatly from overall satisfaction with the hospital stay to parental stress, to patient activation and SDM. The summary Cohen’s d estimate was small at 0.09 (95% CI 0.04 to 0.14, p<0.0001, I2=56%) (figure 4). None of the preplanned subgroup analyses yielded statistically significant differences (online supplementary figures 7–11). Post hoc subgroup analysis revealed a greater effect of BR on patient experience among studies conducted on non-general medical units (Cohen’s d 0.15 (95% CI 0.08 to 0.22, I2=56%)) than general medical units (Cohen’s d 0.02 (95% CI −0.03 to –0.08, I2=23%), subgroup p=0.009), but the effect size was small in both subgroups (online supplementary figure 12). Post hoc sensitivity analysis excluding the most extreme results (Landry21) yielded a similar statistically significant effect size estimate and reduced heterogeneity (data not shown).

    Figure 4
    Figure 4

    Effect of bedside rounds on patient experience.

    Use of services and costs

    Seven studies (24.1%, 0 RCT) reported an outcome within the domain of use of services and costs.26 39 41 43 48 51 54 56 Southwick et al 51 found that BR as part of a bundled intervention led to a statistically significant reduction in 30-day readmission (6.95% vs 9.95%, p=0.039) and relative LOS (0.76 vs 0.93, p=0.01). Another bundled BR intervention was also associated with a reduction in LOS (4.5 days vs 5.0 days, p=0.001).28 Likewise, a non-bundled intervention by Gausvik et al 56 resulted in an improvement in 30-day readmission for patients discharged to a skilled nursing facility (SNF) (11.68% vs 14.7%, p<0.05), decreased LOS for patients discharged to an SNF (5.24 days vs 7.26 days, p<0.001) and decreased LOS for patients discharged to home (3.73 days vs 4.21 days, p=0.001). However, bundled interventions involving BR by Dunn et al 39 and Saint et al 48 did not result in a statistically significant difference in LOS when compared with control units.

    Oshimura et al 43 found that BR were associated with an increase in the proportion of patients discharged during the first nursing shift (47% vs 40%, p<0.005), but Kuo et al 26 found no difference in discharge time (15:01 vs 14:28, p=0.42). Other results in this domain included a statistically significant reduction in ICU LOS (31.58 hours vs 44.59 hours, p=0.01),41 but no clear difference in the number of medications used (2.36 vs 2.68, p=0.53) or hospital charges ($6683 vs $9529, p=0.26).26

    Health behaviour and health status

    Four studies (13.8%, 0 RCT) reported an outcome within the domain of health behaviour and health status.26 28 39 40 Johnson et al 40 found a bundled BR intervention in the ICU led to a statistically significant decrease in the incidence of ventilator-associated pneumonia (23.4/1000 ventilator-days vs 34.4/1000 ventilator-days, p=0.04). Likewise, a bundled BR intervention by Stein et al 28 led to a decrease in unadjusted mortality (1.1% vs 2.3%, p=0.004). However, Dunn et al 39 found no statistically significant effect of BR on composite outcomes of clinical deterioration or hospital-acquired conditions (7.7% vs 9.3%, p=0.46). Other results in this domain included no statistically significant effect of BR on adherence with outpatient follow-up appointments (9.5% vs 14.3%, p=0.63).26

    Discussion

    Summary of main findings

    The results of this systematic review demonstrate that to date BR have been heterogeneous interventions implemented in a variety of hospital-based settings, often paired with cointerventions as part of a ‘bundle’. Studies in this review most often reported outcomes related to patient experience and understanding of care, while relatively few studies measured the impact of BR on objectively measured clinical outcomes such as hospital LOS, costs and adverse events.

    Our results indicate that BR, when compared with other rounding formats, do not consistently improve patient-centred outcomes. Specifically, BR were associated with a small positive effect on patient experience, but this effect is of questionable clinical significance and there was substantial variation across studies. Likewise, our results did not demonstrate a consistent effect of BR on other patient-centred outcomes. However, the overall strength of evidence was graded as low to moderate because of variable risk of bias and unexplained heterogeneity across studies. Methodological limitations leading to bias among the included studies were most often related to issues with selective reporting of outcome measures or analyses, low adherence rates to BR and missing data.

    BR have been proposed as an ideal method to promote PCC and have been adopted in a variety of hospital-based settings.57 58 However, the results of this systematic review do not suggest a consistent or clinically meaningful effect of BR on patient-centred outcomes, according to studies conducted to date.

    Relationship to existing literature

    Existing reviews have typically included BR as part of a broader evaluation of rounding practices within a specific hospital context.32 59 60 For example, Bhamidipati et al 32 conducted a systematic review to identify the structure and outcomes of interdisciplinary rounds on medical wards while Lane et al 60 included studies of BR while attempting to identify best practices for patient care rounds in the ICU. However, both of these reviews included relatively few studies focusing on BR. We have attempted to build on these existing reviews and to identify themes in design and implementation of BR by including studies from multiple hospital settings.

    One major theme gleaned from the studies in this review is the context-specific variation in the implementation of BR which may represent, in part, varying goals of BR. For example, in paediatrics, FCR were often bedside work rounds without a predefined structure or communication script. This unstructured approach allows patients and their family members to participate in the creation and evaluation of the rounding process, a fundamental principle advocated in the paediatrics literature.61

    In contrast, recent studies on adult wards have implemented structured BR as part of bundled interventions, in which key care items and safety checklists are reviewed at the bedside to help create a shared mental model among the interprofessional healthcare team. These studies often used the clinical microsystem framework, which aims to redesign hospital wards into ‘accountable care units’ (ACU) by colocating clinicians and patients, implementing structured care processes (including BR) and providing performance feedback at the ward level.28 The ACU is gaining increased attention in the USA as evidenced by national funding and collaboration to support implementation of microsystems model.62

    Explanation and implications of the findings

    To explain the findings of this systematic review, it is useful to consider the underpinnings of PCC and how this objective might, theoretically, be achieved through BR. One leading conceptual framework identifies three central components to PCC: communication, partnership and health promotion.63 At its core, BR provide a communication platform where information can be shared between the patient and clinicians, ideally with a focus on the patient’s needs and perspective. By bringing together multiple members of the healthcare team at the patient’s bedside, BR can also foster interprofessional collaboration which, in turn, can help form a therapeutic partnership between the patient and care providers. Lastly, BR create an opportunity for health promotion by allowing the patient to participate in his or her care, both in medical decision-making related to acute illness and in case management that focuses on discharged planning and the patient’s health after hospitalisation.

    When viewing BR through the lens of PCC, the potential for improving patient outcomes seems evident. However, one potential explanation for the contrary results of this review is that core features of PCC may not, in fact, be achieved during the practice of BR. For example, observational research has demonstrated that communication at the bedside is often dominated by physicians, focusing mainly on the acquisition of medical information, with little discussion surrounding the patient’s goals or psychosocial circumstances.9 64 Additionally, while hospitalised patients express a desire to participate in their care, studies identify barriers to their engagement during BR.65 66 Ultimately, bringing patients and their physicians together at the bedside may be necessary but not sufficient to promote PCC.

    Another potential explanation for the limited observed effects of BR is low adherence rates reported among studies in this review. Barriers to BR may include individual physician-related factors, such as perceived lack of efficacy or inefficiency, as well as systems issues, such as increased patient volumes and the physical constraints of isolation precautions.67 Hospital leaders and administrators should keep these factors in mind if they plan to implement BR, and carefully consider their current workflow in an attempt to identify opportunities to mitigate potential barriers to BR.

    Future research on BR should focus on overcoming common methodological limitations by consistently reporting all outcomes and adherence rates to the intervention, and using measurement strategies that minimise missing data. Additionally, research should focus on identifying the specific activities during patient-clinician interactions at the bedside that are feasible (ie, can be adhered to by the clinician team) and lead to improved patient outcomes.

    Limitations

    Our systematic review has limitations. First, we applied broad inclusion criteria to ensure a comprehensive review of the implementation of BR for improving patient outcomes in hospital-based settings. However, it is apparent from our results that substantial heterogeneity exists among the included studies that could not be controlled for despite our efforts to classify outcomes according to a valid framework,31 and by exploring for sources of heterogeneity through subgroup analyses. Additionally, we were unable to explore heterogeneity that may have been related to variation in ‘usual care’ among control groups. These facts should be kept in mind when interpreting the results of this review. Second, to allow for meta-analysis across studies, we chose to only include studies reporting a quantitative patient outcome. Therefore, we excluded qualitative research which may have supplemented our quantitative results. Third, due to relatively few studies and disparate outcomes in the domains of use of services and costs and health behaviours/health status, meta-analyses were not deemed appropriate for these domains, making it challenging to draw conclusions regarding the effect of BR on objectively measured clinical outcomes. Lastly, this review focused specifically on the impact of BR on hospitalised patients. However, BR have proposed benefits beyond direct patient care, such as on education and interprofessional teamwork.14 68 Each of these potential benefits should be considered when clinicians and hospital leaders select a rounding strategy.

    Conclusions

    In conclusion, this systematic review highlights the wide variation in the setting, design and implementation of BR. Our results demonstrate no consistent effect of BR on patient-centred outcomes, indicating that simply rounding at the bedside may not lead to meaningful improvement in patient care. Future research should aim to better understand how to facilitate and optimise patient-centred interactions at the bedside.

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    Footnotes

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.