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Abstract
Importance Though interprofessional bedside rounds have been promoted to enhance patient-centred care for hospitalised patients, few studies have been conducted in adult hospital settings and evidence of impact is lacking.
Objective To evaluate the effect of patient-centred bedside rounds (PCBRs) on measures of patient-centred care.
Design and setting Cluster randomised controlled trial involving four similar non-teaching hospitalist service units in a large urban hospital.
Participants Hospitalised general medical patients.
Intervention We assembled working groups on two intervention units, consisting of professionals and patient/family members, to determine the optimal timing, duration and format for PCBR. Nurses and hospitalists rounded together in PCBR using a communication tool to provide a framework for discussion and unit leaders joined PCBR to provide coaching during initial weeks of implementation.
Main outcomes Using patient interviews, we assessed preferred and experienced roles in medical decision-making using the Control Preferences Scale, activation using the Short Form of the Patient Activation Measure, and satisfaction. We also compared postdischarge patient satisfaction survey items related to teamwork, involvement in decisions and overall care. We assessed nurses’, physicians’ and advanced practice providers’ (APP) perceptions of PCBR using a survey developed for this study.
Results Overall, 650 patients were approached for structured interview during hospitalisation: 284 were excluded because of disorientation, 54 were excluded because of non-English language, 72 declined to participate and 4 withdrew from the study after enrolment. Interview data were available for 236 (122 control and 114 intervention unit) patients, and postdischarge satisfaction survey data were available for 493 (274 control and 219 intervention unit) patients. We found no significant differences in patients’ perceptions of shared decision-making, activation or satisfaction with care. Results were similar in analyses based on whether PCBR had been performed (ie, per protocol). We also found no difference in postdischarge patient satisfaction items. Results were similar in multivariate analyses controlling for patient characteristics and clustering of patients within study units. A majority of nurses (78.6%), but only about half of hospitalist physicians and APPs felt that PCBR improved communication with patients (47.4%). A minority of nurses (46.4%) and physicians and APPs (36.8%) agreed that PCBR had improved the efficiency of their workday.
Conclusions PCBR had no impact on patients’ perceptions of shared decision-making, activation or satisfaction with care. Additional research is needed to identify optimal approaches that can be reliably implemented in hospital settings to improve patient-centred care.
- Patient-centred care
- Hospital medicine
- Patient satisfaction
- Teams
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Introduction
Recent years have seen increased emphasis on patient-centred care.1–4 Although definitions differ, patient-centred care can be described as a partnership between patients and healthcare professionals with deliberate efforts to inform and engage patients so that they might share in decision-making.4–7 Hospital settings present unique challenges to patient-centred care, including the lack of a prior relationship with professionals, complexity and rapid pace of clinical care, and potential for uncertainty related to evolving diagnoses and response to treatment. Nurses and physicians seldom visit patients together, creating the potential for patients to receive conflicting information. These challenges have prompted efforts to redesign care teams around the needs of the patient.1 Some hospitals have implemented interprofessional bedside rounds in an attempt to better inform and engage patients. The model is common in paediatric settings, with a recent study reporting 44% of paediatric hospital medicine programmes using them versus traditional sit-down or hallway rounds.8 Despite its prevalence in paediatrics, very little research has evaluated the effect of interprofessional bedside rounds, and the existing studies are limited because of suboptimal study design, small size and/or use of measures that have not been validated.9–11
Interprofessional bedside rounds are less common in adult hospital settings, and little research has evaluated their impact. Gonzalo et al12 ,13 studied interprofessional bedside rounds on an internal medicine teaching service, defining them as “encounters including 2 physicians plus a nurse or other care provider discussing the case at the patient's bedside.” Providers, especially nurses, perceived improvements in teamwork, but patients’ perceptions were not assessed. Stein et al14 recently published a description of an Accountable Care Unit model, including interprofessional bedside rounds. Though the model appeared to reduce length of stay, outcomes more relevant to patient-centred care were not reported. To our knowledge, no prior study of interprofessional bedside rounds in an adult setting has specifically evaluated the impact on aspects of patient-centred care.
We sought to evaluate the effect of interprofessional bedside rounds on key aspects of patient-centred care. We hypothesised that implementation of interprofessional bedside rounds would improve patients’ participation in medical decision-making, activation and satisfaction with care.
Methods
Setting and study design
The study took place on a general medical hospitalist service at Northwestern Memorial Hospital (NMH), an 894-bed urban academic hospital located in Chicago, Illinois, USA. We conducted a cluster randomised controlled trial, randomly selecting two of four similar non-teaching hospitalist service units for the intervention while the others served as the control units. Three units had 30 beds while the fourth had 23 beds. All units were equipped with cardiac telemetry monitoring. One of the control units was designated for use of specific cardiac medications (eg, intravenous diltiazem, adjustment of antiarrhythmics). Each unit was staffed by two hospitalist physicians and one advanced practice provider (APP; ie, nurse practitioner or physician assistant). APPs served as the managing clinician for up to six patients each, supervised by the hospitalist physicians. Hospitalist physicians on the study units worked in 7-day rotations while APPs worked Monday through Friday. Physicians and APPs were localised to specific units.15 During periods of very high volume, a teaching service hospitalist physician, primarily stationed on a non-study unit, cared for up to two patients per unit.
All study units had implemented structured interdisciplinary rounds (SIDR) beginning in 2010.16 ,17 SIDR used a structured format for communication during regular interprofessional meetings facilitated by the unit-based physician and nurse leaders. These interventions resulted in significant improvements in ratings of interprofessional collaboration and teamwork. However, SIDR occurred in a conference room and no deliberate attempt to engage patients as members of the team had previously been taken.
Design and implementation of patient-centred bedside round
We sought to build on our prior efforts and engage patients as essential members of the team. We implemented patient-centred bedside rounds (PCBRs), which we defined as daily, interprofessional rounds conducted at the bedside, designed with input from patients, family members and frontline professionals. Our leadership team developed a proposed description of PCBR and presented it to our Patient and Family Advisory Council. The council was highly supportive but felt strongly that the proposed team visiting the patient (ie, hospitalist physician, APP, nurse, social worker and pharmacist) was too large. Council members expressed concern that a large group might limit patients’ ability to contribute to the conversation and make some patients uncomfortable. Based on the council's recommendation, we prioritised participation of the nurse and either the hospitalist physician or APP.
We assembled working groups for each unit to help design PCBR and ensure that the intervention fit into workflow and met stakeholder needs. Unit medical directors and nurse managers led these groups, which included nurses, physicians, APPs, social workers, pharmacists, and, most importantly, patient representatives. Working groups met weekly for 6 weeks prior to implementation of PCBR to determine the optimal timing, duration and format for PCBR. The working group also created a structured communication tool to be used during PCBR (see figure 1). We provided laminated pocket-cards with the structured communication tool to professionals and encouraged use of the tool as a framework for team members’ contributions to the bedside discussion. Working groups were advised that SIDR could be modified and shortened, but not completely eliminated.
Structured communication tools for physicians and nurses during patient-centred bedside round (PCBR).
PCBR was implemented on 12 May 2014, occurred each weekday at 7:30 thereafter and included the nurse and the hospitalist physician or APP. The unit clinical coordinator (CC) was charged with ensuring that PCBR started on time and communicating PCBR status with staff to optimise transitions. For example, the CC made certain that the second nurse was ready to join the hospitalist physician or APP in PCBR as the first was finishing her or his patients. Each day during the first four weeks, unit medical directors and nurse managers attended PCBR to provide coaching and promote adherence to the PCBR format. We set an a priori goal that PCBR be performed on >75% of patients on the unit each weekday. The working group for each unit continued to meet weekly for 6 weeks postimplementation to review feedback about PCBR and make any needed adjustments in timing, duration and format.
Interview instrument and administration
Each weekday from 14 May to 22 December 2014, a research coordinator randomly selected up to six patients admitted to the study units for interview. We excluded patients disoriented to person, place, or time and those with a preferred language other than English. Using a structured interview, we assessed patients’ preferred and experienced roles in medical decision-making using the Degner Control Preferences Scale,18 a two-item tool used in prior research to characterise discordance in decision-making.19 ,20 Patient activation, the degree to which a person has the knowledge, skills, confidence and inclination to assume responsibility for managing one's own healthcare needs, was assessed using the Short Form of the Patient Activation Measure (PAM-SF).21 The PAM-SF has a theoretical score range from 0 to 100 and has been shown to be reliable and valid in clinical settings.21–23 A recent study found that hospitalised patients with lower PAM-SF scores had higher rates of 30-day postdischarge utilisation.24 Patient satisfaction was assessed using questions adapted from the Picker Patient Experience Questionnaire, a validated instrument to assess patient satisfaction.25 For each patient interviewed, we also contacted his or her physician or APP to assess whether PCBR had been performed on the day of the patient's interview.
Postdischarge patient satisfaction survey data
During the study period, NMH used a third-party vendor, Press Ganey Associates, to administer patient satisfaction surveys to a random sample of 40% of hospitalised patients between 48 h and 6 weeks after discharge. We obtained data from completed patient satisfaction surveys for patients admitted to the intervention and control units from 12 May 2014 through 31 January 2015. We excluded patients transferred to other units and services. Reflecting PCBR goals, we used questions in the Press Ganey survey that best reflected patients’ perception of nurse–physician teamwork and how well professionals included them in decisions about their care. Response options for these questions included very poor, poor, fair, good and very good. We used two questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to assess overall experience with hospital care. One question used a 0–10 rating scale with 0=worst hospital possible and 10=best hospital possible. The other question asked whether respondents would recommend this hospital to friends and family using a four-point ordinal scale (definitely no, probably no, probably yes, definitely yes).
Assessing impact on clinician workflow
We assessed nurses’, physicians’ and APPs’ perceptions of PCBR using a survey developed for this study. Specifically, we asked respondents to indicate their level of agreement with statements regarding PCBR's effect on communication with patients and efficiency of the work day. We also invited respondents to provide comments regarding their experience with PCBR. We administered the internet-based survey via email to nurses and APPs on the intervention units 3 months after implementation and to physicians at the end of completed rotations on either of the intervention units. Non-respondents received up to three reminder emails to complete the survey.
Statistical analysis
We combined information from structured interviews with data from the Northwestern Medicine Enterprise Data Warehouse, an integrated repository of all clinical and research data for patients receiving care in the system. Primary discharge diagnosis International Classification of Diseases, ninth revision codes were grouped using the Healthcare Cost and Utilization Project Clinical Classification Software.26 We compared patient demographic characteristics using χ2 and t tests. For ease of interpretation, we collapsed decision-making roles into the following categories: active, collaborative or passive, as has been done in prior studies.27 ,28 If the preferred and experienced role were the same, the patient's role agreement was categorised as concordant. We compared patients’ preferred and experienced roles in decision-making and concordance between preferred and experienced role using χ2 tests. We used t tests to compare PAM-SF scores and χ2 tests to compare the percentage of patients giving the most favourable rating (‘top box’) to patient satisfaction questions. We used top box comparisons for patient satisfaction, rather than comparison of mean or median scores, because patient satisfaction data are typically highly skewed and this approach is consistent with prior research.27 ,28 Our primary analyses were performed based on intention-to-treat. We repeated analyses based on whether patients had experienced PCBR (ie, per protocol). We also created multivariable regression models using decision-making concordance, activation and satisfaction as outcome variables and unit type (intervention vs control) as the predictor variable. Models used age, sex, race, admission source, payer, case mix, education level, Elixhauser score and length of stay as covariates and SEs robust to the clustering of patients within study units.
We compared the percentage of patients giving top box ratings to postdischarge patient satisfaction items using χ2 tests. We also created multivariable logistic regression models using age, sex, race, admission source, payer, case mix and education level as covariates and used SEs robust to the clustering of patients within study units.
Using baseline data previously collected on a similar patient population in our hospital, we estimated that we would need 230 total patients to have 80% power to detect a five-point improvement in the PAM-SF score. This degree of improvement was felt to be both clinically relevant and achievable. All analyses were conducted using Stata V.11.2 (College Station, Texas, USA).
Results
Patient characteristics
Overall, 650 patients were approached for structured interview during hospitalisation. In total, 284 were excluded because of disorientation, 54 were excluded because their preferred language was not English, 72 declined to participate and 4 withdrew from the study after enrolment. Complete data were available for 236 (122 control and 114 intervention unit) patients. Patients were similar in age, sex, race, admission source, payer, case mix, education level, Elixhauser comorbidity score and length of stay (see table 1). PCBR occurred for 60 of 111 patients (54.1%) on the interventions units and 4 of 120 patients (3.3%) on control units. Excluding patients cared for by teaching service hospitalist physicians primarily stationed on another unit, PCBR occurred for 60 of 103 patients (58.3%).
Characteristics of structured interview patients
Postdischarge patient satisfaction survey data were available for 493 (274 control and 219 intervention unit) patients. Patients were similar in age, sex, race, education level, Elixhauser comorbidity score, length of stay, self reported health status and primary language, but control unit patients were significantly more likely to be directly admitted, insured by Medicare, and have diseases of the circulatory system as the primary diagnosis than intervention unit patients (see table 2).
Characteristics of postdischarge patient satisfaction survey respondents
Decision control, activation and satisfaction as assessed by structured interview
The distribution of experienced and preferred role in decision-making was similar between patients on the control and intervention units (see table 3). There was no difference in the concordance of experienced and preferred roles in decision-making between control units and intervention units (89.3% vs 88.6%; p=0.86). The mean PAM-SF score was similar for control unit and intervention unit patients (64.6±13.9 vs 65.5±15.3; p=0.65). There were also no differences in percentage top box responses to patient satisfaction questions. Analyses performed based on whether patients had experienced PCBR showed similar results. Specifically, concordance in decision-making role was 89.2% for patients who had not experienced PCBR compared with 87.5% for PCBR patients (p=0.71). The PAM-SF score was similar for non-PCBR patients compared with PCBR patients (64.5±14.1 vs 66.4±16.1; p=0.39). Overall satisfaction with care was also similar for non-PCBR patients compared with PCBR patients (60.6% vs 54.7%; p=0.41). Analyses adjusting for patient characteristics and clustering of patients within study units showed similar results with one exception. Intervention unit patients were more likely to indicate that doctors and nurses did not give conflicting information (OR 1.84; p<0.001).
Impact of patient-centred bedside rounds on decision-making, activation and satisfaction
Postdischarge patient satisfaction survey results
In postdischarge patient satisfaction surveys, we found no difference in patients’ perceptions of whether nurses and doctors worked as a team (60.9% vs 59.0%; p=0.68) or whether staff included them in decisions about treatment (51.3% vs 51.8%; p=0.91) (see table 4). Similarly, the percentage of top box responses for overall rating of the hospital (64.0% vs 64.2%; p=0.97) and likelihood to recommend (74.3% vs 70.7%; p=0.37) were not significantly different. Results were similar for all satisfaction items in analyses including age, sex, race, admission source, payer, case mix and education level as covariates and using SEs robust to clustering of patients within study units.
Impact of patient-centred bedside rounds on patient satisfaction surveys
Clinician perceptions
In total, 28 of 42 nurses (66.7%) and 38 of 46 hospitalist physicians and APPs (82.6%) completed the PCBR survey. A majority of nurses (78.6%) but only about half of hospitalist physicians and APPs felt that PCBR improved communication with patients (47.4%). Less than half of nurses (46.4%) and physicians and APPs (36.8%) agreed that PCBR had improved the efficiency of their workday. Also, 30 of 66 (45.4%) respondents provided comments. Although a comprehensive qualitative analysis of survey comments was beyond the scope of our study, comments generally identified challenges such as coordinating the workflow of nurses and physicians during PCBR and competing priorities. Physicians expressed a desire for nurses to be ready to enter the room at the same time as the physician. Nurses expressed a desire for physicians to understand their need to pass medications at specific times and prepare patients leaving the unit for tests and procedures.
Discussion
We found that PCBR, designed in collaboration with patients and family members, had no impact on patients’ perceptions of shared making, activation or satisfaction with care. Our findings question the utility of interprofessional bedside rounds as a strategy to improve patient-centred care.
There are several potential explanations for our results. First, PCBR was performed on only 54.1% of patients, less than our stated goal of >75%. Though professionals helped design PCBR for each unit, our survey results reveal that PCBR introduced significant workflow challenges. Furthermore, hospitalist physicians appeared to question the utility of PCBR as only approximately half of them agreed that PCBR improved communication with patients. Prior studies of interprofessional bedside rounds have either not reported the percentage of time they have occurred or similarly struggled to perform interprofessional bedside rounds as often as intended.12 ,13 Gonzalo et al13 found that interprofessional bedside rounds occurred 64% of the time and were more likely to occur with younger attendings and during periods of lower workload. It is possible that more consistent occurrence of PCBR in our study would have resulted in favourable changes in decision-making, activation and satisfaction. However, analyses based on whether PCBR occurred (ie, per protocol) also did not reveal improvement in aspects of patient-centred care.
Second, the format and the interactions during PCBR may not have engaged patients to the degree we desired. We designed PCBR with input from patients and family members to ensure PCBR met their needs. Additionally, we created a structured communication tool to provide a framework for discussion during PCBR and unit leaders joined PCBR to provide coaching during the initial weeks of implementation. However, we did not formally assess the quality of discussions during PCBR. Based on the recommendation of our Patient and Family Advisory Council, we restricted our interprofessional rounds to the nurse and either the hospitalist physician or APP. While it is possible that a larger team would have made an impact, we are inclined to agree with council members who expressed concern that a larger group might limit the patients’ ability to contribute to the conversation and be intimidating for some patients.
Another potential explanation for our findings relates to the model of care on control units. Control units conducted SIDR, an intervention previously shown to improve interprofessional teamwork.17 SIDR may not be a true reflection of ‘usual care’ in most hospitals. However, comparing PCBR units to SIDR units theoretically allowed us to isolate the effect of conducting interprofessional rounds at the bedside versus a conference room. Collectively, our experience suggests that interprofessional rounds improve teamwork climate,16 ,17 but bringing these rounds to the bedside does not improve measures of patient-centred care.
Interestingly, a minority of patients in our study preferred an active role in decision-making and a larger proportion preferred a passive role than an active role. This finding is similar to that of prior studies of hospitalised patients,29 ,30 suggesting that patients prefer to relinquish decision control during periods of acute illness. Torke et al31 recently published a study showing that nearly half of older hospitalised adults required at least some involvement of a surrogate for decision-making. Thus, efforts to share in decision-making may be better focused on engaging surrogates, at least for some patients.
Our study has several limitations. First, it reflects the experience of a non-teaching medical service in a single hospital. Teaching services may experience different results, but also face the challenge of large physician teams (eg, students, residents, attendings) and the potential for competing priorities among professional team members (eg, nurses may not prioritise teaching during rounds). Second, as previously mentioned, control units had implemented SIDR, which may not reflect usual care in many hospitals. Third, we assessed PCBR adherence by asking the patient's physician or APP whether PCBR had been performed on the day of the patient's interview. We believe the aggregate percentage (54.1%) is an accurate representation of how often PCBR occurred on the intervention units, but an individual patient may have experienced variation in PCBR occurrence (eg, PCBR occurred on days 1 and 3 but not on days 2 and 4). Additionally, we were not able to link PCBR occurrence to individual patient data for the postdischarge survey. Fourth, though patient characteristics were similar for those interviewed, there were differences for postdischarge patient satisfaction comparisons. We used multivariable regression models to adjust for differences and found similar results. We feel it is unlikely that unmeasured confounders would change our findings. Lastly, no specific effort was made to contact family members who were not present during PCBR.
Conclusion
PCBR, designed in collaboration with patients and family advisors, had no impact on patients’ perceptions of shared decision-making, activation or satisfaction with care. Our findings reveal the challenges faced when implementing interventions affecting professional workflow, but also question the utility of interprofessional bedside rounds as a strategy to improve patient-centred care. Additional research is needed to identify optimal approaches that can be reliably implemented to improve patient-centred care.
Acknowledgments
The authors express their gratitude to the Northwestern Medicine Patient and Family Advisory Council and to Karen Burnett and Rosemary Withaeger, who served as patient representatives on the working groups that designed PCBR.
References
Footnotes
Correction notice This article has been corrected since it was published Online First. Figure 1 has been corrected.
Contributors KJO designed the study, conducted all analyses and led the writing of the manuscript. AK and SJ acquired data, contributed to interpretation of results and provided critical review on all drafts of the manuscript. LH, MM, KM and HMS guided study design, led implementation of the intervention, contributed to interpretation of results and provided critical review on all drafts of manuscript.
Funding The Globe Foundation.
Competing interests None declared.
Ethics approval Northwestern University Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.