Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial

BACKGROUND

At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients.

OBJECTIVE

To determine the impact of standardized bedside AR on patient satisfaction with rounds.

DESIGN

Cluster randomized controlled trial.

SETTING

500-bed urban, quaternary care hospital.

PATIENTS

1200 patients admitted to the medicine service.

INTERVENTION

Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices.

MEASUREMENTS

Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction.

RESULTS

We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5-point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR.

CONCLUSIONS

Medicine teams can adopt a standardized, patient-centered, time-saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team. Journal of Hospital Medicine 2017;12:143-149.

Half-life of a printed handoff document

BACKGROUND

Printed handoff documents are nearly universally present in the pockets of providers taking inhouse call. They are frequently used to answer clinical questions. However, the static nature of printed documents makes it likely that information will quickly become inaccurate as a result of ongoing management. This increases the potential for medical errors, especially in clinical services which rely heavily on printed documents for ongoing patient management.

OBJECTIVE

To measure the average time to potential inaccuracy, represented as the 'half-life' of printed handoff documents.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional analysis of 100 adult inpatients during a single 24 h period at an academic medical centre in 2014.

MAIN OUTCOME AND MEASURE

The half-life was defined as the time at which half of the patients would be expected to have inaccurate information on a printed handoff document, based on review of orders which populate data fields on these printed handoff documents.

RESULTS

In our sample, the half-life was 6 h on the 12 h night shift and 3.3 h on the day shift. We identified at least on change within the 24 h period for 92% of patients. Most changes (90% n=1411) were medication-related, but the overall distribution of order types was significantly different between day and night (p=0.002).

CONCLUSIONS AND RELEVANCE

The accuracy of printed handoff documents quickly deteriorated over the course of a physician shift. Based on this decay rate, a typical physician getting sign-out on 20 patients overnight can safely assume that the data for 10 of them will be inaccurate or outdated in 6 h and that it will be inaccurate on another two by the morning.

Achieving Hand Hygiene Success With a Partnership Between Graduate Medical Education, Hospital Leadership, and Physicians

Engaging physicians in hand hygiene programs is a challenge faced by many academic medical centers. Partnerships between education and academic leaders present opportunities for effective collaboration and improvement. The authors developed a robust hand hygiene quality improvement program, with attention to rapid-cycle improvements, including all levels of staff and health care providers. The program included a defined governance structure, clear data collection process, educational interventions, rapid-cycle improvements, and financial incentive for staff and physicians (including residents and fellows). Outcomes were measured on patients in all clinical areas. Run charts were used to document compliance in aggregate and by subgroups throughout the project duration. Institutional targets were achieved and then exceeded, with sustained hand hygiene compliance >90%. Physician compliance lagged behind aggregate compliance but ultimately was sustained at a level exceeding the target. Successfully achieving the institutional goal required collaboration among all stakeholders. Physician-specific data and physician champions were essential to drive improvement.