Bedside Rounds Research Articles

Dr. Ninan T. Mathew--A "Tribute" (1937-2015).

Dr. Ninan T. Mathew--A "Tribute" (1937-2015).

A National Survey Assessing the Current Workforce of Transplant Pharmacists Across Accredited U.S. Solid Organ Transplant Programs

Integration of pharmacists into multidisciplinary transplant patient care has advanced in recent years, with limited data available to evaluate the current status of the profession. This was a national survey developed as an AST Pharmacy COP initiative. Responses were solicited from pharmacists practicing at U.S. transplant programs based on UNOS listing; 176 participants from 113 centers (41%) responded, with 79% practicing ≤10 years. There is a median of 1.4 pharmacist full-time equivalents (FTEs) (range 0.1-7.1) for every 100 transplants. The predominant activities performed by pharmacists during the transplant phase include medication review (95%), lab review (92%), allergy review (88%), medication therapy management (92%), bedside rounds (87%), medication education (79%), documentation (71%), and coordinating discharge medications (58%). Similar activities were reported during the other phases, but participation was less common. The involvement of dedicated transplant pharmacists within multidisciplinary care has become standard at a large number of centers, although expansion is still needed to ensure core pharmaceutical care components are provided to all transplant recipients across all centers. These results inform on the typical responsibilities of pharmacists practicing within the field of transplantation and illustrate that the level of pharmacist involvement significantly varies across transplant centers and the phases of transplantation.

Adding Value—Supporting Patient Education Services at the Bedside

A patient education bedside rounding program was developed and implemented at Munson Medical Center in Traverse City, Michigan. The Knowledge Management Services Department and the Munson Community Health Library worked collaboratively as part of an interdisciplinary team to bring patient education services to inpatient hospital units. In addition, the team launched a process to both improve patient education documentation in the electronic health record and improve patient education materials and wellness packets.

Returning to the Bedside: Notes From a Clinical Educator.

Over the past 3 decades, teaching rounds have drifted away from the bedside in favor of management discussions in a conference room or hallway. As a result, patients and families--2 of the most valuable resources in health care--are being left out of the loop. This trend is now being reversed by bedside presentations of newly admitted patients and structured interdisciplinary bedside rounds.

A Qualitative Analysis of Pediatric Patient Attitudes Regarding Family-Centered Rounds.

The American Academy of Pediatrics recommends family-centered rounds (FCR) as standard practice for the inpatient setting. To date, there is limited research investigating the attitudes of pediatric patients regarding this shift in practice. The goal of this study was to explore pediatric patients' perspectives of their experiences during FCR. We conducted a qualitative descriptive study based on results from 22 semi-structured interviews of school-aged and adolescent inpatients from September 2012 through October 2013. English-speaking patients, aged 7 to 18 years, who participated in FCR were eligible for inclusion. Transcripts were initially analyzed by using a constant comparative method. After completion of this initial analysis, a third reviewer independently reviewed all transcripts to verify the accuracy of the final coding scheme. The final coding scheme consisted of 5 main themes: team size, medical team interactions, content discussed on FCR, setting expectations, and timing and location of FCR. In general, patients expressed a wide array of positive, negative, and neutral impressions within each theme relating to their experiences with FCR. Patient comments regarding their experience with FCR offer unique perspectives from previously studied participants, including physicians, nurses, students, and parents. Future research aimed at evaluating the bedside rounding process should incorporate patients' views to realize the complete FCR experience.

Testing the Feasibility of Skype and FaceTime Updates With Parents in the Neonatal Intensive Care Unit.

Effective provider-parent relationships are essential during critical illness when treatment decisions are complex, the environment is crowded and unfamiliar, and outcomes are uncertain. To evaluate the feasibility of daily Skype or FaceTime updates with parents of patients in the neonatal intensive care unit (NICU) and to assess the intervention's potential for improving parent-provider relationships. A pre/post mixed-methods approach was used. NICU parent participants received daily Skype or FaceTime updates for 5 days and completed demographic and feasibility surveys. Parents also completed Penticuff's Parents' Understanding survey before and after the intervention. Nurses and physicians completed feasibility surveys after each update. Twenty-six parents were enrolled and 15 completed the study. More than 90% of providers and parents perceived the intervention to be reliable and easy to use, and about 80% of parents and providers rated video and audio quality as either excellent or good. Frozen screens and missed updates due to scheduling problems were challenges. Two of the 4 subscores on the Parents' Understanding survey improved significantly. Qualitative data favor the intervention as meaningful for parents. Real-time videoconferencing via Skype or FaceTime is feasible for providing updates for parents when they cannot be present in the NICU and can be used to include parents in bedside rounds. Videoconferencing updates may improve relationships between parents and the health care team.

“Tele-rounding” with a remotely controlled mobile robot in the neonatal intensive care unit

Objective: To investigate the feasibility of ‘tele-rounding’ in the neonatal intensive care. Methods: In this prospective study utilizing telemedicine technology in the NICU for daily patient bedside rounds (‘tele-rounds’), twenty pairs of neonates were matched according to gestational age, diagnoses, and disease severity. One patient was cared for by the on-site NICU team lead by an on-site neonatologist. The other patient was cared for by the on-site team but led by an off-site neonatologist using a remote-controlled robot. Patient rounding data, clinical outcomes, length of stay, and hospital costs were compared between the two groups. Parents and staff were also surveyed about their satisfaction with telemedicine. Results: Except for one parameter, no significant differences in care or outcomes were found between patients cared for by either neonatologist. The exception was the time the off-site neonatologist spent on the patient encounter compared to the on-site neonatologist (median [interquartile range]), (5 minutes [5, 6] vs. 8 minutes [7, 10.5], p = 0.002). This difference was due primarily to time needed to operate and maneuver the robot or occasionally to slower or dropped connection to the Internet. There were positive perceptions of telemedicine among both parents and NICU staff. Conclusion: As long as direct bedside care providers are available, remote-controlled, robotic telemedicine technology can be utilized by neonatologists to perform daily patient rounds in the neonatal intensive care unit.

Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.

Inpatient rotations remain a central component in residency training, particularly in specialties such as internal medicine. However, maintaining the quality of this important learning experience has become a challenge. Recent approaches to redesigning the inpatient rounding experience have included reductions in the number of admissions and in patient census, which may not be feasible or desirable for many programs. The authors designed and implemented an approach to inpatient teaching that maintained the standard patient volume. It had the following five goals: (1) enhance bedside clinical skills, (2) promote a culture of patient safety, (3) emphasize diagnostic reasoning, (4) engage patients, and (5) provide learners with an expanded perspective on patients' experiences of care. This redesign, called the Chiefs' Service (CS) program, was implemented in 2013. The CS team acted as the intervention group in a quasi-experimental design study evaluating and comparing their experiences and outcomes with those of the standard inpatient medical teams not using the CS model. Five key team activities, or elements, were developed, piloted, and refined with learner, attending, and patient feedback. Those elements were morning huddle, bedside rounds, diagnostic "time-outs," day-of-discharge rounds, and postdischarge follow-up rounds. A robust evaluation process is under way; initial impressions from attendings, learners, and patients have been positive. Several educational outcomes also are being measured and compared with those of the standard inpatient medical teams. Further evaluations will guide modifications to the CS program and direct plans for dissemination within the institution and to other institutions.

Implementation of patient-centered bedside rounds in the pediatric intensive care unit.

Implementation of effective family-centered rounds in an intensive care unit environment is fraught with challenges. We describe the application of PDSA (Plan, Do, Study, Act) cycles in a quality improvement project to improve the process of rounds and increase family participation and provider satisfaction. We conducted pre-/postintervention surveys and used 5 process measures for a total of 1296 daily patient rounds over 7 months. We were successful in conducting family-centered rounds for 90% of patients, with 40% family participation and a 64.6% satisfactory rating by pediatric intensive care unit providers.

Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion

BackgroundThere are limited data to inform the choice between parental presence at clinical bedside rounds (PPCBR) and non-PPCBR in neonatal intensive care units (NICUs).MethodsWe performed a single-centre, survey-based, crossed-over randomised...

A feasibility study of the provision of a personalized interdisciplinary audiovisual summary to facilitate care transfer care at hospital discharge: Care Transfer Video (CareTV).

To assess the feasibility and patient acceptance of a personalized interdisciplinary audiovisual record to facilitate effective communication with patients, family, carers and other healthcare workers at hospital discharge. Descriptive pilot study utilizing a study-specific patient feedback questionnaire conducted from October 2013 to June 2014. Twenty General Medical inpatients being discharged from an Acute General Medical Ward in a metropolitan teaching hospital. Audiovisual record of a CareTV filmed at the patient's bedside by a consultant-led interdisciplinary team, within 24 h prior to discharge from the ward, provided immediately for the patient to take home. Patient surveys were completed within 2 weeks of discharge. Technical quality, utilization, acceptability, patient satisfaction and recall of diagnosis, medication changes and post-discharge review arrangements. All patients had watched their CareTV either alone or in the presence of a variety of others: close family, their GP, a medical specialist, friends or other health personnel. Participating patients had good understanding of the video content and recall of their diagnosis, medication changes and post-discharge plans. Patient feedback was overwhelmingly positive. In the context of a General Medical Unit with extensive experience in interdisciplinary bedside rounding and teamwork, CareTV is simple to implement, inexpensive, technically feasible, requires minimal staff training and is acceptable to patients. The results of this pilot study will inform and indicate the feasibility of conducting a larger randomized control trial of the impact of CareTV on patient satisfaction, medication adherence and recall of key information, and primary healthcare provider satisfaction.

Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction.

Efficient, accurate, and timely communication is required for quality health care and is strongly linked to health care staff job satisfaction. Developing ways to improve communication is key to increasing quality of care, and interdisciplinary care teams allow for improved communication among health care professionals. This study examines the patient- and family-centered use of structured interdisciplinary bedside rounds (SIBR) on an acute care for the elderly (ACE) unit in a 555-bed metropolitan community hospital. This mixed methods study surveyed 24 nurses, therapists, patient care assistants, and social workers to measure perceptions of teamwork, communication, understanding of the plan for the day, safety, efficiency, and job satisfaction. A similar survey was administered to a control group of 38 of the same staff categories on different units in the same hospital. The control group units utilized traditional physician-centric rounding. Significant differences were found in each category between the SIBR staff on the ACE unit and the control staff. Nurse job satisfaction is an important marker of retention and recruitment, and improved communication may be an important aspect of increasing this satisfaction. Furthermore, improved communication is key to maintaining a safe hospital environment with quality patient care. Interdisciplinary team rounds that take place at the bedside improve both nursing satisfaction and related communication markers of quality and safety, and may help to achieve higher nurse retention and safer patient care. These results point to the interconnectedness and dual benefit to both job satisfaction and patient quality of care that can come from enhancements to team communication.

Reorganizing a hospital ward as an accountable care unit.

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers.

BackgroundCompetency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds.MethodsThe authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010–2011).ResultsHalf of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace “teachable moments” related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling.ConclusionsBedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching.

Educating medical students about the personal meaning of terminal illness using the film, "Wit".

Addressing the emotional needs of dying patients is rarely found to have a place in formal medical curriculum and is also a difficult area to teach through classical medical lectures. "Cinemeducation" is a wonderful way to educate health care providers about the magnitude of emotions that arise during those difficult situations. The aims of this study were to test the relevance and usefulness of the movie 'Wit' in teaching medical students about the personal meaning of terminal illness and to assess the impact of this teaching method on students' attitudes toward palliative care. This was an education study using qualitative and quantitative data analysis of 518 first-year medical students in a single medical faculty in Turkey. Students watched the entire film, filled out an evaluation questionnaire, and answered questions about the film. Students also expressed their own feelings and thoughts about palliative care. Overall, 88% rated the film as excellent, very good, or good. According to 54% of the students, the emotions of terminally ill patients were fully portrayed in the film and in a very realistic way. Approximately 61.4% of the students found this film emotional. Most students (80.5%) stated that this film made them think about the emotional and spiritual suffering that dying patients go through and found this learning approach about palliative care more useful than didactic lectures and journal article readings but not more useful than bedside rounds. It was thought that caring for dying patients would be very or fairly personally satisfying for 65.3% of the students. The film 'Wit' gave the students an opportunity to explore their beliefs, values and attitudes in terms of the bio-psycho-social-spiritual aspects of health care and encouraged them to think more about the humanitarian issues of the medical profession.

Stimulated recall methodology for assessing work system barriers and facilitators in family-centered rounds in a pediatric hospital

Human factors and ergonomics methods are needed to redesign healthcare processes and support patient-centered care, in particular for vulnerable patients such as hospitalized children. We implemented and evaluated a stimulated recall methodology for collective confrontation in the context of family-centered rounds. Five parents and five healthcare team members reviewed video records of their bedside rounds, and were then interviewed using the stimulated recall methodology to identify work system barriers and facilitators in family-centered rounds. The evaluation of the methodology was based on a survey of the participants, and a qualitative analysis of interview data in light of the work system model of Smith and Carayon (1989, 2001). Positive survey feedback from the participants was received. The stimulated recall methodology identified barriers and facilitators in all work system elements. Participatory ergonomics methods such as the stimulated recall methodology allow a range of participants, including parents and children, to participate in healthcare process improvement.

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice.

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence. A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland. Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers. Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

Capsule Commentary on Gonzalo et al., Patient-Centered Interprofessional Collaborative Care: Factors Associated with Bedside Interprofessional Rounds

Gone are the days of a sagely white-haired diagnostician leading a team of learners to a patient’s bedside and extolling wisdom to his attentive listeners. Today’s rounds are more likely to take place in a hallway or conference room with a computer at center stage instead of the patient.1 This occurs despite the fact that patients prefer to interact with the care team at the bedside.2, 3 In the article “Patient-Centered Interprofessional Collaborative Care: Factors Associated with Bedside Interprofessional Rounds”, Gonzalo et al. examine factors that promote bedside interprofessional rounds (BIR).4 The Affordable Care Act and the potential emergence of more patient-centered and quality-based care are bringing increased attention to the benefits of collaborative care. Healthcare that intentionally includes doctors and other health professionals results in increased care coordination, shared decision making, and communication, all of which are important to meeting the Institute of Healthcare Improvement’s Triple Aim of improving the patient experience (quality and satisfaction), improving health of populations, and reducing costs. Gonzalo and colleagues in an observational study of 412 rounding encounters with 25 attending physicians found that BIR occurred in 64 % of rounding encounters and was more likely to take place if the census size was less than 12, the attending had less than 5 years of experience (compared to attendings with more than 16 years of experience), a senior resident was on the team, or rounds occurred on a weekday. Interprofessional education and patient-centered care deserve increased attention, as there is ample evidence that health care delivered by multidisciplinary teams improves outcomes.5 Gonzalo’s study is the first to examine what factors make BIR more or less likely to occur. There was no data provided on patient-centered outcomes, such as patient satisfaction and no data on learner perceptions of the effectiveness of these rounds. This research offers medical educators interested in maximizing patient-centered interprofessional care the opportunity to anticipate areas of challenge and make more informed decisions about program implementation. The best news that emerges from this study is that bedside rounds are still being conducted regularly.

Can Hospital Rounds With Pocket Ultrasound By Cardiologists Reduce Standard Echocardiography?

BackgroundFrequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative. MethodsThis was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities. ResultsA total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10−7). All outcomes remain significant after correcting for multiple testing using the false discovery rate. ConclusionsThe results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.

Internal medicine rounding practices and the accreditation council for graduate medical education core competencies

The Accreditation Council for Graduate Medical Education (ACGME) has established the requirement for residency programs to assess trainees' competencies in 6 core domains (patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice). As attending rounds serve as a primary means for educating trainees at academic medical centers, our study aimed to identify current rounding practices and attending physician perceived capacity of different rounding models to promote teaching within the ACGME core competencies. We disseminated a 24-question survey electronically using educational and hospital medicine leadership mailing lists. We assessed attending physician demographics and the frequency with which they used various rounding models, as defined by the location of the discussion of the patient and care plan: bedside rounds (BR), hallway rounds (HR), and card-flipping rounds (CFR). Using the ACGME framework, we assessed the perceived educational value of each model. We received 153 completed surveys from attending physicians representing 34 institutions. HR was used most frequently for both new and established patients (61% and 43%), followed by CFR for established patients (36%) and BR for new patients (22%). Most attending physicians indicated that BR and HR were superior to CFR in promoting the following ACGME competencies: patient care, systems-based practice, professionalism, and interpersonal skills. HR is the most commonly employed rounding model. BR and HR are perceived to be valuable for teaching patient care, systems-based practice, professionalism, and interpersonal skills. CFR remains prevalent despite its perceived inferiority in promoting teaching across most of the ACGME core competencies.