Physician Rounds Research Articles

IDEAL PICU Rounds: Improving Daily Efficiency by Applying Lean Principles.

The objective of this project was to improve communication, patient throughput, and rounding efficiency. Primary outcome studied was transfer/discharge order entry time and secondary outcomes included medication order entry time, staff perception, and time spent per patient. The location was a level one pediatric intensive care unit in an academic children's hospital. Utilizing Lean Six methodologies the major contributor to increased variability was different attending physician rounding patterns. These patterns were evaluated by a multidisciplinary committee, and the most efficient was adopted by all attending physicians during the study period. Data was collected by secret observers and a pre-post staff perception survey. Transfer/discharge order entry improved by 45 minutes/patient. Medication order entry improved by 89 minutes/order. Staff survey showed increased satisfaction in 9 of 12 aspects. Time spent per patient increased by 20%. In conclusion, standardization of rounds improved patient throughput, medication order entry, and staff satisfaction while increasing value-added time during rounds.

A digital application and augmented physician rounds reduce postoperative pain and opioid consumption after primary total knee replacement (TKR): a randomized clinical trial

BackgroundSevere postoperative pain not only is a considerable burden for patients but also leads to overprescription of opioids, resulting in considerable health concerns. The remarkable development of new technologies in the health care system provides novel treatment opportunities in this area and could exploit the additional placebo effect, provide added value for patients, and at the same time support hospital staff. We aimed to test the pain- and opioid intake-reducing effects of enhanced postoperative pain management by boosting pain medication by using a technical application and/or augmented physician rounds.MethodsIn a four-arm, randomized clinical trial, 96 patients (24 patients per group) scheduled for a total knee replacement (TKR) were randomized into four groups for four postoperative days: an “application” group (APP) with information via an iPad-based application; a “doctor” group (DOC) with augmented physician rounds; a combination group (APP+DOC), which received both interventions; and a “treatment as usual” group (TAU) as a baseline with no additional intervention besides the standard care which consists of standardized medication, regular physician rounds, and physiotherapy. Postoperative pain and opioid requirements pre- and postoperatively until hospital discharge were recorded.ResultsThe difference between post- and preoperative pain was significantly different between the groups (P=.02, partial η2=.10). APP+DOC experienced greater postoperative pain relief than DOC (mean: 2.3 vs. 0.7, 95% CI: 0.08–3.09; P=.04) and TAU (mean 2.3 vs. 0.1; 95% CI: 0.69–3.71; P=.005), respectively, the difference compared to APP (mean 2.3 vs. 1.7; 95% CI −1.98–1.76) was not significant. Opioid consumption differed significantly between groups (P=.01, partial η2=.12). APP+DOC (72.9 mg) and DOC (75.4 mg) consumed less oxycodone than APP (83.3 mg) and TAU (87.9 mg; 95% CI: 2.9–22.1; P=.003). APP+DOC consumed significantly less oxycodone than DOC (d=0.2–0.4). There were no significant group differences in NSAID and Morphine sulfate consumption. Patients in APP+DOC were more satisfied with their treatment than patients in TAU (P=.03, partial η2=.09).ConclusionsThe combination of an innovative digital app, which implements open drug administration and augmented physician rounds that support the doctor–patient relationship can significantly improve postoperative pain management.Trial registrationThe protocol was approved by the local ethics committee of the ethical commission of the German Psychological Society (Deutsche Gesellschaft für Psychologie; DGPs). The study was registered at DRKS.de (identifier: DRKS00009554).

Adequacy of physician clinical rounds and nursing care elements for non-COVID-19 infected patients admitted during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic created many challenges for healthcare systems. Frontline workers and especially healthcare professionals were the most severely affected through increased working hours, burnout and major psychological distress. ObjectivesTo evaluate the changes in standard care elements which occurred during the COVID-19 pandemic, specifically the physician clinical rounds and nursing care provided to non-COVID-19 infected patients. DesignObservational retrospective study. SettingsThe study was conducted at King Abdulaziz Medical City, Riyadh Saudi Arabia. KAMC is a 1200 bed tertiary care referral academic medical center. Patients (materials) and methodsWe compared the physician clinical rounds and nursing care elements in all admissions due to non-COVID-19 pneumonia and ST elevation myocardial infarction during the lockdown period with similar admissions in a baseline period in the same weeks in the previous pre-lockdown. Main outcome measuresTo evaluates the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care. Sample sizeTotal of 113 patients records were analyzed. ResultsDuring the lock down period, a total of 113 patients were admitted to the medical and cardiology wards, (95 patients with pneumonia and 18 patients with ST segment elevation myocardial infarction (STEMI)) compared to 89 patients in the pre lockdown period (74 patients with pneumonia and 15 patients with STEMI). Both groups were similar in age, gender, disposition, length of stay, goal of care planning and outcome. Chronic respiratory disease and Diabetes were more present in patients admitted on the pre lockdown time. Azithromycin was more frequently used as part of the initial antibiotic regimen for pneumonia during the pre-lockdown while doxycycline was significantly more during the lockdown.For the 95 patients admitted in the medical wards during the lockdown, there were a total of 820 physicians’ clinical rounds opportunities for senior and junior physicians each. The residents missed 133 (16.2%) and consultant missed 252 (30.7%) of those clinical rounds opportunities. Missed clinical rounds opportunities during the pre-lock down period was higher for residents and consultants at 19.3% (P = 0.429 ) and 36.3% respectively (P = 0.027 ). Similarly, missed clinical rounds opportunities was less during the lockdown period from 35.2% to 25% (p 0.022) and from 38.8% to 30.6% (p = 1 ) for junior staff and consultant cardiology respectively compared to pre lockdown period. For nursing care elements, there was a decrease in missed opportunities in vital signs measurement (p 0.47 and p 0.226), pain assessment (p 0.088 and p 0,366) and skin care (p 0.249 and p 0.576) for patients admitted during the lockdown period in medical and cardiology wards. ConclusionsCaring for patients admitted for non COVID 19 infection reasons, physicians’ clinical rounds did marginally increase compared to pre lockdown period while nurses monitoring for those patients was significantly higher. No difference in mortality was observed for patients admitted pre and during lockdown. The number of missed opportunities to do clinical rounds by physicians remains high during both periods and measures to improve adherence of physicians to performed clinical rounds are needed.

SELF-EXTUBATIONS IN THE ICU: A REVIEW OF TIME OF DAY AS A POTENTIAL RISK

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Self-extubation is an uncommon but real phenomenon occurring in ICUs with harmful and potentially fatal implications. Understanding the surrounding variables and mechanisms at play that put an intubated patient at risk for these events is vital to prevent future unplanned extubations. This study was undertaken to identify the factors placing patients at greatest risk of self-extubation and later need for reintubation, namely time of day. METHODS: 55 patients (62% male) with a mean age of 50 were identified across 5 ICUs and 118 ICU beds from a tertiary medical center in Dallas, TX were identified to have self-extubated from 2019 to 2020. A retrospective cohort review of all unplanned extubations was performed. Patient data was organized into two-by-two contingency tables and analyzed using Fisher’s Exact Test. RESULTS: Neither age nor gender were statistically significant predictors for reintubation after self-extubation (p=0.21 and p=0.61, respectively). 24 self-extubations occurred during the day shift (7am-7pm) and 31 occurred during the night shift (7pm-7am). It was statistically more likely for patients to require reintubation during the night shift (p=0.042). Self-extubation at shift change (6am-8am or 6pm-8pm) was not a statistically significant predictor of need for reintubation (p=0.218). CONCLUSIONS: Patients who self-extubated during night shift were more likely to require reintubation than those during day shift. Despite adequate handoff from providers and other staff, cross-cover night teams may be less familiar with the patients and a lack of multidisciplinary rounding at night may lead to more conservative management and more frequent reintubation. Less frequent physician rounding during night shift also may mean that patients are self-extubating because planned extubations are less likely to occur overnight and physicians are less likely to evaluate a patient unless alerted to a change in clinical status. Additionally, if the primary team is considering a next day extubation, sedation holidays at night may play a role in increasing self-extubation. Ultimately, multiple factors contribute and further research into medications administered, respiratory plan of care, and patient specific factors may be able to identify risk factors for overnight self-extubation. CLINICAL IMPLICATIONS: By attempting to understand why patients are self-extubating we will be able to better care for our ventilated patients and ensure that they are safe while in our care. Patients self-extubating during the night shift are requiring reintubation at a higher rate, indicating potential room for improvement in our ICUs, whether this be in nursing education of the team’s plan, making sure our nursing staff has adequate training and experience to handle ventilated patients, or creating a plan that involves more frequent rounding on patients by physicians and respiratory therapists during the night shift. DISCLOSURES: No relevant relationships by Maythawee Bintvihok, source=Web Response No relevant relationships by Jessica Kent, source=Web Response No relevant relationships by Denizen Kocak, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response No relevant relationships by Jiesu Sun, source=Web Response No relevant relationships by Ciara Wisecup, source=Web Response

Interruptions to Attending Physician Rounds and Their Effect on Resident Education.

Daily attending rounds (AR) are a cornerstone of teaching and patient care in academic health centers. Interruptions in health care are common and can cause increased risk of errors, incomplete work, and decreased decision-making accuracy. Interruptions to AR may diminish a trainee's capacity to learn and retain information. We characterized and quantified interruptions that occur during AR. We used a mixed-methods design combining a prospective observational study with a qualitative study. AR were observed January to March 2020 to characterize interruptions, followed by semi-structured interviews with the observed physicians to elucidate the effect of interruptions on workflow and the educational value of rounds. There were 378 observed interruptions over the course of 30 AR sessions, averaging 12.6 (range 1-22, median 13) interruptions per rounding session. Bedside nursing staff was the most common source of interruptions (25%) and consultant recommendations was the most common topic of interruption (21%). Most interruptions occurred during patient presentations (76%), and the most common method of interaction was text message (24%). Most team members described negative effects of interruptions, including loss of focus and missing critical clinical information; some also reported that certain interruptions had positive effects on education and clinical care. Interns were more likely to report negative emotional reactions to interruptions. AR are frequently interrupted for non-urgent topics by a variety of methods and sources. Negative effects included loss of focus, missed information, and increased stress. Proactive communication, particularly between physicians and nurses, was suggested to reduce interruptions.

Perceptions of interdisciplinary bedside rounds by head nurses in Flanders: a cross-sectional exploration

ABSTRACT Objectives Interdisciplinary bedside rounds is gaining ground as a method to improve patient centredness and involvement, quality of care and team collaboration. An exploratory study was conducted in Flemish hospitals to (1) map and (2) examine the current form of rounds and the extent to which these were bedside, patient and family participatory and interdisciplinary. Methods In February 2020, a quantitative cross-sectional self-reporting web-based survey was conducted in 23 hospitals in Flanders, 213 head nurses of 213 wards completed the survey. A self-reporting 19-item questionnaire was developed in Lime Survey®. The questionnaire contained a mix of closed-ended questions an open-ended questions. The data were analysed using SPSS 26.0. Results Most of the wards in Flanders organise a form of daily rounds at the bedside. In only half of the wards these rounds are organised at a fixed time. The rounds most often include a physician and a nurse. Other disciplines are rarely actively involved. Only a minority of wards uses checklists, structures or protocols to standardise the rounds. The majority of the wards reports that patients (and family) get sufficient time to ask questions and say they are actively stimulated to do so. Conclusion In current practice, most rounds are (partially) bedside, open for patient and family participatory and often include only a physician and a nurse. However, these elements of interdisciplinary rounds are not yet well integrated and vary strongly amongst ward. Most rounds should be considered as an extended form of physician rounds, rather than being interdisciplinary.

316 Emergency Department Benchmarking Alliance Survey: Anatomy and Physiology of an Emergency Department Observation Unit

Health care entities can deliver observation services to determine whether or not a patient needs an inpatient admission. Many studies have shown that relative to care in a traditional inpatient bed, managing observation patients in an emergency department observation unit (EDOU), using condition-specific protocols, is associated with shorter hospital length of stays, lower costs, and decreased inpatient admission rates. Because of these advantages, health care entities have been opening these units more frequently. A 2003, survey found that 1/3 of hospitals in the US had EDOUs, and more were planning on building them. This statistic has been the standard talking point in the growth of observation for more than a decade. Since this original survey, there has been very little published data on the number of EDOUs as well as their operating characteristics. We surveyed the members of the Emergency Department Benchmarking Alliance (EDBA) as well as the American College of Emergency Physicians (ACEP) Observation Services Section as to the presence of an Observation Unit at their hospitals. Surveys were sent via email which contained a SurveyMonkey link to the questions. The account is securely maintained by EDBA. The responses were de-identified and entered into an excel spreadsheet for analysis. Respondents: Ninety sites responded to the survey representing 28 states plus the District of Columbia. Five responses answered only the state of practice and an additional 2 respondents answered only who admits to the OU. Unit Characteristics: Most of the OUs in this cohort were closed units. The median number of beds (IQR) for the respondents of the survey was 12 (10-18). Only 7 units reported not using patient care protocols. Unit Staffing: Emergency medicine admitted patients to 61 (67%) of the OUs, Hospitalist/Internal medicine were the admitting physicians in 5 units and Cardiology in 1 unit. Two sites reported they had hybrid units where EM or IM could admit to the OU. Fifteen of the units (16%) were “open,” were any service could admit to the OU. Advanced Practice Providers (APPs) are utilized in the vast majority of sites (69 as opposed to 13 that don’t). In terms of physician rounding in the unit, 49 of the sites (54%) utilize an emergency physician who is concurrently working a shift in the ED. Eighteen sites have a dedicated OU physician. One site reported that their NPs function independently with no physician oversight. The most common RN: Patient ratio is 1:5, used in 42 (46%) of the surveyed sites. The highest and lowest RN:Patient ratios are 1:2 and 1:8, respectively. These were each reported by one site. Unit Throughput Median annual volume (IQR) for this cohort is 4,015 (2,676 - 5,475) patients. Median length of stay in the unit (IQR) is 20 hours (17-23). Average conversion to inpatient status is 16%. Patient characteristics: The most common chief complaint seen in OUs in this cohort is chest pain. Other common reasons for observation include abdominal pain, TIA, syncope, asthma and COPD. Observation units as surveyed in this cohort are mainly emergency department-based and ED managed. Future challenges for these units will be maintaining occupancy in the face of potentially decreasing chest pain cases. Further study needs to be done as to the impact of APPs and role of EM/IM collaboration. Ultimately, a national database of Observation Units and observation patient stays is needed.

Virtual Nursing: The New Reality in Quality Care.

The purpose of this article is to report on an innovative new model of care and the effects this model pilot program had on patient satisfaction, staff satisfaction, physician satisfaction, patient quality metrics, and financial metrics. The Virtually Integrated Care team is a model of care that leverages technology to bring an experienced expert nurse into the patients' room virtually. The advanced technology allows the virtual nurse to direct and monitor patient care, interacting with the patient through 6 core roles: patient education, staff mentoring/education, real-time quality/patient safety surveillance, physician rounding, admission activities, and discharge activities.

Understanding Workflow and Personal Protective Equipment Challenges Across Different Healthcare Personnel Roles.

Hospitals use standard and transmission-based precautions, including personal protective equipment (PPE), to prevent the spread of infectious organisms. However, little attention has been paid to the potentially unique challenges of various healthcare personnel (HCP) in following precaution practices. From September through December 2016, 5 physicians, 5 nurses, and 4 physical therapists were shadowed for 1 hour 30 minutes to 3 hours 15 minutes at an academic medical center. Observers documented activities using unstructured field notes. Focus groups were conducted to better understand HCP perspectives about precautions and PPE-related challenges. Data were analyzed by comparing workflow and challenges (observed and stated) in precaution practices across HCP roles. Precaution patients were interspersed throughout physician rounds, which covered a broad geographic range throughout the hospital. Patient encounters were generally brief, and appropriate use of gowns and cleaning of personal stethoscopes varied among observed physicians. Nurses were unit based and frequently entered/exited rooms. Frustration with donning/doffing was especially apparent when needing supplies while in a precaution room, which nurses acknowledged was a time when practice lapses could occur. The observed physical therapists worked in one geographic location, spent extended periods of time with patients, and noted that given their close physical contact with patients, gowns do not fully protect them. Movement patterns, time with patients, care activities, and equipment use varied across HCP, leading to a diverse set of challenges in following precaution practices and PPE use. Attention to these differences among HCP is important for understanding and developing effective strategies to prevent the potential spread of infectious organisms.

How Much Time are Physicians and Nurses Spending Together at the Patient Bedside?

Bedside rounding involving both nurses and physicians has numerous benefits for patients and staff. However, precise quantitative data on the current extent of physician-nurse (MD-RN) overlap at the patient bedside are lacking. This study aimed to examine the frequency of nurse and physician overlap at the patient beside and what factors affect this frequency. This is a prospective, observational study of time-motion data generated from wearable radio frequency identification (RFID)-based locator technology. Single-institution academic hospital. The length of physician rounds, frequency of rounds that include nurses simultaneously at the bedside, and length of MD-RN overlap were measured and analyzed by ward, day of week, and distance between patient room and nursing station. A total of 739 MD rounding events were captured over 90 consecutive days. Of these events, 267 took place in single-bed patient rooms. The frequency of MD-RN overlap was 30.0%, and there was no statistical difference between the three wards studied. Overall, the average length of all MD rounds was 7.31 ± 0.58 minutes, but rounding involving a bedside nurse lasted longer than rounds with MDs alone (9.56 vs 5.68 minutes, P < .05). There was no difference in either the length of rounds or the frequency of MD-RN overlap between weekdays and weekends. Finally, patient rooms located farther away from the nursing station had a lower likelihood of MD-RN overlap (Pearson's r = -0.67, P < .05). RFID-based technology provides precise, automated, and high-throughput time-motion data to capture nurse and physician activity. At our institution, 30.0% of rounds involve a bedside nurse, highlighting a potential barrier to bedside interdisciplinary rounding.

Implementing a Standardized Nurse-driven Rounding Protocol in a Trauma-surgical Intensive Care Unit: A Single Institution Experience.

IntroductionPatient care in the trauma-surgical intensive care unit (SICU) requires trust and effective communication between nurses and physicians. Our SICU suffered from poor communication and trust between nurses and physicians, negatively impacting the working environment and, potentially, patient care.MethodsA SICU Task Force studied communication practices and identified areas for improvement, leading to several interventions. The daily physician rounding was altered to improve communication and to enhance the role of the registered nurses (RN) in rounds. Additionally, a formal night resident rounding time was implemented.ResultsA post-intervention survey focusing on cooperation, teamwork, and appreciation between nurses and physicians revealed improvement in these domains. Informal feedback from nurses and physicians indicated improved working relationships and satisfaction with the SICU environment. However, results of a national survey performed after the intervention did not show the same level of improvement.ConclusionsA Task Force consisting of SICU nurses and physicians can effectively study a widespread communication issue and implement targeted interventions. While informal feedback may indicate improvement, it can be difficult to demonstrate improvement using formal surveys.

Increased physician and physical therapist communication is associated with earlier mobility and decreased length of stay in the cerebrovascular and trauma neuroscience population.

Recent efforts in neurocritical care have emphasized optimal timing and employment of rehabilitation services. However, there is sparse literature on the effect of team approaches to the intensive care patient. The aim of this study was to evaluate the effect of increased coordination between a physical therapist and an attending cerebrovascular neurosurgeon through daily multidisciplinary rounds. A retrospective review was performed of 235 patients who were admitted to the neuroscience service under a single cerebrovascular neurosurgeon over a 16-month period (April 2014 through July 2015) in a level-I trauma hospital. The study consisted of an eight-month pre-intervention period (n = 117) where the physical therapist did not attend physician rounds and an eight-month post-intervention period (n = 118). In the post-intervention group the physical therapy (PT) assessment occurred on average 1.57 days sooner (p < 0.001). Hospital Length of Stay (LOS) decreased by an average of 3.46 days (p = 0.04) and ICU LOS decreased on average by 1.83 days (p = 0.05) in the post-intervention group. Ventilator days decreased on average by 0.55 days, which was not statistically significant (p = 0.26). In conclusion, daily coordination with multidisciplinary rounds between the physician and the physical therapist was associated with decreased time to initial PT assessment, decreased hospital LOS, and decreased ICU LOS in the neuroscience population.

User participation in a Municipal Acute Ward in Norway: dilemmas in the interface between policy ideals and work conditions.

User participation has become an increasingly important principle in health care over the last few decades. Healthcare professionals are expected to involve patients in treatment decisions. Clear guidance as to what this should entail for professionals in clinical work is not accounted for in legislation. In this study, we explore how healthcare professionals in a Municipal Acute Ward perceived, experienced and performed user participation. The ward represents a new short-time service model for emergency assistance in Norway. We focused on the challenges the professionals faced in clinical work and how they dealt with these. Data were drawn from qualitative interviews with 11 healthcare professionals and from 10 observations in relation to previsits and physician's rounds in the ward. Transcripts of interviews and observations were analysed using a method for systematic text condensation. In the analysis, we applied Lipsky's perspective on dilemmas of street-level bureaucrats. The results show that that the professionals perceived user participation as an important and natural part of their work. They experienced difficulties related to collaboration with patients, caregivers, and professionals in other services, and with framework conditions that caused conflicting expectations, responsibility, and priorities. The professionals seemed to take a pragmatic approach to user participation, managing it within narrow perspectives. Our study indicates that the participants dealt with the dilemmas at the cost of user participation. The results demonstrate that there is a gap between the outlined health policy and the professionals' opportunities to fulfil this policy in clinical work regarding user participation. The policy decision-makers should recognise the balancing work required of healthcare professionals to deal with difficulties in clinical work. The knowledge that professionals possess as performers of services and the need for valuing in policy processes should be acknowledged.

No Patient Left Behind: Patient-Centered Healthcare Reform

No Patient Left Behind: Patient-Centered Healthcare Reform

Abstract WP155: Increased Physician and Physical Therapist Communication is Associated With Earlier Mobility and Decreased Length of Stay in the Cerebrovascular and Trauma Neuroscience Population

Background and Purpose: There is growing interest in methods for early rehabilitation in patients with acute neurologic conditions. The purpose of this study was to identify whether increased coordination between the physical therapist and an attending cerebrovascular neurosurgeon through daily multidisciplinary rounds would correlate with positive changes in overall care. Hypothesis: We evaluated the hypothesis that a physical therapist participating in cerebrovascular neuroscience rounds would decrease the time to initial physical therapy (PT) consult, decrease hospital length of stay (LOS), decrease Intensive Care Unit (ICU) LOS, and decrease ventilator days. Methods: A retrospective review was performed of 235 patients who were admitted to the neuroscience service under a single cerebrovascular neurosurgeon over a 16-month period (April 2014 through July 2015) in a level-I trauma hospital. The study consisted of an eight-month pre-intervention period (n=117) where the physical therapist did not attend physician rounds and an eight-month post-intervention period (n=118). Results: In the post-intervention group the PT assessment occurred on average 1.57 days sooner than before the physical therapist participated in neuroscience physician rounds (p&lt;0.001). Hospital LOS decreased by an average of 3.46 days (p=0.04) and ICU LOS decreased on average by 1.83 days (p=0.05) in the post-intervention group. Ventilator days decreased on average by 0.55 days, which was not statistically significant (p=0.26). Conclusions: In conclusion, daily coordination with multidisciplinary rounds between the physician and the physical therapist was associated with decreased time to initial PT assessment, decreased hospital LOS, and decreased ICU LOS in the neuroscience population.

84: Routine versus delayed timing of morning hospital rounds for postpartum women on patient satisfaction: A randomized quality improvement trial

Early morning physician rounding is a part of traditional hospital culture. Benefits include early patient discharge as well as physician convenience to begin other clinical duties. Potential disadvantages include inadequate communication and sleep disruption. The objective of this study was to determine whether timing of physician rounding of postpartum women impacts patient satisfaction. Women under the care of a university-based OB/GYN faculty practice who delivered at a tertiary care medical center were randomly allocated to either routine rounding (4 - 7am) or delayed physician rounding (after 8 am) from postpartum day 1 until discharge. Women with medical conditions or delivery complications that precluded the ability to delay rounding were excluded. On day of discharge, research staff blinded to rounding group distributed a standardized survey that included questions regarding physician communication and hospital experience. Based on delivery volumes, we planned to conduct the study over a pre-defined two month period. We estimated that the study would require 74 total subjects (N=37 per group) to detect a 20% difference in overall rating of the hospital (0-10 score) between groups (assumption P=0.05 and power 90%). 155 women participated in the study (N= 76 routine rounding; N= 76 delayed rounding). Maternal demographics and clinical characteristics were similar between groups except for delivery mode. More women had cesarean delivery in the routine compared to delayed rounding group (47.4% vs. 22.4%). Patient satisfaction scores were improved not only for quality of physician communication, but also for hospital experience and overall hospital rating (see Table). Adjustment for delivery mode with linear regression did not alter the findings (p < 0.001). There were no differences between groups in timing of maternal discharge occurring after 10 am (25% routine vs. 30.3% delayed; p=0.47) or timing of neonatal discharge after 10 am, 94.7% vs. 90.8% (p=0.35). Postpartum women who received delayed physician rounding were more satisfied with physician communication and overall hospital experience without prolonging their hospital stay or time of discharge.

JOINT COMMISSION INTERNATIONAL (JCI) IN THE PEDIATRIC INTENSIVE CARE UNIT (PICU): PREVENTING MEDICATION INCIDENTS THROUGH REMOTE CONTROL

IntroductionMany medical centers worldwide try to get JCI accreditation in order to improve safety and quality of patient care. Review of medication orders for appropriateness is one of the JCI standards. This process is usually performed by clinical pharmacists joining physician rounds. However, in many medical centers there is a shortage of pharmacists.ObjectivesTo prospectively investigate the process of remote reviewing of medication orders in the PICU, with a pharmacist located at the pharmacy, without joining physician rounds. To characterize pharmacist recommendations (PR) and decisions taken by the physician.MethodsThe study was carried out from 6.3.14–6.10.14 in the PICU (7 beds). Patient demographics, diagnosis and medications prescribed were recorded.Results186 review forms were filled in by the pharmacist, regarding 117 admissions(109 children). In 57 (30.6%) forms there was at least one PR. Most common PRs concerned significant interactions (34.5%), dose (26.2%), technical inappropriateness (22.6%) and contraindications (8.3%). Out of all PRs, 51.2% were accepted by the physician, 11.9% rejected and in 36.9% there was no comment. The estimated review time for one medical record was 8.9 min (95% CI, 6.9–10.9), as every additional medication prescribed increased the total review time by 0.8 min (95% CI, 0.49–1.11). Using Monte-Carlo simulation, 108.42 min per day were needed to review all medical records in 95% of the cases.ConclusionsHospitals facing budget shortages can perform a daily remote review of several departments by an experienced pharmacist instead of participation in physician rounds, and still have a considerable effect on patient safety.

Implementation of Later Morning Specimen Draws to Improve Patient Health and Satisfaction.

Traditionally, morning blood draws are collected by hospital staff from 3:00 AM through 6:00 AM to have the results ready by 9:00 AM for physician rounds. These laboratory results help physicians to make important patient disposition decisions, including discharging patients within the daily hospital cutoff times. However, morning draws can adversely impact patient care due to sleep disruption. In this paper, we describe the systematic implementation of later-morning blood draw times at our large urban hospital. The sustainability of this shift was of special concern to us, so we used the rapid improvement model (RIM) of change to ensure that every aspect was tested and that the changes were viable. The RIM model enabled us to successfully implement the change in 6 months and sustained this change until the present time.

Drug-related problems identification in general internal medicine: The impact and role of the clinical pharmacist and pharmacologist

BackgroundPatients admitted to general internal medicine wards might receive a large number of drugs and be at risk for drug-related problems (DRPs) associated with increased morbidity and mortality. This study aimed to detect suboptimal drug use in internal medicine by a pharmacotherapy evaluation, to suggest treatment optimizations and to assess the acceptance and satisfaction of the prescribers. MethodsThis was a 6-month prospective study conducted in two internal medicine wards. Physician rounds were attended by a pharmacist and a pharmacologist. An assessment grid was used to detect the DRPs in electronic prescriptions 24h in advance. One of the following interventions was selected, depending on the relevance and complexity of the DRPs: no intervention, verbal advice of treatment optimization, or written consultation. The acceptance rate and satisfaction of prescribers were measured. ResultsIn total, 145 patients were included, and 383 DRPs were identified (mean: 2.6 DRPs per patient). The most frequent DRPs were drug interactions (21%), untreated indications (18%), overdosages (16%) and drugs used without a valid indication (10%). The drugs or drug classes most frequently involved were tramadol, antidepressants, acenocoumarol, calcium–vitamin D, statins, aspirin, proton pump inhibitors and paracetamol. The following interventions were selected: no intervention (51%), verbal advice of treatment optimization (42%), and written consultation (7%). The acceptance rate of prescribers was 84% and their satisfaction was high. ConclusionPharmacotherapy expertise during medical rounds was useful and well accepted by prescribers. Because of the modest allocation of pharmacists and pharmacologists in Swiss hospitals, complementary strategies would be required.

Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study.

Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this "weekend effect" is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke. We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91-1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose-response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07-1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77-0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services. Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors' Summary.