Redoing rounding

Learn about the advantages and challenges of different types of rounding, how to set them up effectively, and how to ensure they are working well.

Geographic, unit-based, multidisciplinary, bedside—the catchphrases for improving hospital rounds are growing in number and prevalence. Journals, conferences and even this magazine provide a constant stream of examples in which hospitalist programs have updated their methods of rounding.

“The overwhelming majority of hospitals have room for improvement in their rounding model,” said Kevin J. O’Leary, MD, FACP, an associate professor of hospital medicine at Northwestern University in Chicago.

Illustration by Sarah Ferone
Illustration by Sarah Ferone.

But with so many diverse models being described, hospitals and hospitalists who want to get on the rounding-improvement bandwagon may have trouble deciding how exactly to improve their systems. And they're right to proceed cautiously, experts said.

“Any number of different rounding strategies you might want to adopt can have benefits, but all have costs—financial, time and other,” said John R. Nelson, MD, FACP, a hospitalist at Overlake Hospital in Bellevue, Wash., and partner in Nelson Flores Hospital Medicine Consultants. “You have to look at both your hospitalist group and your institution's capabilities and resources and decide for yourself what's best and what's most practical.”

While hospitals may rival snowflakes in uniqueness, awareness of some common procedures and pitfalls in rounding improvement can make it easier to select and implement a new system. Experts who have successfully executed rounding initiatives recently offered ACP Hospitalist their advice.

The first change

The experts agree that there is an optimal order for implementing new methods of rounding. Whenever possible, start by grouping the patients cared for by each hospitalist near each other, a concept that is often known as geographic or unit-based rounding.

The simplest benefit of geographic rounding is that hospitalists reduce their travel time between patients. “If you wander around a lot of units, you waste a lot of time,” said Philip Vaidyan, MD, FACP, practice group leader at IPC The Hospitalist Company and director of hospital medicine at SSM St. Mary's Health Center in St. Louis, Mo.

The hospitalist's more frequent presence near the patients provides other efficiencies. “Because you are on the unit, you already know which patients are going to be discharged tomorrow, so you can prepare for the discharge earlier,” Dr. Vaidyan said.

The intervention also affects how physicians interact with other clinicians, especially nurses. “A lot of the benefit derives from [an increase in quantity and quality] of communication between the patients and the hospitalists, the hospitalists and the nurses, the hospitalists and the pharmacists. Proximity also lends itself to a more intangible concept of teamwork and empathy between people who are taking care of patients,” said Siddhartha Singh, MD, an associate professor of medicine at the Medical College of Wisconsin in Milwaukee.

Dr. Singh and colleagues studied localized teams (another term for this rounding system) and found that it led to higher productivity and better workflow, as they reported in the September 2012 Journal of Hospital Medicine.

Geographic rounding can be challenging to implement, however. Hospitals that have multiple hospitalist groups, many outpatient physicians seeing inpatients, or locum tenens may have trouble grouping patients, the experts said.

Frequent transfers of patients from one unit to another can also impede the system. “That is tough in some places where, for example, they don't have centralized telemetry, so they have to send patients to a specific unit that's got telemetry, or there's a step-down unit,” said Dr. O’Leary.

But many of these barriers can be overcome. “In the ICU, we assign patients based on where we anticipate they will downgrade to. For example a postoperative [coronary artery bypass graft] patient will assuredly downgrade to our cardiac unit. So the hospitalist assigned to the cardiac unit would pick up that ICU patient,” said Judy Tan Shumway, DO, ACP Member, practice group leader for IPC The Hospitalist Company at HCA Methodist Stone Oak Hospital in San Antonio, Texas.

The problem of multiple hospitalist groups can be solved, too. “What it takes is looking back at historical data and finding out on average how many patients does Hospitalist Group A typically have? If their census is 30 beds on average per day and the units are 30 beds, then can't we designate one unit to be Hospitalist Group A's unit?” said Dr. O’Leary.

Keep in mind that localization doesn't have to be absolute. “It's really hard for a hospitalist program to have 100% of a hospitalist's patients on the hospitalist-designated unit, but if you have 75%, 85% localized, that's a huge step in the right direction. Or if you say our hospitalists are not going to be caring for patients on more than 2 or 3 units—those are reasonable targets,” Dr. O’Leary said.

The unit assignment doesn't have to be permanent, either. “We gave the flexibility for doctors to change from 1 unit to another. Most of the doctors stay in 1 unit for a month or two,” said Dr. Vaidyan. “If you really like it, if you want to stay there forever, that's also possible.”

The next change

Once unit-based rounding has been successfully implemented, a popular next step is interdisciplinary rounding, or including clinicians other than physicians on rounds.

At the simplest, this can mean just bringing a nurse along, but many programs are including case managers, social workers, pharmacists, even respiratory therapists. The challenges of scheduling interdisciplinary rounds make it necessary to localize patients before trying this step.

“If you have a physician who's seeing patients on 6, 7, 8 different units, it's going to be nearly impossible for them to coordinate care with other team members who are mainly unit-based,” said Dr. O’Leary.

Even when geographic rounding is already established, scheduling is the primary challenge to interdisciplinary rounding. Mel Anderson, MD, FACP, associate professor of medicine in the Eastern Colorado Veterans Administration Health Care System in Aurora, Colo., described the problem he encountered.

“Nurses were having to pass medications at the same time that rounds would occur,” he said. “They not only were not available to go with us, but we were actually interrupting them while they were delivering medications, which presents its own safety problems.” The solution was to change the medication dispensing time from 9 a.m. to 7 a.m.

Many other obstacles to interdisciplinary rounds, including attendance and participation, can also be solved, according to Joan Curcio, MD, ACP Member, director of the inpatient medical service at Elmhurst Hospital Center in Elmhurst, N.Y. “For the first couple months, more days than not, you were paging people. Then it became the norm…they were just showing up,” she said.

Getting everyone to actually talk during the rounds took some work, too. “The biggest barrier is finding a time that works…and for everybody to feel like they have something valuable to give and get,” Dr. Curcio said. One solution is to designate a leader who can direct the conversation when necessary. “You need somebody with some willingness to oversee them up front and facilitate, not for the long run, but for the first couple weeks or months.”

Her facilitators have included the directors of nursing and social work and various hospitalists. When the facilitators observe someone not fully engaging in rounds, they pull him or her aside and try to resolve any obstacles to participation. Other programs have found that structuring the rounds, with set topics for each participant, can help with this.

If a hospital can overcome all the barriers, there are major benefits to interdisciplinary rounds, the experts said. “The patients seem to progress much more quickly when everybody on the team knows exactly what's going on. As physicians, we get a lot less pages in the afternoon about clarification of orders or requests to come and talk to the family, because the nurse knows the plan just as well as we do,” said Benjamin Duffy, DO, hospitalist lead at Thedacare's Appleton Medical Center in Appleton, Wis.

The concept is supported by evidence, too. Implementing interdisciplinary rounds reduced adverse events by almost half in a study by Dr. O’Leary and colleagues, which was published in Archives of Internal Medicine in April 2011.

Around the bed or table

The data are more uncertain for the other popular innovation in rounding: taking the interdisciplinary group to the bedside. The idea is to make patients a contributing part of that rounding team, rather than just an object of its work. According to Dr. Vaidyan, the concept works, with improved patient satisfaction scores as the proof. “They are seeing that nurses and doctors are working together and listening to them,” he said.

Dr. Anderson has also seen favorable response from patients to bedside rounds. “I've heard of patients after our joint rounding talking to each other [saying], ‘When is my team going to get here? That was pretty good what you had going on, all those people there,’” he said.

On the other hand, some patients may be taken aback and require a little warning. “Typically, if you're in the hospital and 5 people come into the room, you think you're really sick. When the patient is admitted, we tell the patient about the process we use,” said Dr. Duffy.

Some experts have reservations about bedside rounding. “It's another layer of complexity. How do you coordinate the schedules to be able to come to the bedside, and then how do you make sure that the group that's visiting the bedside isn't so huge that you defeat the purpose of bedside rounds?” said Dr. O’Leary.

If several clinicians gather at the bedside, and each has topics to cover, it could leave little time for the patient to speak. “How do you make sure that the patient is truly providing information to the team and being listened to, rather than just being informed?” Dr. O’Leary asked.

One solution his hospital is trying is to apply both models but not at the same time. The whole group meets in the conference room, and just the physician and nurse round on the patients together. Clinicians like the system so far, but there are questions about efficiency. “People are wondering, ‘Do I need to go to structured interdisciplinary rounds because I already spoke to the nurse?’” said Dr. O’Leary. “Does only the doc go? Or only the nurse?”

Thedacare has another method for bringing a group of clinicians to the bedside. Rather than getting into the nitty-gritty of rounds at the bedside, they have what they call pre- and post-huddles before and after rounding on each patient.

During the pre-huddle, the patient's chart is reviewed, any new updates are discussed and the issues to be addressed during the patient visit are chosen. Then the team goes in to see the patient.

“The nurse and the physician examine the patient together, which cuts down on the nurses having to re-examine,” said Dr. Duffy. “While the doctor is outlining the plan, the nurse or another member of the team will be documenting the plan on a white board by the patient's bed.” The white board information includes the patient's diagnosis, plan of care and expected discharge date.

“The post-huddle is where the team goes out and sits down at computers to put in the orders and write their notes, before moving on to the next patient,” he explained. Participants will drop in and out of these gatherings as necessary. “The care manager may stay [with the patient] while the rest of the team leaves and finish up a conversation about discharge needs, for example,” Dr. Duffy said.

An electronic system that identifies the patient currently being rounded on helps the necessary participants arrive at the right time, Dr. Duffy noted. The hospital's design also facilitates the rounding system, with many small alcoves where the team can gather and sit during the pre- and post-huddles. “Not everybody has that,” he said.

In addition to the spatial logistics, the role change may be an issue for some physicians. “If they're used to running around seeing 25 patients on their own, it's a big change to slow yourself down, to have to answer questions from members of the team, to take suggestions in a group setting, and potentially have your plan challenged,” said Dr. Duffy.

Nurses, on the other hand, may need reassurance that they won't be challenged during bedside rounds. “They were a little hesitant…a little fearful they might get asked questions in the same way we ask medical students,” said Dr. Anderson. “I had to say offline to them, ‘You guys are not going to get pimped.’”

Giving the nurses a checklist of topics to cover helped with this. “The first item might be events overnight or medication questions. The second might be unnecessary IVs or telemetry,” Dr. Anderson said.

Getting started

The experts had a checklist of sorts for hospitalists hoping to implement changes in rounding. As with any initiative, the process starts with consulting all the stakeholders. There are likely to be a lot of them—”nurses, the physicians, if you're in a teaching hospital the residents, the bed assignment department and the emergency medicine folks,” said Dr. O’Leary.

They'll probably have a lot of objections, too. “When you talked to bed [management], they'd tell you why this thing didn't work for them. You'd try to solve that and come back and nursing would say this doesn't work for us. You'd solve that problem and the doctors would say, no, this doesn't work,” said Dr. Curcio.

Compromises will be required. “Everybody [has] to understand the other departments' roles and be willing to give and take a little bit and understand that everything isn't going to be perfect for you,” Dr. Curcio said.

Representatives of the affected departments should meet long before and after the intervention is put into place. “Have a working group of stakeholders meet for weeks before your target go-live date and continue to meet for an equal length of time afterwards, because you will have to revise in minor ways afterwards,” said Dr. O’Leary.

That working group should be clear on the goals of the project and how to measure whether they have been achieved. “Maybe one goal is you want to improve throughput or have more patients discharged early in the day,” said Dr. Nelson. “You might want to change patient satisfaction. You might want to change hospitalist satisfaction and efficiency.”

Measurement methods will vary, from stats already gathered by hospitals and payers to surveys of the members of a hospitalist group.

Keep in mind the costs of the intervention, too. A likely one is time. “It's easy to say let's spend twice as long on our rounds and get more people. Of course, that should yield some benefits, but they have to come at a reasonable cost,” said Dr. Nelson.

An increase in handoffs is another risk of the switch to geographic rounding. Dr. Shumway's team kept an eye on that metric as they converted their system. “In the first year of unit-based rounding, we recorded fragmentation data. The number of physicians a patient saw in a hospital stay was no different,” she reported.

To gather data on your project, it may be appropriate to begin with a pilot. “Maybe start with a couple units and make people believe in the ability to do that, then slowly transition a couple more units,” said Dr. Vaidyan. “Look at the data, and have a conversation and get people's concerns and feedback, and then transition over a period of 6 months to a year.”

It will take at least that long to be sure whether a new system works. “You have to give it a fair trial of at least 6 months before you would say it's not successful and move along,” said Dr. Curcio.

But if you follow all the recommended steps, chances are, you won't have to make that call on your rounding project, the experts agreed. “There may be places that are not able to do it, but I think it's exceedingly rare,” said Dr. O’Leary.