Communication in Academic Hospital Medicine

Communication in Academic Hospital Medicine

Leah Marcotte, MD

Joshua M. Liao, MD, MSc

What are the potential benefits of interprofessional bedside rounding for clinical team members?

Interprofessional bedside rounds can improve perceptions of communication, coordination, and teamwork among physician and nurse team members.

A 2014 single-site study1 evaluated this question by conducting a cross-sectional survey of three groups of clinicians (hospital-based attending physicians, housestaff physicians, and nurses) at an academic teaching hospital with existing experience in interdisciplinary bedside rounds. These rounds were defined as encounters involving at least two physicians and either a nurse or other team member in which a patient’s case presentation was discussed either in or outside the room followed by a bedside discussion in which the patient was encouraged to participate and ask questions. The survey was conducted using an instrument designed for the study based on prior literature and centered on
five domains related to the putative benefits of interprofessional bedside rounds (patient factors; a composite of communication, coordination, and teamwork; education; efficiency/process; and patient outcomes) and four domains related to barriers to such rounds (patient factors; clinician factors; systems-related issues; time-related issues). Pairwise statistical tests were used to compare survey responses between clinician groups, and a Spearman rank test (r) was used to evaluate the correlation in rank ordering of stated benefits and barriers by the clinician group.

Survey response rate was 87% (149/171). There was high correlation between domain rankings for hospital-based physicians, housestaff physicians, and nurses (r = 0.92, P < .001). Benefits of interprofessional bedside rounds that were ranked most highly related to communication, coordination, and teamwork, while the lowest ranked benefits related to efficiency/process and rounding outcomes (e.g., “timeliness of consultations”). For each survey item related to benefits, nurses reported more favorable ratings than hospital-based and housestaff physicians. The greatest perceived barriers to interprofessional bedside rounds related to issues of time (e.g., “nursing staff have limited time”), compared to the least perceived barriers which pertained to patient factors (e.g., “patient lack of comfort”) and clinician factors (e.g., physicians lacking “bedside skills”). The three clinician groups possessed moderate correlation in rank ordering of interprofessional bedside rounds barriers (r = 0.62-0.82 across the three groups). Study caveats include single-site design and lack of psychometric instrument testing.

While more work is needed to understand the full effects of bedside rounding,2 ACGME regulations3 include the expectation that residents work in interprofessional teams to improve safety and quality of care in an environment that optimizes effective communication with all team members.

What are the potential benefits of structured interdisciplinary rounds (SIDRs) to patient care?

SIDR can be associated with perceptions of stronger collaboration, communication, and safety climate, as well as fewer adverse events.

A study conducted in 20114 at a single academic medical center evaluated this question by implementing SIDR via a structured daily meeting between resident physicians, pharmacists, social workers, and case managers assigned to the care of patients on a medical unit. Another unit in the hospital where SIDR was not implemented served as a control. Newly admitted patients on the intervention unit were discussed via a structured communication tool designed by the interdisciplinary care team (Table 29.1). Patients on the control unit were discussed without the communication tool. Clinicians and team members on both the intervention and control units were surveyed using questions adapted from prior studies about the quality of communication and collaboration as well as about the patient safety climate. Multivariable regression, adjusted for factors such as patient demographics, medical complexity, case-mix, admission source, hospitalist as attending physician, and payer, was used to evaluate length of stay (LOS) and hospital costs as other study outcomes.

Survey response rate was 92% (147/159 eligible respondents). Because of small numbers, data from social workers, case managers, and pharmacists were excluded from analysis. Nurses on the intervention unit rated the quality of collaboration and communication (74% rating it as high vs. 44% of nurses on the control unit; P = .02) and teamwork (mean score 84 vs. 74 on the control unit; P = .005) more highly than nurses on the control unit. In contrast, there were no differences observed in resident ratings about the quality of collaboration and communication (91% rating it as high vs. 88% of residents on the control unit; P = .57) or safety climate ratings across all providers (mean score 77 vs. 75 on the control unit: P = .90), along with adjusted LOS and cost of hospitalization. Caveats included single-site design, imbalance in the proportion of patients with hospitalist attendings between intervention and control units, and lack of clinical outcomes.

TABLE 29.1 SIDR Communication Tool

Overall plan of care

  • Diagnosis?

  • Patient’s chief concern?

  • Tests today?

  • Procedures today?

  • Medication changes today?

  • Medication issues?

  • Consulting services?

  • Expected discharge date?

Discharge plans

  • Telemetry needed?

  • Discharge needs?

    ▪ Placement?

    ▪ Home health needs?

    ▪ Transportation?

Patient safety

  • On VTE prophylaxis?

  • Can central lines be discontinued (including PICCs)?

  • Can Foley catheter bed be continued

  • Can we reduce fall risk?

  • Can we reduce pressure ulcer risk?

PICC, peripherally inserted central catheter; SIDR, structured interdisciplinary rounds; VTE, venous thromboembolism.

Reprinted by permission from Springer Nature: Gen Intern Med. Improving teamwork: Impact of structured interdisciplinary rounds on a medical teaching unit. O’Leary KJ, et al., 2010.

A subsequent study conducted at the same academic medical center in 20115 used a similar design of intervention versus control unit to evaluate the relationship between the same SIDR intervention on adverse events as study outcomes. Adverse events were defined as injuries due to medical care rather than illness and were identified via medical record abstraction and application of screening criteria used in prior research on a randomly selected subset of 555 patients. Physician reviewers independently rated the presence and preventability of identified adverse events before coming to consensus (κ 0.78 and 1 for presence and preventability of adverse events, respectively).

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Feb 5, 2020 | Posted by in CRITICAL CARE | Comments Off on Communication in Academic Hospital Medicine
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