Grds international conference on health and life (2)
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Grds international conference on health and life (2)
- 1. A PILOT STUDY ON NURSE-LED ROUNDS: PRELIMINARY DATA ON PATIENT CONTACT TIME Soo-Hoon Lee, Ph.D., Strome College of Business, Old Dominion University Alice Lee; Siang-Ngin Lim; Mei-Jiao Koh; Benjamin Tan, MBBS National University Hospital System Phillip H. Phan, Ph.D, Carey Business School, Johns Hopkins University Reshma A. Merchant, MBChB, MRCP, FAMS; Aisha Lateef, MBBS, MRCP, M.Med, FAMS; Dale A. Fisher, MBBS, FRACP, DTM&H Yong Loo Lin School of Medicine, National University of Singapore
- 2. BACKGROUND Ward rounding is: 1. a historical clinical method of inter- professional collaboration1 2. an opportunity for doctors to spend quality time with patients2 1Weber H, Stockli M, Nubling M, et al. Patient Educ Couns. 2007;67:343-348. 2Cohn A. BMJ. 2013;347:f6451.
- 3. BENEFITS INCLUDE: • Assurance of patient safety3 • Delivery of efficient services4 • Lower lengths of stay & hospital charges5 • Improved patient care & increased patient satisfaction6 3Kohn LT, Corrigan JM, Donaldson MS (eds). To Err is Human: building a Safer Health System. 2000. 4Reeves S, Goldman J, Burton A, et al. J Allied Health. 2010;39:198-203. 5Curley C, McEachern JE, Speroff T. Med Care. 1998;36:AS4-AS12. 6
- 4. YET, EVIDENCE INDICATES THAT… 1. Nurse-physician collaboration during rounds occur infrequently: - attending teams rarely communicate with nurses7 - non-physician inputs are often overlooked by physicians8 2. Patient contact with clinical teams during rounds is brief9 7Stickrath C, Noble M, Prochazka A, et al. JAMA Intern Med. 2013;173:1084-1989. 8Zwarenstein M, Rice K, Gotlib-Conn L, et al. BMC Health Services Research. 2013;13:494. 9Launer J. What’s wrong with ward rounds? Postgrad Med J. 2013;89:733-734.
- 5. PURPOSE OF THIS STUDY To compare patient contact time between nurse- led rounds versus physician-led rounds
- 6. SETTING • A General Medicine ward in a tertiary academic hospital in Singapore • Ward comprises 6 cubicles with isolation beds • Data was collected from 5 cubicles, each comprising 6 beds
- 7. PRE-INTERVENTION WARD ROUND • 2-hour rounds between 0900-1200hr • Rounding team: – Consultant, Senior Resident, Resident & Housestaff • Ad hoc participants: – Medical students, patient’s nurse, nurse trainee, physical or occupational therapist, care coordinator or social worker • Discussions occur mostly within rounding team with occasional inputs from ad hoc participants
- 8. INTERVENTION: NURSE-LED ROUND • A continuous improvement activity in the hospital • A pilot intervention in one ward • Flow chart described in next chart
- 9. NURSE-LED ROUND FLOW CHART
- 10. DESIGN • Cross-over comparative observational study – First day: rounds began with patients in 2 nurse- led cubicles followed by patients in 3 resident-led cubicles – Second day: rounding order was reversed – Final day: all rounds were nurse-led
- 11. MEASURES & ANALYSES • 57 bedside rounds were observed in June 2014: – 31 nurse-led – 26 physician-led • Time spent at bedside was recorded by 2 observers • Informal interviews conducted at the end of each morning
- 12. AVERAGE PATIENT CONTACT TIME 6.5 7.2 5.7 0 1 2 3 4 5 6 7 8 Minutes Overall Average Time Spent at Patient Bedside Average Time Spent at Patient Bedside in Nurse-led Rounds Average Time Spent at Patient Bedside in Resident-led Rounds
- 14. DISCUSSION • Patient contact time was longer & remained consistent in nurse-led rounds • Nurse-physician collaboration had other positive effects: – For Nurses: • more engaged prior to rounds • understood treatment plans better • felt more empowered & had higher morale – For Physicians: • obtained patient information from nurses that they would otherwise not know • fewer inquiries after rounds both from and to nurses
- 15. IMPLICATIONS & CONCLUSION • Bottom line: Nurse-led Rounds… – facilitated better decision making for patients – created more engagement among nurses – reduced follow-up inquiries for physicians • Limitations of study: a small number of observations • Positive results obtained – – a more rigorous pre-post study with a control ward
- 16. Q & A?
- 17. REFERENCES [1] Weber H, Stockli M, Nubling M, Langewitz WA. Communication during ward rounds in Internal Medicine: an analysis of patient-nurse-physician interactions using RIAS. Patient Educ Couns. 2007;67:343-348. [2] Cohn A. Restore the prominence of the medical ward round. BMJ. 2013;347:f6451. [3] Kohn LT, Corrigan JM, Donaldson MS (eds). To Err is Human: building a Safer Health System. Washington, DC: National Academic Press. 2000. [4] Reeves S, Goldman J, Burton A, Sawatzky-Girling B. Synthesis of systematic review evidence of interprofessional education. J Allied Health. 2010;39:198-203. [5] Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Med Care. 1998;36:AS4-AS12. [6] Rush S. Bedside reporting: dynamic dialogue. Nurs Manage. 2012;43:40-44. [7] Stickrath C, Noble M, Prochazka A, Anderson M, Griffiths M, Manhein J, Sillau S, Aagaard E. Attending rounds in the current era: what is and is not happening. JAMA Intern Med. 2013;173:1084-1989. [8] Zwarenstein M, Rice K, Gotlib-Conn L, Kenaszchuk C, Reeves S. Disengaged: a qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Services Research. 2013;13:494. [9] Launer J. What’s wrong with ward rounds? Postgrad Med J. 2013;89:733-734.
Editor's Notes
- 1Ward rounding improves inpatient care when different clinical professions exchange information and discuss plans of care, treatment goals, and discharge plans for the patient. 2Cohn wrote in an editorial that the value of the ward round is increased when doctors spend quality time with patients.
- 3The U.S. Institute of Medicine endorses the value of inter-professional collaboration as it assures patient safety 4Reeves & colleagues found evidence in a systematic review that collaboration among healthcare providers can increase efficiencies in service delivery 5Curley & colleagues found lower LOS & lower total hospital charges in interdisciplinary rounds 6Rush reported improved care when physicians, nurses, and patients work together to make decisions. Patients are also more satisfied when they understand their conditions and treatment plans
- 7Stickrath & colleagues reported that attending teams communicated with nurses only 12% of the time. 8Zwarenstein & colleagues found that physicians interacted almost entirely with other physicians & often overlook the inputs from non-physician. 9Launer reports that patients’ experience with ward rounds is that they are very brief, they have little opportunity to ask questions and they feel annoyed by being seen up to a half-dozen bored-looking strangers who appear to be in a hurry to leave
- We believe that improvements in the conduct of ward rounds may lead to better patient-centered care. In this study, we deploy a pilot intervention to introduce nurse-led ward rounds whereby nurses present their patients prior to physician discussions. The purpose is to prioritize the input of nurses so that the information is formally included in the patients’ plan of care and to increase the exposure of the doctors to their patients. We hypothesize that patient contact time in nurse-led ward rounds would be longer and more consistent compared to physician-led rounds.
- Nurse-led was introduced as part of a continuous improvement process This multi-disciplinary structure for morning rounds was created to: improve communication and relationships ensure continuity of care for patients improve clinical staff’s experience.
- For new patients or when there is a change of consultant coverage, presentation proceeds with (B) before (A) in the above workflow.
- 2nd day: the residents presented first in 3 cubicles followed by the nurses in 2 cubicles
- Informal interviews with the rounding teams were conducted at the end of each morning
- Here are the results: resident-led rounds were significantly shorter at p=0.68 from a Mann-Whitney U test
- X High = longest bedside patient time at a specific cubicle O Low = shortest bedside patient time at a specific cubicle – Average = average bedside patient time at a specific cubicle Medical Officer = resident The average time spent with patients trended down toward the end of the 2-hour morning round for resident-led rounds But the average time spent with patients trended up with nurse-led rounds at the end of the 2-hour round & remained relatively consistent when the rounds were entirely nurse-led.
- Observations & informal interviews surfaced positive effects from nurse-physician collaboration: For nurses: They actively organized clinical tasks and interactions with patients, family members, and other care providers prior to the morning presentation. A nurse commented, “I now have to know my patients better [to make the presentation]”. they understood their patients’ treatment plans better and could better explain the need for tests or procedures to their patients and their family members they felt more empowered as they had a voice in the care of their patients, which improved their morale For Doctors: Nurses contributed patient information during rounds that was otherwise discovered by physicians by chance in an ad hoc manner. Information about the patient’s overnight condition and family concerns raised during visiting hours the night before helped senior doctors make more informed decisions regarding discharge plans. better teamwork and a reduction in inquiries later in the shift by either the physicians or the nurses. A senior resident remarked that, “we have less things to do [information search or answer nurse queries] after the rounds”.
- The protocol was perceived to create more engagement and help facilitate better decision making among the primary caregivers as they were present to share information and hear the presentation of the patient’s condition and plan of care from different perspectives. In particular,