Teaching Rounds

Abstract: Background Communication with family members of patients in intensive care units is challenging and fraught with dissatisfaction. Objectives We hypothesized that family attendance at structured interdisciplinary family rounds would enhance communication and facilitate end-of-life planning (when appropriate). Methods The study was conducted in the 26-bed medical intensive care unit of a tertiary care, academic medical center from April through October 2006. Starting in July 2006, families were invited to attend daily interdisciplinary rounds where the medical team discussed the plan for care. Family members were surveyed at least 1 month after the patient's stay in the unit, completing the validated "Family Satisfaction in the ICU" tool before and after implementation of family rounds. Results Of 227 patients enrolled, 187 patients survived and 40 died. Among families of survivors, participation in family rounds was associated with higher family satisfaction regarding frequency of communication with physicians (P = .004) and support during decision making (P = .005). Participation decreased satisfaction regarding time for decision making (P = .02). Overall satisfaction scores did not differ between families who attended rounds and families who did not. For families of patients who died, participation in family rounds did not significantly change satisfaction. Conclusions In the context of this pilot study of family rounds, certain elements of satisfaction were improved, but not overall satisfaction. The findings indicate that structured interdisciplinary family rounds can improve some families' satisfaction, whereas some families feel rushed to make decisions. More work is needed to optimize communication between staff in the intensive care unit and patients' families, families' comprehension, and the effects on staff workload.

Abstract: Background Effective collaboration and teamwork is essential to providing safe hospital care. The objective of this study was to assess the effect of an intervention designed to improve interdisciplinary collaboration and lower the rate of adverse events (AEs). Methods The study was a controlled trial of an intervention, Structured Inter-Disciplinary Rounds, implemented in 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. We conducted a retrospective medical record review evaluating 370 randomly selected patients admitted to the intervention and control units (n = 185 each) in the 24 weeks after and 185 admitted to the intervention unit in the 24 weeks before the implementation of Structured Inter-Disciplinary Rounds (N = 555). Medical records were screened for AEs. Two hospitalists confirmed the presence of AEs and assessed their preventability and severity in a masked fashion. We used multivariable Poisson regression models to compare the adjusted incidence of AEs in the intervention unit to that in concurrent and historic control units. Results The rate of AEs was 3.9 per 100 patient-days for the intervention unit compared with 7.2 and 7.7 per 100 patient-days, respectively, for the concurrent and historic control units (adjusted rate ratio, 0.54; P = .005; and 0.51; P = .001). The rate of preventable AEs was 0.9 per 100 patient-days for the intervention unit compared with 2.8 and 2.1 per 100 patient-days for the concurrent and historic control units (adjusted rate ratio, 0.27; P = .002; and 0.37; P = .02). The low number of AEs rated as serious or life-threatening precluded statistical analysis for differences in rates of events classified as serious or serious and preventable. Conclusion Structured Inter-Disciplinary Rounds significantly reduced the adjusted rate of AEs in a medical teaching unit.

Abstract: BACKGROUND: Medical educators have raised serious concerns about the decline in bedside teaching and the effect of this decline on trainee skills. We investigated the fraction of time hospitalist attending physicians spend at the bedside during teaching rounds and how often physical examination skills are demonstrated. METHODS: In a prospective, observational study, the authors investigated the rounding behavior of members of Brigham and Women's Hospitalist Service. For 5 weeks from December 2007 to January 2008, interns and residents rotating on the hospitalist service reported in a daily e-mail (1) total time spent with their attending during attending rounds, (2) time spent inside patient rooms during attending rounds, and (3) whether or not a physical examination finding or technique was demonstrated by their hospitalist attending. RESULTS: A total of 61 observations were reported (66% response). Hospitalists spent an average of 101 minutes on teaching rounds and an average of 17 minutes inside patient rooms or 17% of their teaching time at the bedside. Bedside teaching occurred during 61% of teaching sessions and physical examination teaching occurred during 38% of teaching sessions. Rounds that included time spent at the bedside were longer on average than rounds that did not include time spent at the bedside (122 vs. 69 minutes, P < 0.001). CONCLUSIONS: Bedside teaching makes up approximately 17% of the time that hospitalists at this medical center spend on teaching rounds. Physical examination teaching has become infrequent. Research to clarify optimal strategies to improve bedside teaching and its value in patient care is needed. Journal of Hospital Medicine 2009;4:304–307. © 2009 Society of Hospital Medicine.