A Pragmatic Cluster Randomized Controlled Trial to Standardize Attending Morning Rounds in Medicine

Back to Bedside: A Pragmatic Cluster Randomized Controlled Trial to Standardize Attending Morning Rounds in Medicine

Attending morning rounds take place at teaching hospitals every day. They are the primary mechanism for patient care delivery, supervision and education of trainees, and communication with patients, families, and staff. However, they are done with little standardization or widely recognized best practices.

The objective of this quality improvement (QI) initiative is to evaluate the adherence to and impact of implementing standardized attending morning rounds on medicine teams at our institution. A standardized rounding intervention has been developed which includes specific guidance on completing the following activities during morning rounds: (1) Pre-rounds discretion; (2) Pre-rounds huddle; (3) Bedside registered nurse (RN) integration; (4) Patient-centered rounding; (5) Real-time order writing.

This trial will randomize half of the investigators' medicine teams at University of California San Francisco to this rounding intervention whilst the other half will be randomized to continue with usual unstandardized rounding practices.

The investigators will compare medicine teams randomized to undertake standardized rounding to those teams undertaking usual practice. Outcomes assessed will relate to the patient (e.g. satisfaction), providers (e.g. satisfaction), efficiency (e.g. total morning round time) as well as adherence to the intervention .

The investigators' study hypotheses are that patient satisfaction scores will be higher for those patients receiving standardized bedside rounds compared to the usual care group. The investigators also hypothesize that total attending morning rounds time and interns length of workday will be shorter and that the number of consultations ordered before noon will increase for those teams undertaking standardized bedside. Further, the investigator hypothesize higher levels of nurse participation, physician and medical student satisfaction with standardized bedside rounding.

Study Overview

• Status: Completed
• Conditions: Hospitalization; Quality Improvement; Inpatients; Teaching Rounds; Morning Rounds
• Intervention / Treatment: Other: Standardized attending morning rounds

• Study Type: Interventional
• Enrollment (Actual): 1200
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • San Francisco, California, United States, 94143
      • University of California San Francisco Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• All attending physicians, residents, interns and medical students of Medicine teams A through H
• All patients admitted to Medicine teams A through H
• All nurses on the Medicine floors

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Single Group Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Standardized attending morning rounds; Pre-rounds discretion; Pre-rounds huddle; Bedside RN integration; Patient-centered rounding; Real-time order writing	Other: Standardized attending morning rounds
No Intervention: Usual rounding practice; Usual rounding practice (as defined by each clinical team)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient satisfaction with morning rounds	Patient satisfaction with morning ward rounds. This inpatient assessment will occur after day one of hospitalization before the patient is discharged from hospital. This time point will ensure that patients have experienced rounds at least once before completing a patient satisfaction survey.	Once, after day one of hospitalization and before patient is discharged.
Patient satisfaction with provider communication	Post-discharge assessment will be sent by a commercial Vendor (Press Ganey) within a month of discharge following hospitalization	Once, within one month of hospital discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Interns total length of workday	The interns total length of workday will be recorded daily. Over the course of the trial the average length of workday will be determined including any duty hour violations.	Daily during the 3-month trial
Number of consultations ordered before noon	The number of consultations ordered before noon will be recorded daily. Over the course of the trial the average number of consultations ordered before noon will be calculated.	Daily during the 3-month trial
Resident satisfaction	Resident satisfaction and perceptions of with morning rounds (e.g. efficiency, organization, educational value)	Once during the last week of their rotation on a given team
Attending physician satisfaction	Attending physician satisfaction and perceptions of with morning rounds (e.g. efficiency, organization, educational value)	Once during the last week of their rotation on a given team
Medical student satisfaction	Medical student satisfaction and perceptions of with morning rounds (e.g. efficiency, organization, educational value)	Once during the last week of their rotation on a given team
Nurse participation in morning rounds	The presence of RN during morning ward rounds will be recorded daily.	Daily during the 3-month trial
Nurse satisfaction	Nurse satisfaction and perceptions of with morning rounds (e.g. efficiency, organization, team work)	Once during the last week the trial
Intern satisfaction	Intern satisfaction and perceptions of with morning rounds (e.g. efficiency, organization, educational value)	Once during the last week of their rotation on a given team
Total morning rounding time	Total morning rounding time will be recorded daily for each team. Over the course of the trial the average length of morning rounds will be determined.	Daily during the 3-month trial

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of discharges before noon		Daily during the 3-month trial
Cost of care per patient	Average cost of care per patients for each group for entire 3-month study period	For entire 3 month study period
Length of stay	Average length of stay for each group for entire 3-month study period	For entire 3 month study period
30-day readmission rate	Average readmission rate for each group for entire 3-month study period	For entire 3 month study period
Adherence to the intervention	Adherence to the standardized intervention will be recorded throughout the trial to determine the uptake of this intervention in everyday practice.	Daily during the 3-month trial

Collaborators and Investigators

• Sponsor: University of California, San Francisco
• Investigators: Principal Investigator: Brad Monash, MD, University of California, San Francisco; Principal Investigator: James D Harrison, PhD, University of California, San Francisco

Publications and helpful links

General Publications

• Monash B, Najafi N, Mourad M, Rajkomar A, Ranji SR, Fang MC, Glass M, Milev D, Ding Y, Shen A, Sharpe BA, Harrison JD. Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial. J Hosp Med. 2017 Mar;12(3):143-149. doi: 10.12788/jhm.2694.

Study record dates

Study Major Dates

• Study Start: September 1, 2013
• Primary Completion (Actual): February 1, 2014
• Study Completion (Actual): December 1, 2014

Study Registration Dates

• First Submitted: August 16, 2013
• First Submitted That Met QC Criteria: August 26, 2013
• First Posted (Estimate): August 29, 2013

Study Record Updates

• Last Update Posted (Estimate): May 18, 2015
• Last Update Submitted That Met QC Criteria: May 14, 2015
• Last Verified: May 1, 2015

More Information

Terms related to this study

• Other Study ID Numbers: RoundingUCSF