Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Interdisciplinary medical rounds improved patient care efficiency and the care process and decreased costs

ACP J Club. 1999 Mar-April;130:52. doi:10.7326/ACPJC-1999-130-2-052


Source Citation

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 Aug;36:AS4-12.


Abstract

Question

Can interdisciplinary rounds improve efficiency of patient care and staff satisfaction and decrease costs on inpatient medical wards?

Design

Randomized controlled trial.

Setting

3 medical firms and 6 inpatient health care teams of an acute care, tertiary referral, and teaching hospital in Cleveland, Ohio, USA.

Patients

Patients who were admitted to and discharged from medical wards. Patients were excluded if they spent < 50% of their hospital stay on the medical ward, were transferred to another service, or were not admitted to their assigned firm.

Intervention

On their first admission, patients were randomly allocated to 1 of 3 medical firms from which they received all services including those for any subsequent admissions; all admissions were considered separately. Each of the 3 firms comprised 2 independent ward services; the 6 ward services were divided so that 3 conducted daily interdisciplinary rounds, designed by a continuous quality improvement team, and 3 continued traditional rounds. Interdisciplinary rounds included physicians, a nurse patient-care coordinator, a pharmacist, a nutritionist, and a social worker, and orders were written during rounds with the patient charts present. Traditional rounds included physicians only on a daily basis with interdisciplinary rounds once a week; orders were written throughout the day, and patient charts were left at the nursing station. Of 1102 patient admissions, 567 patients were allocated to receive interdisciplinary rounds, and 535 were allocated to receive traditional rounds.

Main outcome measures

Length of hospital stay, total charges (U.S. dollars), hospital death, type of hospital disposition, and self-reported health care provider satisfaction.

Main results

Patients who received interdisciplinary rounds compared with those who received traditional rounds had shorter mean lengths of hospital stay (5.46 vs 6.06 d, P = 0.006) and lower mean total charges (U.S. $6681 vs $8090, P = 0.002), but no differences occurred in the rates of hospital death (1.8% vs 1.9%, P = 0.90), discharge to home (73.9% vs 73.1%, P = 0.79), and discharge to an interim care facility (9.4% vs 12.3%, P = 0.12). Factor analysis and comparison of provider satisfaction surveys, completed by 21 providers of interdisciplinary rounds and 19 providers of traditional rounds, revealed 3 factors that represented underlying concepts; comparison of these factors showed that providers of interdisciplinary rounds had a greater understanding of patient care, more effective communication, and more teamwork than providers of traditional rounds (P < 0.006 for each factor).

Conclusion

Interdisciplinary health care team rounds compared with physician-focused traditional rounds led to decreased length of hospital stay and costs for hospitalized patients on medical wards and improved the care process.

Source of funding: Not stated.

For correspondence: Dr. C. Curley, Division of General Internal Medicine, Department of Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA. FAX 216-778-8334.


Commentary

Curley and colleagues showed that daily interdisciplinary rounds conducted on medical wards in an acute care, tertiary referral hospital provided more efficient and higher-quality patient care than traditional rounds. The finding has a strong theoretical basis: It is logical that medical wards would operate more efficiently if physicians, nurses, social workers, nutritionists, and pharmacists attended rounds together daily and wrote orders during the rounds. This would allow all parties to be aware of the care plan and coordinate their activities on behalf of the patient.

This study has minor methodologic flaws. Although patients were randomly assigned to 1 of 3 firms, interdisciplinary rounds were not randomly assigned to 3 of 6 wards or to 1 of 2 wards within each firm. Only 1 firm conducted both interdisciplinary and traditional rounds (1 type of rounds for each of the 2 wards). The other 2 firms conducted either interdisciplinary or traditional rounds on both wards. Therefore, differences between firms (e.g., housestaff and patients) may account for some of the results. In addition, the patients' severity of illness and patient case mix were measured using demographic data, primary diagnoses, and discharge codes (International Classification of Diseases, 9th revision). No physiologic or other clinical data were used.

Despite these limitations and given the harmless nature of the intervention, the study findings support the recommendation to conduct daily interdisciplinary rounds in hospital inpatient services of academic medical centers. This study should be replicated in community hospital settings to determine whether interdisciplinary rounds would have similar benefits there. Although this study did not examine the inclusion of other ancillary services, such as physical or respiratory therapy or consulting medical specialties, these services might promote even greater efficiency and communication among providers.

Haya R. Rubin, MD, PhD
Johns Hopkins UniversityBaltimore, Maryland, USA