What is the effectiveness of structured multidisciplinary rounding in acute care units on length of hospital stay and satisfaction of patients and staff?
Communication is defined as a process by which information is exchanged between individuals through a common system of symbols, signs, language and behavior. Efficient and effective communication among members of a healthcare team is invaluable for delivering quality patient care.1,2 Ineffective communication within a team is identified as a contributing factor to the high rate of adverse events in the inpatient setting.2 Fragmented care occurs as a result of communication breakdown where important patient care information is not shared timely or adequately. The Institute of Medicine's 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes safe, effective patient-centered care that is timely, efficient and equitable.3 Failures in communication within multidisciplinary healthcare teams are established causes of errors and negative health outcomes, including death.4
Improvements in organizational processes are needed to ensure a culture of patient safety; paramount to this are processes and factors related to communication and coordination.5 Health care typically involves patient management by a number of different specialists. Coordinating care through multiple handoffs necessitates effective communication of critical information.6 These are goals outlined in the Patient Protection and Affordable Care Act that was passed in the United States in 2010.7 Maintaining collaborative efforts within the healthcare team, and between patients and caregivers in inpatient acute care units depends largely on communication.8 Effective communication directly correlates with patient outcomes,9 adverse events,10 and length of stay.11 It is the common denominator of stress within the health care team.12 The ways by which health care providers communicate can also impact on patient satisfaction.13 The World Health Organization recommends improved communication between healthcare providers by allocating sufficient time during patient encounters utilizing a standardized approach.14
Dwindling reimbursement, shifting emphasis on patient outcomes and satisfaction, and rapidly rising health care costs lend impetus to finding new ways of providing safe, effective care in the most timely manner possible, utilizing existing resources. Although the concept is not new, multidisciplinary rounding (MDR), sometimes known as collaborative rounding or interdisciplinary rounding, is being re-evaluated and refocused in many acute care settings to maximize its potential impact on patient care issues. Multidisciplinary rounding has been identified as a way to improve patient care by promoting health care provider communication, leading to a greater shared knowledge of a patient's status, smoother patient care flow, decreased length of stay, and enhanced patient and staff satisfaction.15–18
In order to be considered multidisciplinary, rounds must consist of two or more disciplines meeting together to review the plan of care, determine priorities, and coordinate and facilitate the progression from one point of care to the next, either within the hospital, at another health care facility, or to the community.16,18 Multidisciplinary rounding may be either nurse or physician led and the make-up of the team may vary, depending on the needs of the patient and the unit.15,18 A common team composition may consist of any combination of the primary medical provider, specialty providers, medical residents, nurse practitioners, physician assistants, bedside nurse, case manager, social worker, unit manager, and/or other ancillary service providers, as needed.18
Rounds may be walking, which has the advantage of allowing a quick visual assessment of the patient and patient/family involvement,16 or they may be held at a central location, which may improve the multidisciplinary team's ability to talk more freely about the plan of care.15 Multidisciplinary rounding may be scripted or unscripted. Reimer and Herbener recommend that MDR be held at the same time each day, be brief, be organized in such a manner that the information covered is consistent from patient to patient yet individualized to each patient's needs, and occurs independently of any one discipline's presence or absence.18
Ineffective communication among members of the healthcare team is caused by delays in communication, failure to communicate with the appropriate team member, provision of inaccurate or incomplete information, and matters left unresolved until the point of urgency.19 Many healthcare settings are implementing various communication strategies to add structure to the MDR process with the goal of improving communication among the healthcare teams. One strategy is the use of a standardized communication tool during MDR. A standardized communication tool is a systematic approach that is used to enhance the ability to communicate effectively within or between disciplines.20 According to Narasimhan, Eisen, Mahoney, Acerra, and Rosen, a standardized communication tool may be an important means to achieve reliable, consistent and efficient communication that supports collaborative work in healthcare settings.20
Examples of standardized communication tools include checklists, daily goals sheets, door communication cards, or the situation, background, assessment, and recommendation (SBAR) tool. The SBAR tool is for the purpose of communicating changes on patients' status in a timely fashion.19 As per Diaz-Montes, Cobb, Ibeanu, Njoku, and Geraldi, the use of a checklist during MDR may enhance communication as it acts as an agenda, triggering consistent information exchange, and clarifying patient goals.21 The main purpose of a checklist is to organize and outline criteria to be considered during MDR.21 A daily goals sheet clarifies a patient's goals and provides an accurate information source for each patient.20
The use of structured tools with a systematic approach to communication, either written or verbal, may be a way of improving communication between different team members.19 A structured communication tool used during MDR may be helpful in the busy healthcare environment where important information could be missed resulting in treatment delay. A structured tool may also be useful for informing all healthcare providers involved in a patient's care on changes in the patient's status. Concerns can be addressed quickly, thus ensuring quality patient care.22 Cornell, Townsend-Gervis, Vardaman, and Yates demonstrated decreased time for treatment, increased staff satisfaction with communication, and higher rates of resolution of patient issues when a communication tool was implemented during MDR on an inpatient unit.19 Narasimhan et al. showed that the use of a daily goals sheet improved communication among the healthcare team and decreased the length of stay in an intensive care unit.20 However, Ainsworth, Pamplin, Allen, Linfoot, and Chung reported no improvement in communication during MDR with the use of a daily goals door communication card, a tool similar to the daily goals sheet.23 Ambiguity remains in the literature regarding the overall effectiveness of standardized communications tools used during MDR and which type of tool may yield better outcomes.
The goal of MDR is to improve care coordination with the aim of reducing length of stay while improving the satisfaction of the multidisciplinary team involved in the rounding and the satisfaction of the patient being cared for. Efficient and effective healthcare improves the quality of care delivered which decreases length of stay and provides a seamless transition to the next level of care.20 Length of stay is defined as the number of days admitted to a healthcare facility or a specific healthcare unit, and is calculated by totaling the number of days from admission to discharge or the transition to the next point of care.
Patient satisfaction is an individual's evaluative judgments concerning the quality of care received from healthcare providers. Improved quality of care increases patient satisfaction.24 The use of a structured communication tool may increase patient satisfaction by improving collaboration of care.17 Multiple tools are available to measure patient satisfaction. An example of one measure is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The HCAHPS survey evaluates a patient's perspective of their care across nine essential topics.25
Staff satisfaction is defined as a pleasurable or positive emotional state resulting from the appraisal of one's job or job experiences. Structured MDR utilizing a communication tool may be one method to improve staff satisfaction.26 A number of surveys are available to measure staff satisfaction. The Press-Ganey Employee Partnership Survey and the Gallup Consulting Survey are two widely used survey tools.27
Multidisciplinary rounding is important for coordination of patient care across various specialties in an inpatient setting; however, communication among the members of the healthcare team may sometimes be less than optimal.10 This systematic review aims to determine the effectiveness of using a standardized communication tool during MDR in acute care units on length of stay, patient satisfaction and staff satisfaction. A search of MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the Cochrane Database of Systematic Reviews was performed and no existing or ongoing systematic review on this topic was identified.
Types of participants
This review will consider studies that include samples of healthcare providers, including, but not limited to, physicians (both primary care and specialty providers), medical residents, nurse practitioners, physician assistants, bedside nurses, case managers, social workers, unit managers, and/or other ancillary services who provide direct care for adult patients (18 years and older) hospitalized on inpatient acute care units for the management of any acute or chronic illness. Studies focusing on pediatric, mental health or obstetric patients, or adult outpatients will be excluded.
Types of intervention(s)
This review will consider studies that evaluate the implementation of a structured MDR process on adult patients (18 years and over) hospitalized in acute care units for the management of any acute or chronic illness. For the purpose of this review, structured MDR is defined as the process of patient rounds by a multidisciplinary team utilizing a standardized communication tool. Examples of standardized communication tools include, but are not limited to, checklists, SBAR tools, and daily goal communication tools. A multidisciplinary team consists of two or more disciplines involved in a patient's care meeting to outline the plan of care. A multidisciplinary team may consist of medical providers, nurses, case managers, social workers and/or other ancillary service providers actively involved in the patient's care.
This review will consider studies that compare structured MDR with MDR without the use of a standardized communication tool or rounds without a multidisciplinary approach.
Types of outcomes
The review will consider studies focusing on three primary outcomes of interest: length of stay, patient satisfaction and/or staff satisfaction. Length of stay is defined as the number of days admitted to a healthcare facility or a specific healthcare unit. Length of stay is calculated from the day of admission to discharge or the transition to the next point of care. Patient satisfaction is an individual's evaluative judgment concerning the quality of care received from healthcare providers. Staff satisfaction is defined as a pleasurable or positive emotional state resulting from the appraisal of one's job or job experiences. Studies that evaluate patient satisfaction and/or staff satisfaction, as measured by valid and reliable tools, such as, but not limited to, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which measures patient satisfaction, or the Press Ganey Employee Partnership Survey, which measures staff satisfaction, will be considered for inclusion.
Types of studies
The review will consider randomized controlled trials and quasi-experimental studies for inclusion. In the absence of these, the review will consider other quantitative research designs such as observational or descriptive designs for inclusion.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in or translated into the English language will be considered for inclusion in this review. Studies published from the inception of the databases searched through the current date of the review will be considered for inclusion in this review.
The databases to be searched include: PubMed, CINAHL, Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Health Source: Nursing/Academic Edition, and Scopus.
The search for unpublished studies will include: New York Academy of Medicine, ProQuest Dissertation and Thesis, ClinicalTrials.gov, Google Scholar, and the Virginia Henderson International Nursing Library.
Initial keywords to be used will be: acute care unit, multidisciplinary rounds, rounding, length of stay, patient satisfaction, and staff satisfaction.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data will be extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
The authors have no conflicts of interest to disclose.
This review will partially fulfill degree requirements for successful completion of the Doctor of Nursing Practice Program at Pace University, College of Health Professions, New York, NY for: Angela Mercedes, MS, RN, FNP-BC; Precillia Fairman, MS, RN, FNP-BC; Lisa Hogan, MS, RN, FNP-BC; and Rexi Thomas, MS, RN, FNP.
1. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85-i90.
2. Lingard L, Espin S, Whyte S, Regehr G, Baker G, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4.
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001.
4. Brock D, Abu-Rish E, Chiu CR, Hammer D, Wilson S, Vorvick L, et al. Interprofessional education in team communication: working together to improve patient safety. Postgrad Med J. 2013;89(1057):642-51.
6. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-94.
8. Kelly AE. Relationships in Emergency Care: Communication and Impact. Adv Emerg Nurs J. 2005;27(3):192-7.
9. Hindle D, Braithwaite J, Iedema R, Travaglia J. Patient safety: a review of key international enquiries. Sydney: Clinical Excellence Commission; 2005.
10. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust. 1995;163(9):458-71.
11. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-12.
12. Perry L. Critical incidents, crucial issues: insights into the working lives of registered nurses. J Clin Nurs.1997;6(2):131-7.
13. Saunders K. A Creative New Approach to Patient Satisfaction
. Adv Emerg Nurs J. 2005;27(4):256-7.
15. Geary S, Cale DD, Quinn B, Winchell J. Daily rapid rounds: Decreasing length of stay
and improving professional practice. J Nurs Adm. 2009;39(6):293-8.
16. Sen A, Xiao Y, Lee SA, Hu P, Dutton RP, Haan J, et al. Daily multidisciplinary discharge rounds in a trauma center: A little time, well spent. J Trauma. 2009;66(3):880-7.
17. Vazirani S, Hays RD, Shapiro MF, Cowan M. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14(1):71-7.
18. Reimer N, Herbener L. Round and round we go: Rounding strategies to impact exemplary professional practice. Clin J Oncol Nurs. 2014;18(6):654-60.
19. Cornell P, Townsend-Gervis M, Vardaman JM, Yates L. Improving situation awareness and patient outcomes through interdisciplinary rounding and structured communication. J Nurs Adm. 2014;44(3):164-9.
20. Narasimhan M, Eisen L, Mahoney C, Acerra F, Rosen M. Improving physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Care. 2006;15(2):217-22.
21. Diaz-Montes TP, Cobb L, Ibeanu OA, Njoku P, Geraldi MA. Introduction of checklist at daily progress notes improves patient care among the gynecological oncology service. J Patient Saf. 2012;8(4):189-93.
22. Wilson FJ, Newman A, Ilari S. Innovative solutions: Optimal patient outcomes as a result of multidisciplinary rounds
. Dimens Crit Care Nurs. 2009;28(4):171-3.
23. Ainsworth CR, Pamplin JC, Allen DA, Linfoot JA, Chung KK. A bedside communication tool did not improve the alignment of a multidisciplinary team's goals for intensive care unit patients. J Crit Care. 2013;28(1):112e7-e13.
24. Atallah M, Hamdan-Mansour A, Al-Sayed M, Aboshaiqah A. Patients' satisfaction with the quality of nursing care provided: The Saudi experience. Int J Nurs Pract. 2013;19(6):584-90.
26. O'Leary K, Wayne D, Haviley C, Slade M, Jungwha L, Williams M. Improving teamwork: Impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32.
Appendix I: Appraisal instruments
MAStARI appraisal instrument
Appendix II: Data extraction instruments
MAStARI data extraction instrument