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

Study Overview
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Brief Summary
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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.

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

Conditions
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Morning Rounds, Teaching Rounds, Hospitalization, Inpatients, Quality Improvement

Intervention / Treatment
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* Other: Standardized attending morning rounds


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

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


Arms and Interventions

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

What is the study measuring?
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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 |