Researchers at Johns Hopkins are challenging a practice that's almost as old as American medicine: the venerable doctors' "rounds," visiting hospitalized patients daily to check their health status with eager, white-coated medical students and residents scurrying along from bed to bed as each case is reviewed and discussed.
"It's a great way to teach medicine, but it doesn't seem to be in the best interest of the patient," said Peter Pronovost, associate professor of anesthesiology and critical care medicine at Johns Hopkins and co-author of a study on rounds published in the recent issue of the Journal of Critical Care Medicine.
"Upon listening to discussions between doctor and patient, we discovered that rounds were more provider focused than patient centered," Pronovost said. "The doctors focused on the physiology, pharmacology and so-called 'available evidence' aspect of the patient not on creating a set of goals for their recovery."
The team of researchers, from Johns Hopkins, the Institute for Healthcare Improvement and the Volunteer Hospital Association, said that a better way is to make rounds centered on step-by-step goals for the patient. By developing a list of short-term aims for each patient, timed directly to a daily care plan, the medical team was able to reduce hospital time while also improving patient safety and satisfaction.
The study, implemented from July 2001 to June 2002, involved 112 patients in The Johns Hopkins Hospital's surgical oncology intensive care unit and a team of medical personnel that included staff physicians, postdoctoral fellows, anesthesia and surgery residents, nurse practitioners, nurses and a pharmacist. During daily rounds, the team visited each patient for approximately 25 minutes and created a plan of care for the day.
At the end of rounds, the patient's primary nurse and resident on call were evaluated on their understanding of the daily recovery goals and the work needed to get the patient to the next level.
To evaluate the impact of the daily goals on patient outcomes, researchers assessed how long the patients were in the ICU. During the yearlong study period, length of stay decreased by half, and the number of residents and nurses who understood the daily goals increased by 80 percent. Shorter hospital stays generally are tied to higher patient satisfaction and fewer medical errors, Pronovost said.
"The need for clear team communication among health care providers in the ICU is imperative and paramount," he said. "Improved communication enhances patient care, decreases length of stay and, most importantly, reduces the risk of errors that can result from poor communication between health care provider and patient. While other, simultaneous improvements in our work processes may also have contributed to the shorter stays, improved communication also increases patient and employee satisfaction," he said.
The study was supported by grants from the Agency for Healthcare Research Quality and the National Heart, Lung and Blood Institute. Co-authors at JHU were Sean Berenholtz, Todd Dorman and Pamela Lipsett.