Bedside rounds have a reputation for promoting patient-centered care in the hospital, but a recent systematic review found scant supporting evidence for the practice.
In 29 studies of bedside rounds (20 from adult care, nine from pediatrics), there was no consistent effect on patient-centered outcomes, according to results published in September 2018 by BMJ Quality & Safety. “The evidence didn't seem quite as robust as I would've expected. I thought we would find a fairly clear benefit,” said lead author John T. Ratelle, MD, ACP Member, a hospitalist at Mayo Clinic in Rochester, Minn.
The reviewed articles go back as far as 1988, when interns practically lived in the hospital, and rounds were a way to bring patient information to attendings (who worked in clinics) and make clinical decisions, Dr. Ratelle noted. Today their purpose is less obvious.
“With EHRs and the widening number of clinicians involved in a patient's care, does it still make sense to do things the way that we've done for decades? Or maybe we should think outside the box in terms of what is the best way to care for patients in the hospital,” said Dr. Ratelle. He recently spoke with ACP Hospitalist about the surprising results and whether or not convening at the bedside is worthwhile.
Q: What led you to study this issue?
A: As an academic hospitalist, I feel like I spend about a quarter of my life rounding. . . . I sort of bought into the rhetoric about education at the bedside with learners and getting a chance to provide patient-centered care. But I felt like in my practice, I always had a tough time making it work, and actually, probably the biggest reason was getting learners to buy in and feel comfortable with it. It seems like it's done more frequently in pediatrics, but in internal medicine, at least at Mayo, it's not commonplace to do bedside rounds routinely. That led me to the question of, “Can I demonstrate some concrete evidence about the benefits of bedside rounds?” Having this evidence seemed like it might help increase buy-in among learners.
Q: What did you find?
A: What we found is that the literature is very messy on the subject of bedside rounds. The definitions, the outcomes, and the measures were a little bit all over the board. The most commonly reported outcome was patient experience, things like satisfaction, communication outcomes, etc. The next most frequent was patient understanding of their care, although this was usually measured subjectively. . . . Regardless of setting or context or any of our explored subgroup analyses, bedside rounds wasn't meaningfully better than rounding away from the bedside in terms of any of those outcomes that we measured. We did find a statistically significant improvement in patient experience, but if you look at the effect size, it's pretty negligible, and I'm not sure there's any clinical relevance there.
Based on the fact that bedside rounds are advocated by multiple national professional organizations and it seems to be the trend in terms of what people are doing, I thought there would be more of a clear signal that when we do bedside rounds as compared to another form of rounds, the patient outcomes are clearly better.
Q: Do you think bedside rounds are still worthwhile?
A: I think it depends on the situation. For example, if I have 18 patients to round on and a number of them are critically ill and we have a lot of competing time pressures, bedside rounds may not make as much sense because achieving the objectives of patient engagement and education is pretty tough to do in a really short period of time. You'd hate to start engaging a patient in an important or complex care discussion during bedside rounds, only to wind up cutting it short when you see the clock and say “Well, we have to go. We'll come back later.” It seems better to save those conversations for outside of rounds, when the appropriate time can be allotted. . . . I'd say it also depends on the preferences and comfort level of the clinicians involved. Forcing an inexperienced and/or uncomfortable trainee to present at the bedside may not lead to a positive experience. Likewise, sometimes patients may not want to be involved in bedside rounds . . . and oftentimes it may not be feasible for an elderly patient's family caregivers to be at rounds at 9 in the morning.
Q: What are the main takeaways of this study for hospitalists?
A: One of my takeaways is we shouldn't just assume because we're doing bedside rounds that we should drop the mic and say, “Hey, we've done patient-centered care because we do bedside rounds.” . . . We have to tailor the way that we do rounds to meet the needs of the patient and the situation.
Q: What are your next steps for future research in this area?
A: This particular study is part of a larger program of research where we're looking at not just patient outcomes, but also learning outcomes and teamwork outcomes with conducting bedside rounds as compared to other forms of work rounds. The jury's still out, but from what I can tell, we're probably going to wind up in a similar situation where it doesn't clearly benefit learners the way that we think it should. The learners seem to have this quandary where they recognize that there's value in bedside rounds, or at least they think there's value for the patient, but they oftentimes don't like doing it. With teamwork, I think the signal is maybe a little bit more clear that bedside rounds does seem to benefit, particularly teamwork from the nursing perspective. Whether that's truly the process of bedside rounds (meaning involving the patient) or just the fact that we're getting doctors and nurses together to talk with one another is kind of unclear.