Heterogeneity of Interdisciplinary Rounds

I had the pleasure of interviewing Surekha Bhamidipati, a hospitalist in the Department of Medicine at Christiana Care Health System. She and her team sought to analyze the current literature on the structure and outcomes of interdisciplinary rounds among hospitalized medicine patients, to determine the composition and impact of such rounds in her recent Journal of Hospital Medicine (JHM) paper, Structure and Outcomes of Inter-Disciplinary Rounds in Hospitalized Medicine Patients: A Systematic Review and Suggested Taxonomy.

What is your background and how did you become interested in evaluating interdisciplinary rounds?

I am a Faculty Hospitalist and completed my residency in Internal Medicine. I have been exposed and trained to participate in interdisciplinary rounding since Day#1 of my residency training. After my training, in my first job I also had the experience with very valuable bedside interdisciplinary rounding. Then in my current position, I found that we did interdisciplinary rounding, but physicians were not a part of these rounds. I had strong institutional partnership in starting physician led interdisciplinary rounds in Christiana Care. I sought to understand the current evidence around the practice. We based our rounds on IHI recommendations and knowledge from other institutions. I found that I needed to figure out what were the best (highest yield) components to be included in these rounds. So that is how my interest got started, and I quickly recognized that no one really knew exactly how best to do this. I am not a trained researcher and I started this work with an interest in implementation, but I developed an interest in systematically studying the existing work in this field. I had a lot of research mentorship along the way.

You note in your introduction that the Institute for Healthcare Improvement (IHI) recommendations for rounds includes guidance on team membership, patient-family participation, using daily goals sheets, and addressing safety concerns; can you expound more of their recommendations and how these recommendations should be implemented by hospitalists?

I think it is hard to say if these are evidence based, although they certainly make sense. I would certainly recommend aiming for these elements, but it is not clear how necessary each of these components actually is in producing highly effective rounds.

What is your “best guess” on ideal design for interdisciplinary rounding (IDR)? Timing, location, duration, frequency, time per patient, geographic cohorting, use of team training, format of IDR (scripted versus free discussion), use of patient communication tools, use of safety checklists, etc.

It really is hard to say what is ideal, and often boils down to an institutional cost-benefit analysis; in some centers it may be hard to justify some interventions based on cost. But across the board I would recommend at a minimum to have a physician and a nurse, a discharge planner, a pharmacist, and a manager of rounds (this is key to keeping rounds efficient). I would also highly recommend that the rounding team get formal team training. One of the barriers to effective IDR is historically most of us have not been trained on how to efficiently and effectively carry out interdisciplinary communications (not just physicians but all health care team members). There needs to be an ease and comfort in communicating succinctly and effectively across disciplines. At Christiana Care, we have implemented team interdisciplinary training via a variety of modalities.

How should hospitalists coordinate and run IDRs?

Hospitalists should be leading the individual patient discussions but should not be coordinating or managing IDRs. IDRs work best if there is a manager that runs the rounds, one that does not have a speaking role and keeps the team moving along. At Christiana Care, this role is usually filled by a charge nurse (that does not have a patient assignment) or a patient care facilitator (with a nursing background).

Were there any unexpected findings in your study?

We asked some questions of the literature and we were surprised about how little literature there is available (e.. head-to-head comparisons of different IDR models); there was so much heterogeneity within the literature it was very difficult to come to firm conclusions about IDRs, and it quickly led us to becoming more comfortable with pragmatic research in this setting.

In addition, we were hoping to understand the role and outcomes of patient participation in IDRs. Although, there is some knowledge in the Pediatrics and ICU literature on this subject, unfortunately, we did not find substantial information with our review.

Where does this take you with respect to future research efforts?

Operationally we are heavily focused on training interdisciplinary teams in communication skills. We have based our training on Team STEPPS. We used the framework of Team STEPPS to help teams understand the concept of a shared mental model regarding patient plans and the trajectory of a hospitalization. We have trained several teams to have interdisciplinary conversations to arrive at this shared mental model and have some action oriented take away for each patient at the end of a rounds discussion. We are also studying the outcomes from our IDRs.

Anything we did not cover that you want to mention?

My message to institutions that intend to implement IDRs is to carefully document the intervention and outcomes as standardization in reporting is the key to the growth of this literature. In order to advance the science, we need to design pragmatic but robust research studies. This will allow for evidence based IDR implementation in the future.

 

SBhamidipatiDr. Surekha Bhamidipati is a faculty member in the Department of Medicine and an attending physician in the division of Hospital Medicine at Christiana Care Health System in Delaware. She also serves as a unit medical director on a Medicine patient care unit and as Assistant Medical Director for the hospitalist group in health care delivery research. She completed her medical education at Gandhi Medical College, Hyderabad, India and post graduate training in Internal Medicine at Maimonides Medical Center, Brooklyn, NY. In her role as a Hospitalist during the past six years, Dr. Bhamidipati focused on interprofessional collaborative practice to improve patient outcomes and Hospitalist efficiency. She has extensively worked on interdisciplinary team based care in hospitalized medicine patients including the completion of a research study that is currently in the analysis phase. She graduated from the IHI improvement scholar’s program in 2015. Her project was training interdisciplinary teams to improve interdisciplinary communication. She presented posters and has given oral presentations at several national meetings on topics including interprofessional collaborative teamwork and Nephrology. She actively takes part as an ad hoc reviewer in regional and national Internal Medicine and Hospital Medicine society meetings and journals. She lives with her husband and two children in Delaware. She enjoys gardening, interior design and traveling with her family in her spare time.

Danielle Scheurer

Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

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