HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Online Discussion (Pediatric) Online Discussion (Adult) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marcelo Cardarelli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cardarelli, M. Articles by Xiao, Y. Search for Related Content PubMed PubMed Citation Articles by Cardarelli, M. Articles by Xiao, Y. Related Collections Education Professional affairs

---

Original Articles: Adult Cardiac

Dissecting Multidisciplinary Cardiac Surgery Rounds

^a Department of Surgery, Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland
^b Department of Pediatrics, Division of Critical Care, University of Maryland Medical Center, Baltimore, Maryland
^c Department of Anesthesia, University of Maryland Medical Center, Baltimore, Maryland
^d School of Nursing, University of Maryland Medical Center, Baltimore, Maryland

Accepted for publication May 4, 2009.

^_* Address correspondence to Dr Cardarelli, University of Maryland Medical System, 22 S Greene St, Baltimore, MD 21201 (Email: mcard001{at}umaryland.edu).

This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org/sections/newsandviews/discussions/index.html

 

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background: Multidisciplinary rounds in the critical care environment have demonstrated increased communication, a reduction in medical errors, a shorter hospital stay, and consequently, economic savings. We attempt to assess the cost of this intervention, and to review the time utilization of professionals participating in the process.

Methods: We analyzed video-recorded weekly multidisciplinary teaching rounds on cardiac patients in a pediatric intensive care unit (n = 22). Rounding time was categorized as presentation or discussion and was measured in minutes. The cost of a round was calculated by multiplying the hourly salary of all healthcare professionals present by the time spent rounding and measured in US dollars.

Results: Median rounding time per patient was 15 minutes (range, 5 to 29). Patient presentation took between 2 and 8 minutes (median 4), or 26% of the rounding time. Time needed for discussion, including teaching and planning, varied between 2 and 25 minutes (median 10.5). Median number of participants was 13.5 (range, 11 and 16). Mean cost in salaries per patient rounded was $140.87 (95% confidence interval: $106.80 to $174.90).

Conclusions: Multidisciplinary rounds are a low-cost medical intervention with proven benefits. Available tools and rounding cultural changes should be adopted to shorten data retrieval and presentation time to the benefit of discussion and teaching. Current billing requirements for rounding multidisciplinary teams do not reflect the realities of their time use.

Ward rounds have their roots on the apprenticeship model of American medical training as early as 1763 [1], but the Oslerian method of bedside teaching during the late 19th century institutionalized a very early form of specialty rounds [2]. As medicine evolved into a very complex form of care, multidisciplinary rounds became a central component of hospital care, representing today the keystone of the intensive care philosophy [3]. Despite our current dependency on computers and monitors for the care of the critically ill, we continue to depend on the daily face-to-face interactions of multidisciplinary rounds to efficiently relay information, reach management consensus and to carry-out our medical education responsibilities.

Based on the current literature, the American College of Critical Care Medicine, recommends the availability of a full-time intensivist and a multidisciplinary team approach as a way to "improve outcomes as measured by reduced mortality, improved efficiency, decreased length of stay or decreased cost of care" [4]. Multidisciplinary rounds have also demonstrated a degree of positive impact on mortality [5] and length of hospitalization [6] in areas other than the intensive care.

Most of the studies on the advantages of multidisciplinary rounds in critical care are limited to clinical outcomes. Not much has been published on the subject of cardiac surgery critical care rounding or the particulars of time usage and salary costs. To that extent, we conducted a detailed time-motion study on multidisciplinary rounds to understand allocation of rounding time, healthcare personnel participation, and associated salary costs.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
After obtaining Institutional Review Board approval and in compliance with Health Insurance Portability and Accountability Act (HIPPA) regulations to prevent patient identification, multidisciplinary teaching cardiac rounds were video recorded once a week (every Friday) for 12 consecutive weeks in a 10-bed general pediatric intensive care unit of an academic medical center. Written consent was obtained from all regular multidisciplinary rounds participants before data collection. Occasional participants (specialty residents, medical students, family members, and visitors) were approached for consent immediately after rounds. The camera was positioned in a platform in a fixed position with a viewing angle that included all participants but not any features (patient's face, family members) to avoid identification.

The process of data collection for rounds presentation occurred before the start of multidisciplinary rounds and was not video recorded. Video recordings were analyzed for times and participants. Two analysts independently coded times and participants. Discrepancies were resolved by joint video reviewing.

The start-time of the round was defined as the moment the case presenter announced: "This is [patient's name]." The end time was defined as the moment the faculty-in-charge verbally announced the end or requested to move on to the next patient. Rounding time was divided into presentation and discussion. The case presenter was either a resident or a nurse practitioner. The case presentation for each patient had a similar organization, starting with a brief history of the patient's current problems followed by a review of overnight issues, vital signs, laboratory results, and medications for the last 24-hour period in an organized manner and by body systems. Some case presentations contained an overall assessment of the patient's status and a plan. Case presentations were frequently interrupted, but fragments of time within a patient presentation were added. The total presentation time was calculated by separating the time devoted to presentation itself from any interruptions and discussions that followed.

The roles of the participants were identified as pediatric intensive care unit attending, pediatric cardiologist, cardiac surgeon, intensive care fellow, intensive care and cardiac nurse practitioners, residents, clinical pharmacists, registered nurses, clinical dietitian-nutritionist, certified respiratory therapist, and medical students.

Salary cost was calculated by multiplying the hourly salary of each participant by the time spent rounding on each patient and measured in US dollars.

Estimated costs were calculated on annual base salaries and do not include benefits. The salary wages of nonphysician professionals involved in multidisciplinary rounds were confirmed to be close to the 75th percentile of a salary survey database in the mid-Atlantic region [7]. Actual figures used as representative salaries for members of our multidisciplinary team included clinical pharmacist ($104,449), registered nurse ($59,895), clinical nurse practitioner ($90,741), clinical dietitian-nutritionist ($56,535), and certified respiratory therapist ($61,079). Physicians' salaries were included at the median values for an assistant professor level in a public medical school and taken from published data from the American Association of Medical Colleges [8]. Yearly salaries used in the calculations according to specialty were pediatric intensivist ($149,000), pediatric cardiologist ($173,000), and pediatric cardiac surgeon ($263,000). Salaries for pediatric residents and for the intensive care fellow were entered in the calculation at a postgraduate year 2 level ($46,685) and postgraduate year 5 ($51,163), respectively. All resident's salaries were entered using the median values for trainees in a hospital affiliated with a public medical school [9]. Medical students were not considered in the cost calculations because they receive no remuneration from either the university or the hospital.

	Results

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
A total of 22 cardiac surgery patients were rounded during the study period. Two patients were excluded from the study owing to lack of a complete set of consents. A total of 312 minutes (5 hours and 12 minutes) were logged as time spent rounding on all 20 patients. The rounding time per patient ranged 5 to 29 minutes, with a median duration of 15 minutes.

Case presentation time took 2 to 8 minutes (median 4) per patient. Of the total 312 minutes used for rounding, 88 minutes were devoted to patient data presentation and consumed 26% of the rounding time. The time spent on discussion of the patient's clinical status, teaching, and planning varied between 2 and 25 minutes with a median of 10.5 minutes per patient.

Each multidisciplinary round was attended by between 11 and 16 participants, with a median attendance of 13.5. The average attendance for the total number of patients was as follows: intensivist (1.2), pediatric cardiologist (1.1), surgeon (0.75), intensive care fellow (0.55), intensive care nurse practitioner (1.5), cardiac surgery/cardiology nurse practitioner (1.1), pediatric residents (6), patient's nurse (.75), pharmacist (0.2), nutritionist (0.05), and respiratory therapist (0.2). Table 1 shows a detailed account of rounds attendance by role with salary costs for individual rounds and total.

View larger version (46K): [in this window] [in a new window]   Fig 1. Cases ranked by total rounding duration (minutes). Both presentation time (diamonds) and discussion time (boxes) were correlated with the total rounding time (triangles [Pearson r = 0.56 and 0.98, respectively, p < 0.01]). Discussion times varied more than presentation time (p < 0.005). The salary cost per patient rounded correlated with the total duration of rounds (Pearson r = 0.97, p < 0.01).

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

Multidisciplinary rounds in the intensive care unit are recommended as one of the measures to improve communication among caregivers [17]; however, time commitment to rounds can be an enormous burden to a clinicians. Our data demonstrate that some of the most critical members of the team were not present on a consistent basis (namely, surgeon required to be available in the operating room while rounds were carried out). Our clinical pharmacist and clinical respiratory technician were available for only 20% of the rounds, and surprisingly, our bedside nurses were present only 75% of the time.

As healthcare resources become ever more constrained, efforts to improve multidisciplinary communication should be considered as a priority. Rounds can be conducted in time-efficient manner if organized well [18].

In our study, more than a quarter of the time spent rounding was devoted to patient data presentation. The use of time for data presentation highlighted another practice associated with rounding: the overextended time spent collecting the data for presentation. In an informal survey of 16 residents rotating through the pediatric intensive care unit, the retrieval of information from the electronic medical record into a paper format consumed anywhere between 5 and 15 minutes per patient, even though all laboratory and medication data needed by the presenter was harvested from electronic format. Accessing medical records during rounds was hampered by different barriers, such as the need for different usernames and passwords or the existence of too many information systems (eg, laboratory, microbiology, and diagnostic images). At our institution, as we suspect is the case in many other healthcare facilities, we have failed to implement the use of current available technologies and tools to shorten rounds preparation time [19, 20].

These data induced us to critically examine our own rounding practices, especially the process by which we collect and disseminate information in the age of electronic medical records [21]. One may argue that the use of electronic medical records has increased, rather than decreased, the time we spent looking for data [22]. Current design of clinical information systems has yet to consider the workflow of clinicians [23]. Because of real and perceived barriers in accessing clinical data, attendings allow themselves to be tempted by secondary data sources as reported by a trainee or other clinician assistants through a paper format, with all the potential risks for clerical error. This backward process undermines one of the main goals of the implementation of electronic medical records, the limitation of errors by minimization of human handling of data.

The ritual practice of rounding in teaching hospitals has an implicit underlying assumption about the role of collecting data. Trainees, whose time is not compensated nearly as much as the attendings, should spend larger amounts of time helping the attending (the "time-poor") by collecting the data needed for the crucial clinical decision-making process that the attending otherwise must conduct.

One of medicine's paradoxes is that, as the success rate of our diagnostic and interventional abilities to treat the most complex diseases improves, the time spent in bedside teaching has decreased to a minimal expression. Bedside teaching represented 75% of the time dedicated to medical instruction in the early 1960s, declining to 16% by the late 1970s [24]. Although no recent data are available, time dedicated to medical students is likely to be even lower today, particularly in the intricacies of our critical care wards, where students and junior residents have been relegated—whether due to the critical complexity of the patients or the demanding pace of the circumstances—to the role of information scouts, with very little return on experience.

The teaching component of multidisciplinary rounds is not accounted for in the Current Procedure Terminology system. This might be particularly important for most university-affiliated medical centers where, for the same proportion of time, a faculty physician may generate as much as 9.8% more relative value units through teaching than through clinical practice [25].

Study Limitations
This is a descriptive study of the components of multidisciplinary rounds, and it does not compare different ways of improving communication among caregivers or forms to expedite the decision-making process through available technology. Our video-recording study was limited to a single institution with a low case volume load. The duration of the study covers a relatively short period of time, and it is confined to a specific day of the week. Although every cardiac patient in the intensive care unit at the time of the intervention was included, our study makes no specific distinction as to whether the rounds were on fresh postoperative or established patients; therefore, no conclusions can be drawn whether the former may require more detailed rounding than the latter. Although preparation for rounds consumes a fair amount of time and work on the part of residents and nurse practitioners, no recording of this activity was performed; therefore, salary calculations for this effort were not included in the analysis. Despite shortcomings, however, we believe the data collected show a likely portrayal of the dynamics of healthcare delivery in an cardiac intensive care environment.

In conclusion, multidisciplinary rounds represent a perfectible medical intervention, based on tradition as opposed to clinical evidence. Early data would seem to uphold the effectiveness and safety of multidisciplinary rounds in the critical care environment, and while their continuing practice is unlikely to be abandoned in our lifetimes, further research is needed to prove their efficacy.

As further clinical evidence on the role of multidisciplinary rounds as a medical error prevention strategy continues to consolidate, this clinical practice should be incorporated into the National Patient Safety Goals as set forth by the Joint Commission [26]. Likewise, measures should be enacted by the American Medical Association to make the necessary changes in the Current Procedure Terminology manual to compel payers, both public and private, to appropriately reimburse multidisciplinary rounds participants. Current time requirements for multidisciplinary rounds billing (starting at a fraction of 30 minutes or longer) should be more realistic (perhaps starting at 10-minute fractions) since the effectiveness of this intervention has not been proven to have a direct association with the time spent rounding but rather with the level of professional attendance and participation. Along these lines, and owing to the time constrains placed on clinicians, academic medical centers should find the appropriate format to recognize and properly compensate the relative value units, matching the teaching component of the intervention.

Available technologies should be used in innovative ways, so a larger component of the time spent in multidisciplinary rounds is allocated to the decision-making portion and less to data retrieval and presentation. The focus should also be on improving the effectiveness of multidisciplinary rounds as a comprehensive learning opportunity for trainees.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The authors would like to acknowledge the contribution by Peter Hu, Steve Seebode, Danny Ho, and Wayne Change for their support in video recording.

The project was funded in part by The National Science Foundation (Grant #0534646). The opinions are those of the authors and do not necessarily reflect the position of the sponsors.

	References

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Packard FR. The history of medicine in the United StatesPhiladelphia: JB Lippincott; 1901. pp. 175.
2. Rothstein WG. American medical schools and the practice of medicine—a historyLondon: Oxford University Press; 1987.
3. Chang A. How to start and sustain a successful pediatric cardiac intensive care program: a combined clinical and administrative strategy Pediatr Crit Care Med 2002;3:107-111.[Medline]
4. Brilli RJ, Spevetz A, Branson RD, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. American College of Critical Care Medicine task force on models of critical care delivery. Crit Care Med 2001;29:2007-2019.[Medline]
5. Plantinga LC, Fink NE, Jaar BG, et al. Frequency of sit-down patient care rounds, attainment of clinical performance targets, hospitalization, and mortality in hemodialysis patients J Am Soc Nephrol 2004;15:3144-3153.[Abstract/Free Full Text]
6. Dutton RP, Cooper C, Jones A, et al. Daily multidisciplinary rounds shorten length of stay for trauma patients J Trauma Injury Infect Crit Care 2003;55:913-919.
7. Salaries in healthcarewww.salary.com 2003Accessed August 6, 2008.
8. Association of American Medical Colleges (AAMC) Report on medical school faculty salaries 2007–2008Washington, DC: AAMC; 2009.
9. 2006 AAMC survey of housestaff stipends, benefits and fundinghttp://www.aamc.org/data/housestaff/hss2006report.pdf 2009Accessed October 22, 2008.
10. Jain M, Miller L, Belt D, et al. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change Qual Safety Health Care 2006;15:235-239.
11. Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses Am J Crit Care 2005;14:71-77.[Abstract/Free Full Text]
12. Durbin CG. Team model: advocating for the optimal method of care delivery in the intensive care unit Crit Care Med 2006;34(Suppl):12-17.
13. Cohen IL, Bari N, Strosberg MA, et al. Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team Crit Care Med 1991;19:1278-1284.[Medline]
14. Rothen HU, Stricker K, Einfalt J, et al. Variability in outcome and resource use in intensive care units J Intens Care Med 2007;33:1329-1336.
15. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors Am J Health Syst Pharm 2002;59:2089-2092.[Free Full Text]
16. Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist Health Syst Pharm 2007;64:2483-2487.
17. Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administration J Qual Patient Saf 2007;33:317-325.
18. Sen A, Xiao Y, Lee S, et al. Daily multidisciplinary discharge rounds in a trauma center: a little time, well spent J Trauma 2009;66:880-887.[Medline]
19. Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours J Am Coll Surg 2005;200:538-545.[Medline]
20. Sarkar U, Carter JT, Omachi TA, et al. SynopSIS: integrating physician sign-out with the electronic medical record J Hosp Med 2007;2:336-342.[Medline]
21. Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology J Am Med Inform Assoc 2006;13:267-276.[Abstract/Free Full Text]
22. Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic N Engl J Med 2008;358:1656-1658.[Medline]
23. Apkon M, Singhaviranon P. Impact of an electronic information system on physician workflow and data collection in the intensive care unit J Intens Care Med 2001;27:122-130.
24. El-Bagir M, Ahmed K. What is happening to bedside clinical teaching? Med Educ 2002;36:1185-1188.[Medline]
25. Yeh MM, Cahill DF. Quantifying physician teaching productivity using clinical relative value units J Gen Intern Med 1999;14:617-621.[Medline]
26. The Joint Commission National patient safety goalshttp://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals 1999Accessed October 7, 2008.

This article has been cited by other articles:

				H. Li, S. Lu, R. E. Schumacher, and F. J. Seagull Why Multidisciplinary Rounds are not Multidisciplinary: Examination of a Neonatal ICU Rounding Process Reviews of Human Factors and Ergonomics, September 1, 2011; 55(1): 758 - 762. [Abstract] [PDF]

				K. W. Lobdell, S. C. Stamou, A. K. Mishra, L. Lilley, D. Safrit, R. M. Stiegel, and E. R. Skipper Multidisciplinary Rounds: The Work, Not More Work Ann. Thorac. Surg., March 1, 2010; 89(3): 1010 - 1010. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Online Discussion (Pediatric) Online Discussion (Adult) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marcelo Cardarelli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cardarelli, M. Articles by Xiao, Y. Search for Related Content PubMed PubMed Citation Articles by Cardarelli, M. Articles by Xiao, Y. Related Collections Education Professional affairs