The effectiveness of structured multidisciplinary rounding ...

JBI Database of Systematic Reviews & Implementation Reports 2015;13(8) 41 - 53

doi: 10.11124/jbisrir-2015-2305 Page 41

The effectiveness of structured multidisciplinary rounding in acute care units on length of hospital stay and satisfaction of patients and staff: a systematic review protocol

Angela Mercedes1

Precillia Fairman1

Lisa Hogan1

Rexi Thomas1

Jason T Slyer1,2

1. College of Health Professions, Pace University, New York, USA

2. The Northeast Institute for Evidence Synthesis and Translation (NEST): a Collaborating

Center of the Joanna Briggs Institute

Corresponding author:

Angela Mercedes

[email protected]

Review question

What is the effectiveness of structured multidisciplinary rounding in acute care units on length of

hospital stay and satisfaction of patients and staff?

Background

Communication is defined as a process by which information is exchanged between individuals

through a common system of symbols, signs, language and behavior. Efficient and effective

communication among members of a healthcare team is invaluable for delivering quality patient

care.1,2

Ineffective communication within a team is identified as a contributing factor to the high

rate of adverse events in the inpatient setting.2 Fragmented care occurs as a result of

communication breakdown where important patient care information is not shared timely or

adequately. The Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health

System for the 21st Century, emphasizes safe, effective patient-centered care that is timely,

efficient and equitable.3 Failures in communication within multidisciplinary healthcare teams are

established causes of errors and negative health outcomes, including death.4

Improvements in organizational processes are needed to ensure a culture of patient safety;

paramount to this are processes and factors related to communication and coordination.5 Health

mailto:[email protected]


doi: 10.11124/jbisrir-2015-2305 Page 42

care typically involves patient management by a number of different specialists. Coordinating

care through multiple handoffs necessitates effective communication of critical information.6

These are goals outlined in the Patient Protection and Affordable Care Act that was passed in the

United States in 2010.7 Maintaining collaborative efforts within the healthcare team, and between

patients and caregivers in inpatient acute care units depends largely on communication.8

Effective communication directly correlates with patient outcomes,9 adverse events,

10 and length

of stay.11

It is the common denominator of stress within the health care team.12

The ways by

which health care providers communicate can also impact on patient satisfaction.13

The World

Health Organization recommends improved communication between healthcare providers by

allocating sufficient time during patient encounters utilizing a standardized approach.14

Dwindling reimbursement, shifting emphasis on patient outcomes and satisfaction, and rapidly

rising health care costs lend impetus to finding new ways of providing safe, effective care in the

most timely manner possible, utilizing existing resources. Although the concept is not new,

multidisciplinary rounding (MDR), sometimes known as collaborative rounding or interdisciplinary

rounding, is being re-evaluated and refocused in many acute care settings to maximize its

potential impact on patient care issues. Multidisciplinary rounding has been identified as a way to

improve patient care by promoting health care provider communication, leading to a greater

shared knowledge of a patient’s status, smoother patient care flow, decreased length of stay, and

enhanced patient and staff satisfaction.15-18

In order to be considered multidisciplinary, rounds must consist of two or more disciplines

meeting together to review the plan of care, determine priorities, and coordinate and facilitate the

progression from one point of care to the next, either within the hospital, at another health care

facility, or to the community.16,18

Multidisciplinary rounding may be either nurse or physician led

and the make-up of the team may vary, depending on the needs of the patient and the unit.15,18

A

common team composition may consist of any combination of the primary medical provider,

specialty providers, medical residents, nurse practitioners, physician assistants, bedside nurse,

case manager, social worker, unit manager, and/or other ancillary service providers, as needed.18

Rounds may be walking, which has the advantage of allowing a quick visual assessment of the

patient and patient/family involvement,16

or they may be held at a central location, which may

improve the multidisciplinary team’s ability to talk more freely about the plan of care.15

Multidisciplinary rounding may be scripted or unscripted. Reimer and Herbener recommend that

MDR be held at the same time each day, be brief, be organized in such a manner that the

information covered is consistent from patient to patient yet individualized to each patient’s

needs, and occurs independently of any one discipline’s presence or absence.18

Ineffective communication among members of the healthcare team is caused by delays in

communication, failure to communicate with the appropriate team member, provision of

inaccurate or incomplete information, and matters left unresolved until the point of urgency.19

Many healthcare settings are implementing various communication strategies to add structure to

the MDR process with the goal of improving communication among the healthcare teams. One

strategy is the use of a standardized communication tool during MDR. A standardized

communication tool is a systematic approach that is used to enhance the ability to communicate


doi: 10.11124/jbisrir-2015-2305 Page 43

effectively within or between disciplines.20

According to Narasimhan, Eisen, Mahoney, Acerra,

and Rosen, a standardized communication tool may be an important means to achieve reliable,

consistent and efficient communication that supports collaborative work in healthcare settings.20

Examples of standardized communication tools include checklists, daily goals sheets, door

communication cards, or the situation, background, assessment, and recommendation (SBAR)

tool. The SBAR tool is for the purpose of communicating changes on patients’ status in a timely

fashion.19

As per Diaz-Montes, Cobb, Ibeanu, Njoku, and Geraldi, the use of a checklist during

MDR may enhance communication as it acts as an agenda, triggering consistent information

exchange, and clarifying patient goals.21

The main purpose of a checklist is to organize and

outline criteria to be considered during MDR.21

A daily goals sheet clarifies a patient’s goals and

provides an accurate information source for each patient.20

The use of structured tools with a systematic approach to communication, either written or verbal,

may be a way of improving communication between different team members.19

A structured

communication tool used during MDR may be helpful in the busy healthcare environment where

important information could be missed resulting in treatment delay. A structured tool may also be

useful for informing all healthcare providers involved in a patient’s care on changes in the

patient’s status. Concerns can be addressed quickly, thus ensuring quality patient care.22

Cornell,

Townsend-Gervis, Vardaman, and Yates demonstrated decreased time for treatment, increased

staff satisfaction with communication, and higher rates of resolution of patient issues when a

communication tool was implemented during MDR on an inpatient unit.19

Narasimhan et al.

showed that the use of a daily goals sheet improved communication among the healthcare team

and decreased the length of stay in an intensive care unit.20

However, Ainsworth, Pamplin, Allen,

Linfoot, and Chung reported no improvement in communication during MDR with the use of a

daily goals door communication card, a tool similar to the daily goals sheet.23

Ambiguity remains

in the literature regarding the overall effectiveness of standardized communications tools used

during MDR and which type of tool may yield better outcomes.

The goal of MDR is to improve care coordination with the aim of reducing length of stay while

improving the satisfaction of the multidisciplinary team involved in the rounding and the

satisfaction of the patient being cared for. Efficient and effective healthcare improves the quality

of care delivered which decreases length of stay and provides a seamless transition to the next

level of care.20

Length of stay is defined as the number of days admitted to a healthcare facility or

a specific healthcare unit, and is calculated by totaling the number of days from admission to

discharge or the transition to the next point of care.

Patient satisfaction is an individual’s evaluative judgments concerning the quality of care received

from healthcare providers. Improved quality of care increases patient satisfaction.24

The use of a

structured communication tool may increase patient satisfaction by improving collaboration of

care.17

Multiple tools are available to measure patient satisfaction. An example of one measure is

the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

The HCAHPS survey evaluates a patient’s perspective of their care across nine essential

topics.25


doi: 10.11124/jbisrir-2015-2305 Page 44

Staff satisfaction is defined as a pleasurable or positive emotional state resulting from the

appraisal of one’s job or job experiences. Structured MDR utilizing a communication tool may be

one method to improve staff satisfaction.26

A number of surveys are available to measure staff

satisfaction. The Press-Ganey Employee Partnership Survey and the Gallup Consulting Survey

are two widely used survey tools.27

Multidisciplinary rounding is important for coordination of patient care across various specialties in

an inpatient setting; however, communication among the members of the healthcare team may

sometimes be less than optimal.10

This systematic review aims to determine the effectiveness of

using a standardized communication tool during MDR in acute care units on length of stay,

patient satisfaction and staff satisfaction. A search of MEDLINE, Cumulative Index to Nursing and

Allied Health Literature (CINAHL), the Joanna Briggs Institute Database of Systematic Reviews

and Implementation Reports, and the Cochrane Database of Systematic Reviews was performed

and no existing or ongoing systematic review on this topic was identified.

Keywords

Multidisciplinary rounds, length of stay, patient satisfaction, staff satisfaction

Inclusion criteria

Types of participants

This review will consider studies that include samples of healthcare providers, including, but not

limited to, physicians (both primary care and specialty providers), medical residents, nurse

practitioners, physician assistants, bedside nurses, case managers, social workers, unit

managers, and/or other ancillary services who provide direct care for adult patients (18 years and

older) hospitalized on inpatient acute care units for the management of any acute or chronic

illness. Studies focusing on pediatric, mental health or obstetric patients, or adult outpatients will

be excluded.

Types of intervention(s)

This review will consider studies that evaluate the implementation of a structured MDR process

on adult patients (18 years and over) hospitalized in acute care units for the management of any

acute or chronic illness. For the purpose of this review, structured MDR is defined as the process

of patient rounds by a multidisciplinary team utilizing a standardized communication tool.

Examples of standardized communication tools include, but are not limited to, checklists, SBAR

tools, and daily goal communication tools. A multidisciplinary team consists of two or more

disciplines involved in a patient’s care meeting to outline the plan of care. A multidisciplinary team

may consist of medical providers, nurses, case managers, social workers and/or other ancillary

service providers actively involved in the patient’s care.

Comparator intervention

This review will consider studies that compare structured MDR with MDR without the use of a

standardized communication tool or rounds without a multidisciplinary approach.


doi: 10.11124/jbisrir-2015-2305 Page 45

Types of outcomes

The review will consider studies focusing on three primary outcomes of interest: length of stay,

patient satisfaction and/or staff satisfaction. Length of stay is defined as the number of days

admitted to a healthcare facility or a specific healthcare unit. Length of stay is calculated from the

day of admission to discharge or the transition to the next point of care. Patient satisfaction is an

individual’s evaluative judgment concerning the quality of care received from healthcare

providers. Staff satisfaction is defined as a pleasurable or positive emotional state resulting from

the appraisal of one’s job or job experiences. Studies that evaluate patient satisfaction and/or

staff satisfaction, as measured by valid and reliable tools, such as, but not limited to, the Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which measures

patient satisfaction, or the Press Ganey Employee Partnership Survey, which measures staff

satisfaction, will be considered for inclusion.

Types of studies

The review will consider randomized controlled trials and quasi-experimental studies for inclusion.

In the absence of these, the review will consider other quantitative research designs such as

observational or descriptive designs for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search

strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be

undertaken followed by an analysis of the text words contained in the title and abstract, and of the

index terms used to describe the article. A second search using all identified keywords and index

terms will then be undertaken across all included databases. Third, the reference list of all

identified reports and articles will be searched for additional studies. Studies published in or

translated into the English language will be considered for inclusion in this review. Studies

published from the inception of the databases searched through the current date of the review will

be considered for inclusion in this review.

The databases to be searched include: PubMed, CINAHL, Excerpta Medica Database

(EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Health Source:

Nursing/Academic Edition, and Scopus.

The search for unpublished studies will include: New York Academy of Medicine, ProQuest

Dissertation and Thesis, ClinicalTrials.gov, Google Scholar, and the Virginia Henderson

International Nursing Library.

Initial keywords to be used will be: acute care unit, multidisciplinary rounds, rounding, length of

stay, patient satisfaction, and staff satisfaction.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological

validity prior to inclusion in the review using standardized critical appraisal instruments from the

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-


doi: 10.11124/jbisrir-2015-2305 Page 46

MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved

through discussion, or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review by two independent reviewers using the

standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include

specific details about the interventions, populations, study methods and outcomes of significance

to the review question and specific objectives. Any disagreements that arise between the

reviewers will be resolved through discussion, or with a third reviewer.

Data synthesis

Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI.

All results will be subject to double data entry. Effect sizes expressed as weighted mean

differences (for continuous data) and their 95% confidence intervals will be calculated for

analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also

explored using subgroup analyses based on the different study designs included in this review.

Where statistical pooling is not possible, the findings will be presented in narrative form including

tables and figures to aid in data presentation where appropriate.

Conflicts of interest

The authors have no conflicts of interest to disclose.

Acknowledgements

This review will partially fulfill degree requirements for successful completion of the Doctor of

Nursing Practice Program at Pace University, College of Health Professions, New York, NY for:

Angela Mercedes, MS, RN, FNP-BC; Precillia Fairman, MS, RN, FNP-BC; Lisa Hogan, MS, RN,

FNP-BC; and Rexi Thomas, MS, RN, FNP.


doi: 10.11124/jbisrir-2015-2305 Page 47

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doi: 10.11124/jbisrir-2015-2305 Page 49

Appendix I: Appraisal instruments

MAStARI appraisal instrument


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Appendix II: Data extraction instruments

MAStARI data extraction instrument


doi: 10.11124/jbisrir-2015-2305 Page 53

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