Background and Objective: Family-centered rounds (FCR) involve multidisciplinary rounds at the patient bedside with an emphasis on physicians partnering with patients and families in the clinical decision-making for the patient. Although the purpose of FCR is to provide patient-centered care, an unanticipated benefit of FCR may be to improve time to discharge. The objective of this study was to determine the impact of FCR on time to discharge for pediatric patients in an academic medical center.
Methods: We retrospectively compared the timing of patient discharges from July 2007 to June 2008 (before FCR) versus those from July 2008 to May 2009 (after FCR) on the pediatric hospital medicine service. We further compared time from order entry to study completion on a subset of patients receiving head MRIs and EEGs, studies that typically occurred on the day of discharge.
Results: In our center, before FCR, 40% of patients were discharged before 3:00 pm (n = 912). After FCR, 47% of children were discharged before 3:00 pm (n = 911) (P = .0036). Time from order entry to study completion for MRIs and EEGs decreased from 2.15 hours before FCR (n = 225) to 1.73 hours after FCR (n = 206) (P = .001).
Conclusions: FCR provided a modest improvement in the timeliness of the discharge process at our institution.
In 2003, the American Academy of Pediatrics developed a policy statement regarding family-centered care. According to this statement, “Family-centered care can improve patient and family outcomes, increase patient and family satisfaction, build on child and family strengths, increase professional satisfaction, decrease health care costs, and lead to more effective use of heath care resources.”1 Family-centered rounds (FCR) were developed in an effort to improve family-centered care. FCR are “multidisciplinary rounds that occur inside patients’ rooms, in the presence of patients and family members, and integrate patient and parent perspectives and preferences into clinical decision-making.”2 Families and patients are encouraged to be active participants during rounds. During these rounds, orders, consults, and discharges can be completed while in the patient’s room. In July 2008, our institution initiated FCR on the hospitalist medicine service. Our daily multidisciplinary rounds involve attending physicians, pediatric residents, medical students, nursing staff, pharmacists, and other appropriate staff who meet with patients and families inside the patient room to facilitate family involvement and communication
During the same time period, there has been a nationwide effort to reduce length of hospital stay and improve the timeliness of discharge within hospitals.3 One study found that discharge delays occurred due to inadequate communication between nursing staff and physicians.4 Nurses also attributed delays to morning conferences and traditional conference room–style rounding. Nurses found it difficult to access physicians in the mornings, leading to poor communication regarding the plans for the patient’s day. In 2010, the American Academy of Pediatrics promoted FCR as a system that can improve coordination and communication between nursing staff, families, and physicians as well as decrease misunderstandings and improve the timeliness of the daily plan.5 A policy statement published in 2012 recommended physicians round at the bedside with the family and bedside nurse present.6 Nursing participation may theoretically assist the physician team in anticipating the patient’s medical and social needs earlier in the hospital stay to result in a more timely patient discharge.3–9 Studies have also shown an increase in nursing satisfaction and nursing perception of improved patient care when nurses are included in FCR.5–7 In one early study on FCR, there was an increase in the number of patient discharges during first shift from ∼40% to >60% over 3 years.10 This outcome was hypothesized to be due to an increased focus on discharge goals with families more aware of the discharge timing and the medical team’s ability to better prepare for discharge.
The objective of the present study was to determine the impact of FCR on patient discharge times in an academic children’s hospital. We further analyzed the time from order entry to study completion in a subset of patients who underwent head MRIs or EEGs. These tests were chosen because of their adequate volume for study and the fact that they are often performed on the day of discharge at our institution. We hoped such a subanalysis would contribute further understanding to our hypothesis that poor communication surrounding intent to order testing and coordination of testing was leading to delays in discharge for our patient population.
This trial was a retrospective, before and after study of the impact of FCR on discharge time. A chart review of patients admitted to the pediatric hospitalist service at an urban tertiary care children’s hospital was performed, comparing discharge timing as well as time from study order to completion of MRIs and EEGs before and after institution of FCR. Once initiated, FCR were conducted on a daily basis, including weekends. At our institution, the hospitalist team comanages many patients with the neurology team, and often an abnormal EEG requires an MRI. Although many MRIs are performed in the outpatient setting, a good proportion is done during hospitalization due to the patient’s ability to return, age of the child, and clinical condition. The institutional review board at Riley Hospital for Children approved this study.
Primary Outcome: Discharge Time
All patients admitted to the pediatric hospital medicine service between July 2007 and May 2009 were included in this study. A computer-assisted screening tool was used to determine the time of discharge of these patients. The time of discharge of patients between July 2007 and June 2008, before FCR was implemented, was compared with the time of discharge of patients between July 2008 and May 2009, after FCR was implemented (Fig 1). Time of discharge was segmented into 3 shifts. First shift was defined as 7:00 am to 3:00 pm, second shift was 3:01 pm to 11:00 pm, and third shift was 11:01 pm to 6:59 am.
Secondary Outcome: Time to Study Completion for MRI or EEG
The subset of patients who had a head MRI or EEG ordered and performed during their hospital stay were included in a secondary analysis. Patient charts were manually reviewed to assess the time between when the order was entered to when the study was performed (Fig 2).
The proportions of patients discharged during the first shift versus second or third shifts and 95% confidence intervals were calculated for patients discharged before and after the implementation of FCR. These proportions were compared by using a χ2 test, with a P value <.05 considered significant. The average time from ordering to completion of head MRIs and EEGs was calculated. Because the distributions of time to completion were skewed, data were transformed, and the natural log was used in statistical testing. We compared times to study completion by using a t test with a significance level of P < .05.
A total of 1823 patients were admitted to the pediatric hospital medicine service during the entire study period (July 2007–May 2009). A total of 912 patients were in the pre-FCR group and 911 patients were in the post-FCR group.
In the pre-FCR group, 363 (40%) of 912 patients were discharged before 3:00 pm; in the post-FCR group, 424 (47%) of 911 patients were discharged before 3:00 pm (P < .004) (Table 1).
The time to completion of EEGs and MRIs decreased from 2.15 to 1.73 hours. Using a t test to compare the log of the time to completing these studies, this difference was statistically significant (P < .001).
The present study showed that after implementation of FCR, there was a significantly increased percentage of discharges during the first shift, rather than second or third shift. Patients discharged earlier in the day may improve hospital efficiency by allowing increased hospital throughput and potentially decreasing emergency department (ED) crowding. It also showed that EEGs and head MRIs were completed faster after the implementation of FCR. These studies, if completed later in the day, could delay patient discharge.
A report in 2006 by the Institute of Medicine found that 91% of EDs operated over their designed capacity, resulting in crowding; ∼40% reported that crowding occurred daily.11 ED crowding can result in decreased patient satisfaction and negatively affect patient outcome and quality of hospital care.12,13 The most frequent cause of ED crowding is lack of available hospital beds.14 When hospitals operate at near-capacity, it is important for discharges to be completed earlier in the day to improve hospital throughput and decrease ED crowding. Improving patient flow by enhancing discharge efficiency can increase the volume of patients treated, improve patient care, and decrease the cost of care.11–14 Our results suggest that by facilitating early order writing, FCR improve timing of the tests and thereby facilitate earlier discharges. Using FCR to improve throughput may assist pediatric hospitalists to partner with emergency medicine providers and hospital administrators to improve hospital capacity and patient flow.
FCR allow all involved to be present at the same time to develop a mutually agreed upon plan of care for patients and therefore help to close the communication loop. Family members can provide input about the patient that may ultimately help guide diagnostic and treatment options. Nursing can also provide crucial information during FCR. In a recent study to improve nursing presence on FCR, nurses surveyed indicated that they were better equipped to care for their patients when they were included in FCR.6 Family engagement and satisfaction have also improved with the implementation of FCR.2,7 Comanagement of patients between hospital medicine teams and subspecialty teams is becoming more common and requires another level of communication to ensure that the family, nurses, and physicians all agree and understand the care needed for the patient. By partnering with our neurology team to care for some of our patients, we were able to improve our discharge timing and create a culture of FCR on their service. Although communication and patient satisfaction were out of the scope of the present study, our finding of decreased study wait times suggests that FCR, by facilitating earlier discharge times, can also aid in throughput and lead to higher quality of care for our patients, which may have cost implications.
There are several limitations to our study. This study was conducted at a single academic children’s hospital; it may therefore have limited generalizability. We did not assess changes in patient morbidity that may have happened over the 2 years of the study, nor did we examine early readmission rates. Our study is also vulnerable to secular changes in care, and we also did not assess changes that may have occurred in the radiology department or the EEG laboratory during our study period. However, we know of no such changes. This study was retrospective, which may have decreased some participant bias because we had not yet developed our hypothesis during the time period in which our study took place. We also had ∼10 attending physicians participating in FCR at that time. The introduction of an entirely new way of rounding (FCR) to these attending physicians during the second part of our study period may have actually dampened our results due to learner bias requiring increased time for each attending to become comfortable and efficient with FCR. Our study was also conducted before the onset of computerized physician order entry at our institution. Thus, we still used paper charts with patients on multiple floors, which delayed the entry of orders during conference-style rounding because orders were written after rounds. Although the use of paper charts may be a limitation, we feel that it was balanced by the more important aspect of FCR, which includes having nursing staff present during rounds to improve communication because they are crucial for carrying out patient treatment plans. We feel that the improved communication was more important in improving discharge timeliness and completion of studies than the actual time of the order entry that may occur with computerized physician order entry during conference-style rounds. Another limitation is that we were not able to perform a subgroup analysis of changes in discharge timing on patients who specifically did not need an MRI or EEG after FCR was implemented.
Our findings suggest that FCR significantly improved discharge timeliness and reduced time to completion of MRIs and EEGs in a large tertiary care hospital. These findings have implications for improving efficiency and throughput for the hospital. In a busy hospital with a fixed number of beds, increased throughput may allow increased patient volume.
Dr Oshimura helped design the study, completed the chart review, and drafted the initial manuscript; Dr Downs critically reviewed the study design, analyzed and interpreted the data, and reviewed and revised the manuscript; and Dr Saysana conceptualized and designed the study, completed the chart review, reviewed the initial analyses, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- emergency department
- family-centered rounds
- magnetic resonance imaging
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- Copyright © 2014 by the American Academy of Pediatrics