Length of Stay as a Healthcare Setting

Length of stay is a persistent problem in a healthcare setting. The increasing complexity of treatment processes, the growing cost of care delivery combined with a decrease in reimbursement, and the increasing pressure created by regulations lead to a situation where length of stay (LOS) significantly increases both the complexity and the cost of the care delivery process (Townsend-Gervis, Cornell, & Vardaman, 2014). In order to respond to the issue, managers look for an intervention that would be easy to implement and would not require allocation of significant time and resources. One of the suggested approaches is the implementation of interdisciplinary rounds (IDR) – a practice that facilitates discussion of the patient’s health and treatment plan among the participants in the healthcare delivery process. The current approach to care delivery requires the involvement of numerous specialists from different fields, which introduces the possibility of miscommunication, numerous errors, and, as a result, an adverse effect on the overall quality of care. The establishment of regular and transparent communication channels is expected to mitigate these risks by increasing coordination and the overall understanding of the treatment process. Recently, interdisciplinary rounds have garnered significant attention due to their potential for improving care delivery. However, the assumed positive effects of the practice have not been conclusively proven experimentally. While some of the studies provide evidence of a decreased LOS associated with IDR, these results are not replicated consistently and vary depending on the tool and methods of data collection and analysis used by the researchers. The following literature review aims to determine whether the implementation of interdisciplinary rounds can reduce the length of stay in a surgical unit.

The following PICOT question can be formulated based on the identified goal:

In a surgical unit (P), should interdisciplinary rounds (I) be implemented for reducing the length of hospital stay (O)?

The literature review will draw on original research articles for data collection. Both primary (experimental design) and secondary studies (systematic reviews and meta-analyses) can be used for evidence synthesis. The highest priority is given to the articles using objective data (e.g. medical records) rather than participants’ perceptions. In addition, only the articles with reliable quantitative tools intended to ascertain validity and reliability of findings will be used. The search will be conducted using the PubMed and EBSCO databases using keywords such as “interdisciplinary rounds,” “multidisciplinary rounds,” “length of stay,” “systematic review,” “meta-analysis,” and “controlled trial,” among others. Filters will be used to narrow down the inquiry. Articles published within the most recent five-year range will be given top priority to ensure the relevance of the included data. An approximate number of sources sufficient for obtaining a reliable result is estimated at eight articles. If the necessary number is not reached, articles using subjective data and those older than five years may be used.

Literature Review

Background

The importance of communication between members of a healthcare team for the quality of care delivered to patients is a relevant topic in the academic community. According to the consensus, inefficient communication has multiple adverse effects on patient outcomes (Townsend-Gervis et al., 2014). The primary reason for this is that gaps in communication lead to a loss of data that may be crucial for the facilitation of an appropriate intervention, for monitoring the process, and for introducing adjustments into care plans. In the majority of cases, the quality of communication depends on the establishment of an appropriate organizational culture in order to achieve the desired level of coordination between team members. By extension, the resulting improvement in communication is expected to positively impact several determinants of the quality of care, such as length of stay, readmission rates, mortality, and patient satisfaction rates, among others.

At this point, it should be understood that effective communication requires a certain amount of resources dedicated to improving the organizational culture. Thus there is a need for an observably efficient approach that would provide consistent and predictable results, instill a sustainable process of improving the organizational culture, and exclude unnecessary expenses. One of the approaches used for this purpose is interdisciplinary rounds. This method is being adopted in multiple healthcare settings at an increasing rate. It is commonly associated with several positive changes, such as the promotion of reliable communication, an enhanced flow of care, and numerous improvements in patient outcomes (Townsend-Gervis et al., 2014). Nevertheless, it should be pointed out that despite increasing recognition and adoption, there is not yet general agreement on the expected benefits of interdisciplinary rounds. In some cases, researchers provide an encompassing picture of its effect on patient outcomes and establish an indirect effect based on inferred relationships between various factors (Huynh, Basic, Gonzales, & Shanley, 2016). It is also important to note that the findings of some studies point to the inefficiency of interdisciplinary rounds for the identified purpose. Therefore, it would be reasonable to distinguish between an overall improvement of care quality and improvements in specific areas.

Overall Impact on Quality of Care

A number of studies dealing with the effects of interdisciplinary rounds investigate their overall impact on the quality of care by including a number of independent variables in the research design. A study by Cornell, Townsend-Gervis, Vardaman, and Yates (2014) measured the effects of the introduction of interdisciplinary rounds on patient outcomes and staff awareness rates. The former was established by measuring several specific patient review conditions observed over a time span of nine months. The authors included length of stay as one of the factors suggesting a positive impact of using interdisciplinary rounds, in addition to situation awareness exhibited by the facility staff, improved consistency of nurses’ actions, and patient satisfaction with nurses’ communication and knowledge (Cornell et al., 2014). The study was conducted within a single acute care hospital. The interdisciplinary rounds were organized by charge nurses and covered pharmacists, care managers, and dietitians as members of the care team (Cornell et al., 2014). The quality of care was determined by analyzing changes in patient review times, HCAHPS data, data provided by Press Ganey, and patient length of stay. The data for the first variable were obtained experimentally by an observer, whereas the other data were retrieved from hospital records. The results of the study suggested a positive impact of the use of interdisciplinary rounds on patient outcomes, as well as an increase in awareness among nursing staff. However, the conclusion was based primarily on a decrease of patient review times and a positive change in some patient satisfaction indexes. Some of the indexes remained unchanged after the intervention. More importantly, the researchers did not observe a change in the length of stay. Finally, interdisciplinary rounds were only one of the independent variables used in the study, which compromises the validity of findings.

A comprehensive systematic review of literature conducted by Pannick et al. (2015) reported somewhat similar results. The aim of the research was to identify the most common patient outcomes in the academic literature on various interdisciplinary team care interventions and determine the validity of the proposed interventions by comparing their results to the identified criteria. The evidence was obtained from academic literature retrieved from the EMBASE, MEDLINE, and PsycINFO databases. The research team successfully identified several outcomes, with length of stay being the most common objective (used in 77 percent of the studies), followed by in-hospital mortality rate and 30-day readmission rate (Pannick et al., 2015). However, the exploratory quantitative analysis revealed that the specified outcomes were not consistent across the studies. All of the identified outcomes were not met in the majority of cases. In addition, hospital length of stay was among the least affected dependent variables, with 70 percent of the studies reporting no improvement associated with the introduction of interdisciplinary rounds. The effect in other areas was equally minor, with 80 and 93 percent of the studies reporting no progress in the reduction of readmission rates and mortality rates, respectively (Pannick et al., 2015). In summary, interdisciplinary interventions did not create a practically significant improvement detectable using traditional approaches to assessing quality of care.

As can be seen from the information above, the widespread belief in the effectiveness of interdisciplinary interventions is only partially confirmed by the results of scholarly studies. The most probable reason for this is the overarching approach adopted by the researchers. In the reviewed examples, length of stay is used as one of several determinants of success, and while in some cases the overall results create a favorable impression, a more in-depth inquiry reveals that at least some of the factors associated with quality remain relatively unaffected. Thus a more focused approach may be necessary in order to establish interdisciplinary rounds’ capacity for quality improvement.

Available Data

In addition to establishing the overall positive effect of interdisciplinary rounds on care quality, it may be more feasible to detect its impact on specific areas of care delivery. The clearest impact is the effect of interdisciplinary rounds on length of stay. A recent study by Dunn et al. (2017) aimed at determining the feasibility of IDR as an intervention for the reduction of hospital length of stay and associated complications. It should be mentioned that a custom-designed IDR model was used in the study. The model emphasized patient engagement scripting, a rigidly defined structure, and patient safety checklists as its principal components. In addition to hospital length of stay, clinical deterioration was included as a primary outcome. The analysis of data revealed the lack of any practically significant reduction in either of the identified outcomes, with 6.6 days in the intervention group versus 7 days in the control group (Dunn et al., 2017). Clinical deterioration displayed a similar lack of significant improvement. Interestingly, the perceptions of quality of care obtained from the facility staff before and after the intervention showed positive results, with the majority of nurses reporting improvement. A similar result was observed concerning the patient safety culture reported by the participants. Despite the absence of quantifiable results, the hospital staff assessed the culture as significantly improved compared to the pre-intervention period (Dunn et al., 2017). The study was conducted in the form of a controlled trial, which ascertains the validity of the results. However, it was performed within a single hospital, which introduces the possibility of bias. It is also important that the implementation was not accompanied by the comprehensive changes necessary for consistent results, which necessitates further inquiry on the matter.

A similar approach was used in a study by Huynh et al. (2016) that aimed to evaluate the effect of structured interdisciplinary bedside rounds on patient length of stay. The study was focused on older patients who were hospitalized due to acute illnesses. The statistical analysis of data revealed no clinically significant change between the hospital where the rounds were implemented and a control patient population from a similar facility (Huynh et al., 2016). The implementation also did not affect 28-day readmission rates. Interestingly, the research team also looked into the potential influence of mental disorders, such as dementia and delirium, on the effectiveness of IDR use, which returned negative results (Huynh et al., 2016). Thus the study concluded that an independent assessment of the efficiency of the chosen model should be conducted by the organizations that choose to use it as a component of a quality improvement process. At the same time, some areas, such as staff efficiency, teamwork, and morale, are known to benefit from IDR implementation (Huynh et al., 2016). Thus it is possible to expect a positive indirect effect that may be nullified in the process.

A study by Dutton et al. (2003) explored the effects of interdisciplinary rounds on patient outcomes as well as on organizational performance. Both categories required the assessment of several parameters, including the average length of stay derived from the medical records of 90 patient beds in a single trauma center. The findings of the study suggested that interdisciplinary rounds had a major positive effect on patient flow, indicated by a 36% increase in patient volume. In addition, a bypass scenario, where admissions could not be accepted, was eliminated. An improvement in quality of care was also observed, with the data indicating a 15% decrease in average length of stay (Dutton et al., 2003).

While the results of the study in question indicate a significant improvement in the desired direction, several factors should be taken into account. First, although the data were retrieved from the unit’s medical records, the sample was not randomized, which introduces the potential for bias. More importantly, the study was performed on a single sample without the use of a control group. Thus it is possible that the observed effect was due to another factor or a combination of factors that were not controlled for by the research team. Therefore the reported improvement should be considered a viable direction for further research rather than definitive proof of the intervention’s effectiveness.

An article by O’Mahony, Mazur, Charney, Wang, and Fine (2007) explored the effects of interdisciplinary rounds on several performance measures, including hospital length of stay, as well as other important variables, such as resident education. The data were obtained using JCAHO core measure performance for care quality, and anonymous questionnaires for resident knowledge and attitudes. The results indicated significant improvement in quality core measure performance. A positive trend could be observed both in results disaggregated by category and in aggregated data (O’Mahony et al., 2007). Most importantly, the introduction of IDR was associated with a decrease in adjusted average length of stay by 0.5 and 0.6 days for a separate group and the aggregated sample, respectively (O’Mahony et al., 2007). The involved staff also reported improvements in communication, core measure knowledge, and system-based care. The demonstrated results were adjusted for certain trends and patient characteristics to eliminate confounding variables. In addition, two sets of measures were conducted in order to establish that a change had occurred. However, it should be noted that the study did not include a control group, which adds to the possibility of bias. Thus despite the fact that the majority of the findings were based on objective data, the results should be used with caution until replicated in a properly controlled trial.

A study exploring the perceived effects of interdisciplinary rounds was performed by Gonzalo, Kuperman, Lehman, and Haidet (2014). According to the research team, knowledge of the perception of IDR is essential for the implementation process since it enhances the current conceptualization. Thus, an observational, cross-sectional survey was administered to attending physicians and nurses in order to identify the potential benefits of IDR use as well as common barriers to its implementation. The definition of IDR, as well as lists of benefits and barriers, was predetermined in order to improve the accuracy of the research. The analysis of data revealed that the benefits that fall under the “communication” category were ranked the highest by the respondents. On the other hand, both the “decreased length of stay” and the “improved timeliness of consultations” categories received the lowest score. Interestingly, the survey results also highlighted some of the common barriers to the practice, including limited time at the nurses’ disposal as the most significant one. Other barriers, such as the compromised comfort of the patients, were ranked as insignificant (Gonzalo et al., 2014).

The research team used a quantitative approach for analyzing the data, which identified a high statistical significance of the ratings reported by the participants (p < 0.05). The researchers pointed out that the benefits associated with coordination and teamwork were generally perceived as a greater benefit resulting from IDR implementation than those contributing to patient outcomes (e.g. length of stay). This conclusion is consistent with the findings of the research by Huynh et al. (2016), which also point to communication as the main area of improvement associated with IDR implementation. Finally, it should be mentioned that the results illustrate staff perceptions rather than actual measured outcomes, and should thus be viewed as a viable direction for research rather than the basis for developing an intervention.

An article by Geary, Cale, Quinn, and Winchell (2009) proposed a transferable model intended to decrease LOS that would be applicable to various medical units. In order to verify the model’s effectiveness, the research team implemented their model within several units of a single hospital. The data on length of stay were obtained from an electronic system that calculated average LOS by unit and generated reports that were used by the researchers. The results indicated a decrease in LOS for each of the units within the observation period. The survey administered to participants also indicated overwhelmingly positive perception of IDR implementation, including a perceived improvement in quality of care (Geary et al., 2009). However, it should be noted that the results were presented using descriptive statistics and visual means (charts and tables). In addition, the authors did not disclose their methodology and did not provide information on the use of controls. While such an approach is sufficient for confirming the model’s efficiency, it can only be considered as an illustration of a favorable trend rather than a demonstrated outcome.

As can be seen from the available literature, a growing amount of evidence suggests that the positive effect of interdisciplinary rounds on patient length of stay is either negligible or non-existent. However, it is equally valid to recognize its potential indirect effects due to improvement of workplace culture as well as to collaboration both within and between hospital teams. Finally, it is important to recognize the major positive impact on the perception of care quality detected in one of the studies, which may explain the difference between the expectations and the quantifiable results. Appendix A presents a literature matrix.

Conclusions and Implications

The information obtained from the review of literature allows us to draw several conclusions. First, the data on the effects of interdisciplinary rounds is currently insufficient for concluding with certainty concerning its ability to decrease patient length of stay. However, several trends can be observed in the literature. For instance, the studies that measure the effect of IDR on LOS based on objective data (e.g. medical records adjusted for patient data) either report effects that are negligible from the standpoint of clinical significance, or fail to detect any effect at all (Dunn et al., 2017). On the other hand, the studies that use subjective data (e.g. perceptions of patients and staff) report significant improvement. Finally, the majority of the articles report an improvement in communication and coordination, which suggest an indirect favorable effect on LOS.

Considering all of the above, it would be reasonable to conclude that interdisciplinary rounds can be implemented for LOS reduction. However, the amount of improvement cannot be reliably predicted due to lack of data. Thus it is necessary to conduct additional research to improve our understanding of IDR’s effects on LOS.

References

Cornell, P., Townsend-Gervis, M., Vardaman, J. M., & Yates, L. (2014). Improving situation awareness and patient outcomes through interdisciplinary rounding and structured communication. Journal of Nursing Administration, 44(3), 164-169.

Dunn, A. S., Reyna, M., Radbill, B., Parides, M., Colgan, C., Osio, T.,… Egorova, N. (2017). The impact of bedside interdisciplinary rounds on length of stay and complications. Journal of Hospital Medicine, 12(3), 137-142.

Dutton, R. P., Cooper, C., Jones, A., Leone, S., Kramer, M. E., & Scalea, T. M. (2003). Daily multidisciplinary rounds shorten length of stay for trauma patients. Journal of Trauma and Acute Care Surgery, 55(5), 913-919.

Geary, S., Cale, D. D., Quinn, B., & Winchell, J. (2009). Daily rapid rounds: Decreasing length of stay and improving professional practice. Journal of Nursing Administration, 39(6), 293-298.

Gonzalo, J. D., Kuperman, E., Lehman, E., & Haidet, P. (2014). Bedside interprofessional rounds: Perceptions of benefits and barriers by internal medicine nursing staff, attending physicians, and housestaff physicians. Journal of Hospital Medicine, 9(10), 646-651.

Huynh, E., Basic, D., Gonzales, R., & Shanley, C. (2016). Structured interdisciplinary bedside rounds do not reduce length of hospital stay and 28-day re-admission rate among older people hospitalised with acute illness: An Australian study. Australian Health Review. Web.

O’Mahony, S., Mazur, E., Charney, P., Wang, Y., & Fine, J. (2007). Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. Journal of General Internal Medicine, 22(8), 1073-1079.

Pannick, S., Davis, R., Ashrafian, H., Byrne, B. E., Beveridge, I., Athanasiou, T.,… Sevdalis, N. (2015). Effects of interdisciplinary team care interventions on general medical wards: A systematic review. JAMA Internal Medicine, 175(8), 1288-1298.

Townsend-Gervis, M., Cornell, P., & Vardaman, J. M. (2014). Interdisciplinary rounds and structured communication reduce re-admissions and improve some patient outcomes. Western Journal of Nursing Research, 36(7), 917-928.

Appendix A

Literature Matrix

Author and Year Theoretical and Conceptual Framework Research Question Methodology Method Study Type Setting and Population Result
Cornell, P., Townsend-Gervis, M., Vardaman, J. M., & Yates, L. (2014) Working hypothesis the impact of interdisciplinary rounds (IDRs) and the situation-backgroundassessment- recommendation (SBAR) communication protocol on staff situation Clinical trial Readmission rates (30 days) were used to assess the effectiveness of the Situation-Background-Assessment-Recommendation (SBAR) protocol. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores helped to measure patient satisfaction. Quantitative 339-bed, suburban, acute care hospital. Length of stay did not change
Pannick, S., Davis, R., Ashrafian, H., Byrne, B. E., Beveridge, I., Athanasiou, T.,… Sevdalis, N. (2015). Descriptive categories describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them Systeamtic review Selected articles were categorized into two groups: early and late outcomes. The data was presented with the help of an exploratory analysis because its heterogeneity decreased the reliability of summary effect statistics. Quantitative 30 articles Of 23 interventions, 16 (70%) had no effect on length of stay
Dunn, A. S., Reyna, M., Radbill, B., Parides, M., Colgan, C., Osio, T.,… Egorova, N. (2017) Working hypothesis decrease length of stay (LOS) and complications through the transformation of daily IDR to a bedside model. Controlled trial The study measured the impact of IDR on the following variables: LOS and “composite of death, transfer to a higher level of care, or development of a hospital-acquired complication” (Dunn, et al., 2017, p. 137). In addition, IDR perceptions and safety culture measures were assessed before and after the intervention. Quantitative 2 geographic areas of a medical unit using a clinical microsystem structure no difference in LOS (6.6 vs 7.0 days, P = 0.17, for the MICRO and control groups, respectively)
Huynh, E., Basic, D., Gonzales, R., & Shanley, C. (2016). Working hypothesis effect of SIBR on two interconnected outcomes, namely length of stay (LOS) and 28-day re-admission Controlled trial Pre-and post-SIBR data on LOS, readmission rates, and diagnoses, was extracted an administrative database of the facility. The data was analyzed with Cox regression models, the multivariate model, and t tests. Quantitative 3644 patients, two aged care wards no significant difference in median (interquartile range) LOS before and during SIBR (8 (5-15) vs 8 (4-15) days respectively; P=0.51).
Dutton, R. P., Cooper, C., Jones, A., Leone, S., Kramer, M. E., & Scalea, T. M. (2003). Working hypothesis daily multidisciplinary “discharge rounds” would improve patient flow and increase readiness. Uncontrolled trial The rounds were conducted by a senior physician, orthopedic surgeon, discharge planner, and nursing staff of the center. Daily rounds were conducted over one hour. Quantitative 90 inpatient trauma service beds in a trauma center a 36% increase in patient volume and a 15% decrease in length of stay.
O’Mahony, S., Mazur, E., Charney, P., Wang, Y., & Fine, J. (2007). Working hypothesis determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay. Pre and post observational study LOS data was collected from the hospital’s database. Core measures of heart failure, pneumonia, and myocardial infraction were gathered by a nurse abstractor and reported on a monthly basis. Bivariate analyses, chi square test, and t tests were used to assess the data. Quantitative Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents. Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001).
Geary, S., Cale, D. D., Quinn, B., & Winchell, J. (2009) Working hypothesis provide a transferable model for daily rounds that can be used on many units to help decrease length of stay while improving communication, collaboration, and coordination. Observational study Four units participated in daily rounds. LOS were measured on a weekly basis. The implementation of the intervention involved the following stakeholders: case manager, bedside nurse, CNS/educator, nursing director/manager, and hospital administration (Geary et al., 2009). Quantitative medical-surgical and telemetry units from a single hospital An observed decrease in LOS in all involved units
Gonzalo, J. D., Kuperman, E., Lehman, E., & Haidet, P. (2014). Working hypothesis improving communication, collaboration, and coordination. Observational, cross-sectional study A survey instrument was developed for the study. The instrument was used to assess domains related to bedside interprofessional rounds: education communication, collaboration, coordination, and efficiency, and health outcomes (Gonzalo et al., 2014). Barriers to bedside interprofessional rounds were also assessed with the survey. Quantitative 171 hospital-based medicine nurses, attending physicians, and housestaff physicians. lowest-ranked benefits were related to efficiency, process, and outcomes, including “decreases length-of-stay” and “improves timeliness of consultations.”