Physician behaviors associated with increased physician and nurse communication during bedside interdisciplinary rounds.

BACKGROUND: Effective team communication during interdisciplinary rounds (IDRs) is a hallmark of safe, efficient, patient-centered care. However, there is limited understanding of optimal IDR structures and procedures. OBJECTIVE: This study aimed to analyze direct observations of physician and nurse interactions during bedside IDR to identify behaviors associated with increased interprofessional communication. DESIGNS, SETTINGS AND PARTICIPANTS: Trained observers audited general medicine ward rounds at an academic medical center using a standardized tool to record physician and nurse behavior and communication in 1007 patient encounters in October 2019 to March 2020. RESULTS: There were significant differences in physician and nurse interaction time among physicians with different levels of training, with attendings demonstrating higher interaction time than residents (5.4 ± 4.6 vs. 4.3 ± 3.7 min, p = .02) and interns or medical students (3.0 ± 3.2 min, p = .002). Attendings were more likely to initiate a conversation about nurse concerns (76.9%) compared to residents (67.9%) and interns or medical students (59.3%, p = .03). Early nurse participation in bedside visits was associated with increased physician and nurse interaction time (5.0 ± 4.6 vs. 1.9 ± 1.7 min, p < .001) and physician initiative to ask about nurse concerns (74.8% vs. 64.3%, p = .04). In addition, physician initiative to ask the nurse for concerns rather than waiting for the nurse to offer concerns without being prompted was associated with a subsequent conversation about those concerns (74.5% vs. 61.8%, p < .001) and the physician asking about patient or family concerns (94.2% vs. 88.4%, p = .01). CONCLUSIONS: Implementing IDR structures and procedures that promote attending physician involvement, physician initiative, and early nurse participation could optimize interdisciplinary communication and quality of care.

Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project.

Background: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital. Objective: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution. Design: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer. Measure: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer. Results: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) (p < 0.01). Conclusions: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.

Comparing the effectiveness of a hybrid simulation/lecture session versus simulation alone in teaching crew resource management (CRM) skills: a randomised controlled trial.

Introduction: Various methods have been used to teach crew resource management (CRM) skills, including high-fidelity patient simulation. It is unclear whether a didactic lecture added on to a simulation-based curriculum can augment a learner's education. Methods: Using an already existing simulation-based curriculum for interdisciplinary teams composed of both residents and nurses, teams were randomised to an intervention or control arm. The intervention arm had a 10 min didactic lecture after the first of three simulation scenarios, while the control arm did all three simulation scenarios without any didactic component. The CRM skills of teams were then scored, and improvement was compared between the two arms using general estimating equations. Results: The differences in mean teamwork scores between the intervention and control arms in scenarios 2 and 3 were not statistically significant. Mean scores in the intervention arm were lower than in the control arm (-0.57, p=0.78 for scenario 2; -3.12, p=0.13 for scenario 3), and the increase in scores from scenario 2 to 3 was lower in the intervention arm than in the control arm (difference in differences: -2.55, p=0.73). Conclusions: Adding a didactic lecture to a simulation-based curriculum geared at teaching CRM skills to interdisciplinary teams did not lead to significantly improved teamwork.

Self-directed versus traditional classroom training for neonatal resuscitation.

OBJECTIVE: Neonatal Resuscitation Program instructors spend most of their classroom time giving lectures and demonstrating basic skills. We hypothesized that a self-directed education program could shift acquisition of these skills outside the classroom, shorten the duration of the class, and allow instructors to use their time to facilitate low-fidelity simulation and debriefing. METHODS: Novice providers were randomly allocated to self-directed education or a traditional class. Self-directed participants received a textbook, instructional video, and portable equipment kit and attended a 90-minute simulation session with an instructor. The traditional class included 6 hours of lectures and instructor-directed skill stations. Outcome measures included resuscitation skill (megacode assessment score), content knowledge, participant satisfaction, and self-confidence. RESULTS: Forty-six subjects completed the study. There was no significant difference between the study groups in either the megacode assessment score (23.8 [traditional] vs 24.5 [self-directed]; P = .46) or fraction that passed the "megacode" (final skills assessment) (56% [traditional] vs 65% [self-directed]; P = .76). There were no significant differences in content knowledge, course satisfaction, or postcourse self-confidence. Content knowledge, years of experience, and self-confidence did not predict resuscitation skill. CONCLUSIONS: Self-directed education improves the educational efficiency of the neonatal resuscitation course by shifting the acquisition of cognitive and basic procedural skills outside of the classroom, which allows the instructor to add low-fidelity simulation and debriefing while significantly decreasing the duration of the course.