This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on http://humanfactors.jmir.org, as well as this copyright and license information must be included.
Recent research has shown evidence of disproportionate time allocation for patient communication during multidisciplinary rounds (MDRs). Studies have shown that patients discussed later during rounds receive lesser time.
The aim of our study was to investigate whether disproportionate time allocation effects persist with the use of structured rounding tools.
Using audio recordings of rounds (N=82 patients), we compared time allocation and communication breakdowns between a problem-based Subjective, Objective, Assessment, and Plan (SOAP) and a system-based Handoff Intervention Tool (HAND-IT) rounding tools.
We found no significant linear dependence of the order of patient presentation on the time spent or on communication breakdowns for both structured tools. However, for the problem-based tool, there was a significant linear relationship between the time spent on discussing a patient and the number of communication breakdowns (
The use of structured rounding tools potentially mitigates disproportionate time allocation and communication breakdowns during rounds, with the more structured HAND-IT, almost completely eliminating such effects. These results have potential implications for planning, prioritization, and training for time management during MDRs.
Multidisciplinary rounds (MDRs) serve as a common venue for formulating shared patient care goals and plans of care by care providers from different clinical specialties [
Notwithstanding these patient care benefits, researchers have pointed out several divergent perspectives regarding MDRs [
One of the underexplored areas of research on MDRs is related to the time allocation and distribution during patient discussions. Recent research has illustrated that verbal discussions during rounds were vulnerable to unequal time allocation––a phenomenon that has been described as a “portfolio problem” or “end of round time compression” [
The presence of such a disproportionate allocation of time can lead to potential decision-making and communication failures, with a consequent detrimental impact on care coordination and safety outcomes [
In this exploratory study, we evaluate the effect of 2 structured rounding tools on time allocation for patient case presentation and communication during daily rounds. As a secondary research question, we also examine whether the distribution of time allocation has an impact on the effectiveness of round communication.
The data used for this study were collected as part of a larger study that compared the communication practices in a medical ICU (MICU) [
This study was conducted in a 16-bed MICU at a tertiary medical center with approximately 55,000 emergency department visits per year. This MICU follows a “closed” model of care, where patient care decisions are internally managed by the MICU multidisciplinary team comprising an attending physician (ie, intensivist), a fellow, residents and interns, critical care nurses, a pharmacist, a respiratory therapist, and a nutritionist. The MICU residents’ and interns’ shifts lasted for approximately 24 hours, with additional 4 hours for participating in care transition activities during rounds (from ~8:00 am, day 1 to ~12:00 pm, day 2).
The unit has an average of 1200 patient admissions per year (Case Mix Index=4.72; average patient LOS=3.8 days; average number of vent days=3.1; and top 2 diagnosis-related group codes were sepsis and respiratory failure).
The formal morning MDRs were led by an attending physician, and focused on transferring information, responsibility, and control from the outgoing team (postcall resident and intern) to the incoming team (on-call resident and intern). At this setting, there were no formal protocols and practices on the selection of the order of patient case presentations during rounds.
Two paper-based rounding tools were used: a patient problem-oriented, Subjective, Objective, Assessment, and Plan (SOAP) note, and locally developed, body systems-oriented, Handoff Intervention Tool (HAND-IT) [
SOAP is based on the problem-oriented medical record format [
HAND-IT was developed based on a previous evaluation study that showed that structuring information in a checklist-based, body-systems format improves filtering, retrieval, and documentation of information in preparation for rounds [
Subjective, Objective, Assessment, and Plan (SOAP)-based tool that was used for the rounds.
There were 16 participants during the 2-month study period, divided into 2 independent teams. Each team was in the MICU for a 1-month period and consisted of 8 core participants for the entire month (1 attending physician, 1 fellow, 3 residents [PGY2/3], and 3 interns [PGY1]). In addition to this, there were 6 critical care nurses, 1 pharmacist, 1 respiratory therapist, and 3 medical students who participated in the rounds each month. The institutional review board of the University and Hospital approved this study and written consents were obtained from all participants.
Morning rounds on 8 randomly selected days over the course of 2 months with 2 independent MICU care teams were audio recorded. The recordings consisted of round discussion of 82 patient cases (nSOAP=41, nHAND-IT=41). Follow-up informal interviews with physicians confirmed that the order of patient presentation and discussion varied depending on the attending physician’s priority and patient acuity.
During the first month of data collection, team 1 trained with SOAP for 4 days, followed by 2 days of testing; then trained with HAND-IT for 4 days, followed by 2 days of testing. During the second month, a new team followed the same process of training and testing with the reverse order of tool usage (ie, HAND-IT followed by SOAP). This was done to counterbalance the effects of tool use. The training period involved introductory training on the structure and various content fields of each tool. During the training period, residents used their assigned tool during rounding to gain familiarity.
The testing period involved collection of verbal communication data through audio recording of the rounds. The total audio recorded time was approximately 40 hours. In addition, a researcher (the first author, JA) observed these sessions, made field notes, and conducted informal interviews after the rounds. An illustrative representation of the study design is shown in
Given the exploratory nature of this study, and limited previous research results, our purpose was to compare our results with the results reported in other published research articles [
Audio-recorded verbal communication during rounds was used to compute the length of time spent presenting each patient. The verbal transcripts were used to evaluate the quality of communication during rounds.
Body systems-oriented Handoff Intervention Tool (HAND-IT) with the various body system elements highlighted.
The study design showing the organization of training and testing using both tools is shown. The measurements (time spent and communication breakdowns, shown in the center) were compared with the order of patient case presentation. SOAP: Subjective, Objective, Assessment, and Plan; HAND-IT: Handoff Intervention Tool.
Two researchers (the first author, JA, and a research assistant) listened to audio recordings to note the time spent on discussing each patient. The start time of each handoff was identified as the moment when the resident or intern started a patient presentation. The end time of each handoff was identified as the moment when the attending physician signed-off on his or her progress note for a patient case. This denoted the end of patient discussion. The audio recordings were also marked-up for interruptions, and other distractions unrelated to the patient case being presented. The total time was calculated by combining the duration of patient presentation and discussion, and excluding the time periods of interruptions, similar to the time coding performed by Cardarelli and colleagues [
There was a significantly high inter-rater agreement between the 2 coders (Cohen
Breakdowns were defined as any failure in information flow and transfer from the outgoing postcall team to the on-call team (ie, receiving team consisting of the attending physician, fellow, resident, intern). The breakdowns in communication were evaluated using a validated communication framework [
Two authors (JA, TK) coded the breakdowns in communication with a high degree of inter-rater agreement (Cohen
Different types of communication breakdowns that were coded for each of the transcripts.
Type of communication breakdowns | Description |
Incomplete information | Lack of complete patient information provided by the postcall team to the oncall team during rounds |
Inaccurate and conflicting information | Erroneous patient information provided by the postcall team to the on-call team during rounds |
Irrelevant information | Inappropriate care plan provided by the postcall team to the oncall team during rounds (that does not follow the clinical reasoning logic nor suitable for the patient at that moment in time) |
To determine whether there was a significant relationship between the order of presentation of patient cases and the time spent on the discussion for each of the tools, we computed the Kendall τ rank order coefficient for each session. Kendall τ rank order coefficient is a nonparametric test statistic that is used to determine the measure of association between 2 variables. The test statistic provides a measure of the rank correlation between the ordering of data ranked by each of the variables. As the predictor variable is ordinal, Kendall τ provides an appropriate test regarding the hypothesized relation with values varying between −1.0 and +1.0. A negative Kendall τ between the order of presentation and time spent shows lesser time for patients presented later, zero correlation shows that relatively equal time was spent across all patients, and a positive correlation shows more time spent for patients presented later. Given that the data were collected across 8 sessions (4 sessions per tool), similar to Cohen et al [
Similar rank order coefficients were also computed for evaluating whether the order of presentation had any effect on communication breakdowns for each of the tools. Linear regression analysis was also used to investigate the relationship between the time spent on patient discussion and communication breakdowns. A significance level of
There were no differences in the number of patients discussed per day between the 2 rounding tools (
In terms of the time spent per patient with respect to the order of presentation, the mean (SD) Kendall τ correlations were marginally negative for SOAP (−0.11 [0.38]), and HAND-IT (−0.01 [0.30]). In terms of the communication breakdowns with respect to the order of presentation, the mean (SD) Kendall τ correlations were negative for SOAP (−0.25 [0.41]), and marginally positive for HAND-IT (0.05 [0.17]). In other words, the time spent on discussing a patient or the number of breakdowns did not change significantly over the course of a session for either rounding tool, potentially showing no disproportionate time allocation or communication breakdown effects.
However, based on regression analysis, there was a significant linear dependence between time spent discussing patients and breakdowns (
The number of breakdowns as a function of the time spent per patient for Subjective, Objective, Assessment, and Plan (SOAP) and Handoff Intervention Tool (HAND-IT) tools. For SOAP, the number of breakdowns increases (n=41 patient discussions)—the trend line for the estimated linear regression is b=.0038t+.59 (
Our results suggest that structured tools are likely to mitigate the effect of disproportionate time allocation during rounds. Although correlations of the order of presentation in relation to both time spent and breakdowns in communication were marginal for both HAND-IT and SOAP, the relative effect was lesser for HAND-IT: with almost no correlation; Kendall τ being .01 and .05 for time spent and breakdowns in communication, respectively. We also found that additional time spent in discussing a patient during MDRs may lead to more breakdowns in communication in SOAP than that in HAND-IT.
Although further research is required to ascertain how structured tools mitigate the disproportional time allocation across patients, we acknowledge that there would be instances where structured tools may not be strictly followed due to patient-, clinician-, and environmental-related factors in critical care settings, in which cases, disproportionality in time allocation may be preferred (eg, differences in patient complexity and acuity, number of days the patients has been in the unit, and recent changes in the patients’ condition).
We discuss 3 implications of our results within the context of the MDR process: supporting communication, planning for distribution of time, and prioritization of patient order. Research on rounds has focused primarily on developing tools for supporting information presentation by outgoing clinicians using an information transmission perspective [
Research in psychology and cognitive sciences has shown human limitations regarding planning for tasks––both in terms of biases in time allocation, and overconfidence in the precision of outcomes [
Another closely related aspect of rounding is prioritization. Physicians often select and prioritize patients for discussion during MDRs. These selections are based on patient criticality (eg, the sickest patient first), time of admission (ie, LOS in the unit), bed order, or costeffectiveness ratio [
We acknowledge that this exploratory study has several limitations.
First, the study was conducted at a single academic MICU setting using a nonrandomized design with only 2 clinical teams. However, we evaluated a large number of handoffs (N=82 patients) providing validity for our preliminary results.
Second, we did not control for any patient-related, unit-related, or other external variables in our analysis. Our assumption was that, given the unpredictability of patient arrivals or discharges and similar resource availability for all patients, the order of patient discussion was effectively randomized, making any of the patient, unit, or external variables unrelated to the discussion order (a similar claim was made by Cohen et al [
Third, the increased number of breakdowns for longer communications may have been an effect of length-biased sampling: the greater the length of the conversation, the greater the likelihood of communication breakdowns.
Fourth, in this study, we did not have a true “control” condition; that is, a condition where we showed the existence of disproportionate time allocation during rounds. Instead, drawing on a prior study—by one of the coauthors [
Finally, although our exploratory findings demonstrate the moderating effects of structured rounding tools on time allocation, we would like to acknowledge that at times, disproportionate time allocation maybe unavoidable. Such situations arise due to complexity of patient cases, LOS of patient, prior knowledge of the patient, limited changes in therapeutic regimen, or other time constraints.
Time constraints impose challenges to critical care practice, often adding additional cognitive load on the physician’s already complex work activities. One of the unintended effects of time constraints is their disproportionate time allocation to similar tasks. Although there is no evidence on whether disproportionate time allocation can have any detrimental outcomes, it increases the possibility for errors and inefficient patient care delivery and management. We found preliminary evidence that structured rounding tools may mitigate such disproportionate time allocation effects during MDRs. In addition, increased structure within the tools can also mitigate the communication breakdowns during MDR discussions. Although our results provide preliminary evidence of the time allocation and quality of communication using structured tools, further research is required to establish the causal underpinnings of time allocations during rounds.
Handoff Intervention Tool
intensive care unit
length of stay
multidisciplinary rounds
Medical ICU
Subjective, Objective, Assessment, and Plan
This research was supported in part by a grant from the James S McDonnell Foundation (Grant No. 220020152), and by a training fellowship from the Keck Center AHRQ Training Program in Patient Safety and Quality of the Gulf Coast Consortia (AHRQ Grant No. 1 T32 HS017586-02).
None declared.