BEDSIDE₂‐R: A framework for team‐based, patient‐centered bedside rounds

Historically, bedside rounds (BSRs) served as a cornerstone of in-patient clinical training in Internal and Family Medicine. A traditional BSR encounter on a Hospital Medicine teaching team includes at least two physicians (including a trainee) delivering a presentation, performing a physical examination maneuver, or alternative bedside teaching skill, and discussing the daily plan at the patient's bedside.1 Despite the benefits of BSR, which include positive changes in patient outcomes (satisfaction with clinical care and reductions in hospital admissions) and trainee clinical competence (communication, teamwork, and professionalism),2 its practice has declined due to numerous barriers to implementation.3 One key barrier is the dearth of role models for leading effective BSR, exacerbated by the COVID-19 pandemic.4 Without experienced attendings and residents to champion the benefits of BSR, in-patient teams may default to alternative rounding styles such as "walk rounds" or "card flip rounds."5 A second barrier is the time and resource intensity of previously published interventions to promote BSR. For example, Southwick et al.6 applied Toyota Production System principles to BSR, creating a playbook and "game films," while Huang et al.7 changed admitting workflows to regionalize patients and hired new medical directors. Accordingly, a recent systematic review of BSR underscored the ongoing need to "identify facilitators of educationally successful BSR."2 Hospitalists would benefit from a memorable framework for BSR they can readily implement with their teaching teams. Mnemonic acronyms are especially effective for creating a shared mental model for complex sequential tasks, such as BSR.8 Therefore, we propose BEDSIDE2-R: a framework for conducting patient-centered, evidence-based BSR. BEDSIDE2-R stands for Brief team, Engage patient, Delineate roles, Summarize events, Investigate data, Demonstrate exam, Explain plan, Ensure understanding, and Reflect in transit (Appendix 1). BEDSIDE2-R synthesizes our literature review with our experiences as academic in-patient attendings to organize evidence-based practices for before (BED), during (SIDE2), and after (R) BSR into a sequential construct. We rationalize each step and provide tips to optimize trainee engagement. In our experience, BEDSIDE2-R enables 15–17 min encounters, consistent with previous appraisals of efficient BSR.1 Huddle with the team outside the patient's room, including their nurse and clinical pharmacist if available. Establish any additional goals for BSR beyond discussing the clinical plan (e.g., Does the patient need counseling on discharge medications?) and review patient preferences and needs (e.g., Do they require hearing aids?). Importantly, discussing psychosocial or complex issues, such as substance-use disorders or pathology results, should not deter the team from BSR.5 These conversations demonstrate empathy and effective patient communication, and do not significantly prolong encounters.9 Lastly, identify the presenter. Upon entering the room, greet the patient, ensure their comfort, and address any physiological needs. Team members introduce themselves, and the patient introduces visitors. If it's the patient's first experience with BSR, the resident or attending reviews its structure, invites the patient to listen, acknowledges that they may hear medical terminology, and reassures them that they may ask questions afterwards. We provide a script for introducing BSR to patients (Box 1). Ms. O'Maley, we'd like to discuss your plan of care today using a style of rounding called bedside rounds. We'll start by summarizing the overnight events and any pertinent physical exam findings. Then, we will investigate data by reading aloud your vital signs, lab results, and any new reports since yesterday. Next, we will demonstrate a cardiac examination as a team to listen to your heart murmur. Finally, we will explain the problem-based plan of care for today. Throughout our discussion, you may hear some medical terminology, so we will make sure to ensure understanding and answer any questions you have at the end. How does that sound to you? Effective BSR empower each team member with a value-added role.10 During expectations meetings with their clinical teams, hospitalists should rationalize each role. At the bedside, the presenter delineates each team member's role. Based on our experience and literature review,10-12 we propose the following roles and positioning around the bedside to optimize trainee engagement (Figure 1). Presenter: The presenter reviews interval events, describes their history and exam from prerounds, and discusses their problem-based plan in third person, oriented towards the leader. When directly addressing the patient, the presenter pivots to make eye contact and may sit or kneel at the bedside to enhance communication.13 This practice is particularly effective during the "Ensure understanding" portion, described later. Scribe: The scribe is the nonpresenting intern or medical student who updates the whiteboard. They ensure team members' names are legibly written and transcribe two to three summary points from the plan. If no whiteboard is present, the scribe may write on a sheet of paper and fix it on the wall. Leader: The resident leads the encounter. They should have access to the electronic health record (EHR) to review objective data (e.g., vitals, labs, and reports) and to place time-sensitive orders. They stand at the foot of the bed with a clear view of all participants to facilitate communication. Teacher/Consultant: The attending serves as the teacher and consultant. As teacher, they demonstrate a key physical examination finding, explain a pathophysiologic mechanism or model patient-centered communication.10 As consultant, they listen, ask clarifying questions, and then make additions to the plan. They stand to the side of the bed which allows the patient and presenter a clear view of the leader and optimizes observation of communication between the patient and team members to inform feedback.11 Nurse: The patient's nurse adds important insights and their presence during BSR improves patient care coordination.12 Among their myriad value-added contributions, the nurse may point out a concerning exam finding, clarify orders, and suggest interventions. Clinical Pharmacist: The clinical pharmacist reads aloud the medication list, noting dose, frequency, and route. This practice helps to clarify the appropriateness and accuracy of the medication regimen.12 They answer questions about medication administration, interactions, and side effects. To start BSR, the presenter summarizes the history of the present illness (new patient) or 24 h events (established patient) and their exam from prerounds. These summaries are concise, understanding that the resident and attending reviewed sign-outs, and the pertinent EHR data. Following the presenter's summary, the leader reads aloud pertinent data, including vital signs, labs, and new imaging/testing reports. To engage the scribe, the teacher asks one targeted question.14 For example, "Lauren, how are you interpreting today's urine output and creatinine values?" If the patient asks about a data point, the presenter provides a brief explanation once all values are read. If available, the clinical pharmacist reads the medications, otherwise the leader concludes with this data. BSR allow teachers to model the value of the physical examination in clinical diagnosis or management. Attendings and residents may choose from numerous strategies and resources to teach physical examination maneuvers.15, 16 During BSR, the teacher chooses one salient physical examination finding relevant to clinical decision-making, demonstrates the proper technique, "thinks aloud" to explain their clinical reasoning and maintain learner engagement, and cites evidence supporting the maneuver. Alternatively, teachers can demonstrate other bedside skills: interviewing and counseling patients, navigating challenging conversations, and exemplifying humanistic care.17 The nurse points out any additional concerning exam findings from their evaluation, such as new skin breakdown. The presenter details their problem-based plan to the leader, starting with the principal problem and then active problems (those requiring new diagnostics or changes in treatment). To save time, the team may choose not to address stable problems (those requiring no change in management). Importantly, BSR empower the presenter to take ownership of their clinical decision-making.18 The resident and attending avoid interruptions and weigh in at the end in succession by asking, "Could I add something?" This strategy reinforces trainee autonomy and helps build patients' trust in them as their primary doctors.19 The scribe records two to three summary points on the whiteboard. Facing the patient, the presenter briefly summarizes the plan using patient-centered language and then ensures understanding by asking an open-ended question (e.g., "What questions or concerns do you have about our team's plan?"). Additionally, asking the patient to teach-back a key point can further solidify their understanding.20 The scribe displays the summary points on the whiteboard. The nurse may ask clarifying questions and the leader should ask "what else does the patient need from a nursing perspective?" Lastly, the team attends to the patient's comfort before exiting and reassures them that a team member will check in later.17 To maintain rounds efficiency, the attending debriefs with the team in-transit to the next patient. These "interstitial spaces" facilitate providing positive, concrete feedback to trainees on their roles in the encounter, which may enhance their confidence in BSR.21 The attending can pose a general reflection question to the team such as, "How did we handle the patient's response to the biopsy results?"17 Reserve sensitive or corrective feedback for a later time in a private setting. The attending may also deliver one salient teaching point, labeling it as such for learners. Trainee buy-in is crucial to BSR success, so hospitalists should introduce BEDSIDE2-R during their initial expectations meetings with clinical teams.10 First, conduct a needs assessment of trainees' experiences with and concerns about BSR.17 Second, review, rationalize, and demonstrate enthusiasm for BEDSIDE2-R, noting that physical examination skills, patient communication, and humanism are best taught at the bedside.2 Third, explain how BEDSIDE2-R affords each team member a value-added role in patient care. Lastly, highlight that BSR are time-efficient and patient-centered.1, 2 BEDSIDE2-R is best incorporated early in team rounds to evaluate new admissions, decompensating patients, diagnostically challenging cases, and planned discharges.11 Prioritizing BEDSIDE2-R at the beginning and saving "walk rounds" and "card-flip rounds" towards the end of rounds follows the natural decline in learner attention.5 Residents should prespecify patients appropriate for BEDSIDE2-R, which improves rounding efficiency, increases resident autonomy, and allows attendings to assess their rounding leadership skills.22 We acknowledge that BEDSIDE2-R is a "tool in the toolkit," not a one-size-fits-all approach to efficient and patient-centered rounding.23 For example, a patient with hyperactive delirium may necessitate "walk rounds" with a subsequent bedside encounter focused on performing a shared physical examination. When BSR truly aren't proceeding as planned, the leader or attending may call a "time out" to re-direct the patient, refocus the team, or in rare circumstances (e.g., inappropriate behavior) redirect rounds to outside the room. We implemented BEDSIDE2-R at our institution with positive feedback from trainees and colleagues. Employing a simple intervention—integrating our mnemonic acronym into expectations meetings with teaching teams to create a shared mental model for BSR—significantly improved the quality and quantity of BSR. BEDSIDE2-R encodes a sequential, team-based, patient-centered framework for BSR, which we hope will help facilitate educationally successful BSR and expand the pool of hospitalist role models for its practice.2 The authors declare no conflict of interest. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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