Remote Post-Operative Rounding and the Physician Ability to Identify Morbidity

Design: Two hundred seventy patients were recruited from three sites into a prospective multi-center randomized trial. Participating institutions were the University of California, Davis Medical Center (Sacramento CA), Johns Hopkins Hospital (Baltimore MD) and Sentara Health (Norfolk VA). Internal Review Board approval was granted at each institution independently. The study population consisted of patients scheduled for urologic surgery, over age 18, and able to read and understand English. Patients undergoing the following laparoscopic procedures were offered participation: nephrectomy, partial nephrectomy, nephroureterectomy, retroperitoneal lymph node dissection, partial ureterectomy, and radical prostatectomy. Patients had an expected hospital stay of 24 to 72 hours. Eligible patients who were unable to provide consent or who do not wish to participate in the study received the standard of care provided at each institution. A total of two hundred seventy patients consented to participation.

Randomization: A stratified block scheme was used for randomization. Participating patients were randomized to either: standard daily bedside rounding by the attending surgeon (control arm), or daily telerounding only by the attending surgeon (intervention arm).

Outcome Measures: The primary outcome measure was differences in rates of attending surgeon-identified complications between standard rounds and telerounds. The secondary outcome measures included differences in length of stay and patient reported satisfaction with their hospitalization.

Protocol: Consenting patients had their scheduled surgery and received the standard peri-operative and immediate post-operative care. All patients were managed with a rapid recovery protocol. This included: liquid diet beginning twelve hours after surgery with immediate advancement as tolerated; complete blood count, serum electrolytes, BUN and creatnine in the recovery room and each morning until discharge; and usual nursing data recorded each shift. These data points included oral temperature, blood pressure, pulse, respiratory rate, fluid intake, fluid output, and pain scale Once transferred to the patient floor, all patients communicated with their attending physician on a daily basis. The visit, either at the bedside or via telerounds followed a set scripting. The visit was conducted between the patient and the attending without other staff present. The focus of the visit was review of objective data (vital signs, fluid balances and laboratory values), subjective data (cursory abdominal exam if at the bedside and evaluation of drain effluent) and a discussion of the anticipated goals for the day. Visit duration was timed. Intervention patients could remove themselves from the study at any time by requesting a bedside visit by the attending physician. Telerounding concluded with either the hospital discharge or identification of a major post-operative complication.

Definitions: A major complication was defined as an event that required transfer to a monitored setting. Minor complications included events that delay discharge greater than 24 hours beyond the expected length of stay. For example (but not limited to): post-operative ileus, drop in hematocrit, prolonged drain output or fever Event monitoring: Identification of complications was recorded prospectively. Usual resident-level bedside rounds were maintained throughout the study. The resident team and the attending surgeon recorded identified events independently, thus allowing for evaluation of concordance. This dual rounding design served as a minimally acceptable standard as stipulated by the various internal review boards. As a precondition of IRB approval, identification of an event required notification of the attending surgeon in a timely fashion.