PM2056: Pretending: Assessing the Effect of Senior Resident-led Rounding on Patient Safety and Delivery of Care

Background: The Accreditation Council of Graduate Medical Education (ACGME) has highlighted the importance of graduated autonomy in preparation for independent practice, yet many residents continue to have direct supervision throughout their training. An attending’s desire to mitigate safety errors and deliver optimal quality of care may contribute to the persistent level of oversight. One purpose of the Senior Resident-led Rounding with Attending Indirect Supervision (SRR) project is to evaluate the impact of senior-led rounds on safety, quality, and efficiency of delivery of care on the inpatient pediatric service.

Methods: The SRR project is an ongoing prospective, observational cohort study starting May 2021. Post-Graduate Year (PGY) 2, PGY-3, and PGY-4 pediatrics and medicine-pediatrics residents who opted into the study rounded independently once per week during their inpatient pediatric wards rotation. Pre-implementation surveys were given to attendings at the start of the project. Attendings completed post-implementation surveys at the end of every service week they participated in. In the survey, attendings were asked to report any safety events and medical errors. They also commented on any general delays in care, transfer of patients to the intensive care unit, or discharges. These surveys were collected via RedCAP, de-identified, and analyzed using descriptive statistics.

Results: 80 iterations of senior-led rounding occurred during the SRR project to date. 72 (90%) attending physicians completed the post-service survey. Of these, one safety/sentinel event was noted and described as an inappropriate medication being ordered at the wrong dose and given. The attending added, “I don't think having the attending on rounds would have prevented the error, as the resident misunderstood the recommendation from a subspecialist regarding the dosing of a medication”. There were four medical errors noted. These medical errors included ordering an intravenous anxiolytic instead of oral, an ultrasound for cervical lymphadenopathy, albuterol for bronchiolitis, and inappropriate labs and imaging. None of these events were associated with harm. One attending answered ‘yes’ when asked if their presence on rounds would have facilitated a more efficient transfer of care to a higher acuity unit. Five instances of delay in care were documented, including not ordering nasogastric tube placement, feeds, medications, or waiting until after rounds to discuss new patient care plans with the attending if rounds provided additional information. Six attendings noted delay in discharges of one or more patients.

Conclusion: The absence of preventable sentinel events and medical errors that cause harm suggests that senior residents can round independently while still maintaining an environment of safety. Preparing residents to formulate robust patient care plans in real time and improved communication between the attending and resident before rounds regarding possible discharges and optimal rounding order should be prioritized to mitigate delays and issues with care and discharges when senior residents round independently.