LETTER TO Does Surgical Ward Round Quality Really Impact on Patient Outcomes? To the Editor: read with great interest the article by Pucher et al.1 The authors report on how surgical ward round (WR) quality impacts patient outcomes. The authors have to be congratulated for their effort in studying this important daily clinical routine, which has the potential to improve patient outcome if carried out in a thorough manner. Evidence from most studies indicate that many patients show signs of deterioration much before the diagnosis of complication and hence WR plays a vital part in identifying these events early and treating them diligently, or in some cases even preventing these complications from occurring.2 Research has shown that patients who become or who are at risk of becoming acutely unwell on general surgical wards often receive suboptimal care before the event.3 The current study, although clinically valuable and interesting, is not without limitations. The authors have clearly explained why they have chosen High Dependency Unit (HDU) for their study, as any improvement in outcomes in the highrisk patient group with a thorough WR can be easily adapted in a less busy and less intense environment such as general surgical wards. However, it is unclear why the authors have reported only 72% of the HDU WRs for the patients, as the excluded 28% of the WR data could have added more strength to the study. Also, it is not very clear why a single observer has been used to rate the WRs, as it is likely to lead to a high risk of ‘‘bias’’ on the part of the observer and ‘‘reactivity’’ on the part of those observed. As the WRs are viewed through a single observer’s eyes, the objectivity is lost and the complexity of the WR situation is unlikely to be grasped without observer-expectancy bias. Because the observer is a participant in the activities and events being observed, it is easy to influence those who are being observed (reactivity). It is likely that those who are leading and participating in the WR change their usual behavior leading to Hawthorne effect. Using independent observers and rating anonymous video recordings of the WR
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Disclosure: The author declares there are no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000926
THE
EDITOR
could mitigate the problems of observer bias and Hawthorne effect.4 The authors highlight that lack of chest examination during the WR led to high rates of pneumonia, which could have been picked up earlier and preventive measures applied if the WRs were thoroughly performed. It has to be clarified here that there are no reported associations between regular chest examination in a surgical patient and prevention of hospital-acquired pneumonia. It is unclear why all these patients with major abdominal and thoracic surgeries did not receive ‘‘active’’ prophylactic chest physiotherapy and early mobilization, rather than ‘‘reactive’’ and guided by patient’s respiratory examination findings, as most abdominal and thoracic surgery patients will show signs of basal atelectasis or effusion. It is also unlikely that a patient will be treated with antibiotics in the absence of deterioration in vital signs or evidence of systemic inflammatory response syndrome.5 The authors report a 10% urinary tract infection rate and ascertain this to leaving in the catheter for longer than the protocol. The removal of catheter in a surgical patient is usually guided by multiple factors, including the individual patient’s level of confidence, mobility, postoperative complication, etc, and hence cannot be protocol driven. Although early removal of catheter has been shown to reduce urinary tract infection, the approach to removal of catheter should be flexible and guided by patient recovery.6 It is also unclear from the study if enhanced recovery protocols were used for elective planned HDU admissions (which constitute more than half of the patients in this study), as this would lead to more protocol-driven WR and can confound the overall results of the study. Lack of comparative WRs in other setups such as in a general surgery ward is a potential weakness for the study. The authors have accounted only for the WR decision-making, and other non-WR communication between the medical and allied health care professionals has been overlooked as part of the general assessment toward decision making and patient outcome. It is well known that the staffing levels are very limited during the weekends, as compared to the weekdays. The authors have not clarified if the lack of thorough WRs were the ones done during the weekend, when it is likely that the WRs are done in a rushed manner and by a team who do not know much about the patient, which again could have impacted on the results of the study. Although it has to be agreed that the WRs need to be as thorough as possible, it is unlikely that examination of all systems is
Annals of Surgery Volume 263, Number 1, January 2016
possible during each and every day WR for every patient. The current working time regulations do mean that the trainee or even the supervisor has to rush to theaters or clinics, which means it is unlikely that they can spend more time on a thorough WR, although this should not be an excuse for a poor-quality patient assessment.7 Ensuring adequate training in WRs and quality control checklists can solve the problem of variability in WR quality.8,9 In the United Kingdom, this could shape in a course similar to the care of critically ill surgical patients, which focuses only on assessment and management of critically ill ward patients.10 Before embarking on a simulated WR training or WR assessment tools, there is a definite need for more high-quality evidence to clarify the association between WR quality and patient outcomes.
Abdul R. Hakeem, MRCS Department of General Surgery Addenbrooke’s University Hospital Cambridge University Hospitals NHS Trust Hills Road, Cambridge, UK [email protected]
REFERENCES 1. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 2. Churpek MM, Yuen TC, Park SY, et al. Using electronic health record data to develop and validate a prediction model for adverse outcomes in the wards. Crit Care Med. 2014;42:841–848. 3. Massey D, Aitken LM, Chaboyer W. What factors influence suboptimal ward care in the acutely ill ward patient? Intensive Crit Care Nurs. 2009;25:169–180. 4. Rampersad SE, Martin LD, Geiduschek JM, et al. Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives. Paediatr Anaesth. 2013;23:627–633. 5. Ludikhuize J, Smorenburg SM, de Rooij SE, et al. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care. 2012;27:424e7–e13. 6. Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. Am J Infect Control. 2013;41:1178–1181. 7. Herring R, Desai T, Caldwell G. Quality and safety at the point of care: how long should a ward round take? Clin Med. 2011;11:20–22. 8. Krautter M, Koehl-Hackert N, Nagelmann L, et al. Improving ward round skills. Med Teach. 2014;36: 783–788. 9. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg. 2014;259:215–221. 10. Zotti MG, Waxman BP. A qualitative evaluation of the Care of the Critically Ill Surgical Patient course. ANZ J Surg. 2009;79:693–696.
www.annalsofsurgery.com | e9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
I
Disclosure: The author declares there are no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000926
THE
EDITOR
could mitigate the problems of observer bias and Hawthorne effect.4 The authors highlight that lack of chest examination during the WR led to high rates of pneumonia, which could have been picked up earlier and preventive measures applied if the WRs were thoroughly performed. It has to be clarified here that there are no reported associations between regular chest examination in a surgical patient and prevention of hospital-acquired pneumonia. It is unclear why all these patients with major abdominal and thoracic surgeries did not receive ‘‘active’’ prophylactic chest physiotherapy and early mobilization, rather than ‘‘reactive’’ and guided by patient’s respiratory examination findings, as most abdominal and thoracic surgery patients will show signs of basal atelectasis or effusion. It is also unlikely that a patient will be treated with antibiotics in the absence of deterioration in vital signs or evidence of systemic inflammatory response syndrome.5 The authors report a 10% urinary tract infection rate and ascertain this to leaving in the catheter for longer than the protocol. The removal of catheter in a surgical patient is usually guided by multiple factors, including the individual patient’s level of confidence, mobility, postoperative complication, etc, and hence cannot be protocol driven. Although early removal of catheter has been shown to reduce urinary tract infection, the approach to removal of catheter should be flexible and guided by patient recovery.6 It is also unclear from the study if enhanced recovery protocols were used for elective planned HDU admissions (which constitute more than half of the patients in this study), as this would lead to more protocol-driven WR and can confound the overall results of the study. Lack of comparative WRs in other setups such as in a general surgery ward is a potential weakness for the study. The authors have accounted only for the WR decision-making, and other non-WR communication between the medical and allied health care professionals has been overlooked as part of the general assessment toward decision making and patient outcome. It is well known that the staffing levels are very limited during the weekends, as compared to the weekdays. The authors have not clarified if the lack of thorough WRs were the ones done during the weekend, when it is likely that the WRs are done in a rushed manner and by a team who do not know much about the patient, which again could have impacted on the results of the study. Although it has to be agreed that the WRs need to be as thorough as possible, it is unlikely that examination of all systems is
Annals of Surgery Volume 263, Number 1, January 2016
possible during each and every day WR for every patient. The current working time regulations do mean that the trainee or even the supervisor has to rush to theaters or clinics, which means it is unlikely that they can spend more time on a thorough WR, although this should not be an excuse for a poor-quality patient assessment.7 Ensuring adequate training in WRs and quality control checklists can solve the problem of variability in WR quality.8,9 In the United Kingdom, this could shape in a course similar to the care of critically ill surgical patients, which focuses only on assessment and management of critically ill ward patients.10 Before embarking on a simulated WR training or WR assessment tools, there is a definite need for more high-quality evidence to clarify the association between WR quality and patient outcomes.
Abdul R. Hakeem, MRCS Department of General Surgery Addenbrooke’s University Hospital Cambridge University Hospitals NHS Trust Hills Road, Cambridge, UK [email protected]
REFERENCES 1. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 2. Churpek MM, Yuen TC, Park SY, et al. Using electronic health record data to develop and validate a prediction model for adverse outcomes in the wards. Crit Care Med. 2014;42:841–848. 3. Massey D, Aitken LM, Chaboyer W. What factors influence suboptimal ward care in the acutely ill ward patient? Intensive Crit Care Nurs. 2009;25:169–180. 4. Rampersad SE, Martin LD, Geiduschek JM, et al. Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives. Paediatr Anaesth. 2013;23:627–633. 5. Ludikhuize J, Smorenburg SM, de Rooij SE, et al. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care. 2012;27:424e7–e13. 6. Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. Am J Infect Control. 2013;41:1178–1181. 7. Herring R, Desai T, Caldwell G. Quality and safety at the point of care: how long should a ward round take? Clin Med. 2011;11:20–22. 8. Krautter M, Koehl-Hackert N, Nagelmann L, et al. Improving ward round skills. Med Teach. 2014;36: 783–788. 9. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg. 2014;259:215–221. 10. Zotti MG, Waxman BP. A qualitative evaluation of the Care of the Critically Ill Surgical Patient course. ANZ J Surg. 2009;79:693–696.
www.annalsofsurgery.com | e9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
