International Journal of Risk & Safety in Medicine 27 (2015) 23–33 DOI 10.3233/JRS-150640 IOS Press
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Measuring ward round quality in urology Daniel Darbyshirea,b,∗ , Charlotte Barrettc , David Rossc and David Shackleyc a
Health Education North West, Manchester, UK Accident and Emergency, The Royal Oldham Hospital, UK c Department of Urology, Salford Royal Hospital, UK b
Received 17 September 2014 Accepted 10 January 2015 Abstract. BACKGROUND: Ward rounds are the traditional process by which clinical information is interpreted and management plans made in the inpatient setting and the only time during which patient-doctor interaction can reliably occur. Efforts to improve quality and safety have started looking at the ward round but this has mainly been in the acute medical setting. OBJECTIVE: To begin the quality improvement process for Urological ward rounds. METHODS: Twenty indicators thought to relate to quality were recorded for every weekday ward round by the Urology team for one month. RESULTS: Twenty ward rounds, 93 patient encounters, were reviewed. A consultant was present for 37% of the patient encounters. 84% of observation charts were reviewed; drug charts 28% and antibiotics 70%. Plans were communicated to the doctors, patient and nursing staff. All notes were typed directly onto the electronic system, 20% of notes were checked by the lead clinician. Mean time per patient was 6 minutes. CONCLUSIONS: By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them. Keywords: Urology, quality improvement, audit, ward round, patient safety
1. Background Ward rounds are the daily point of contact between the patient and the clinical team caring for them. Despite a long held belief and public perception that ward rounds are vital for safe and effective patient care [1] they are often performed in a less than optimal fashion [2]. Katherine Murphy, chief executive of the Patients Association, said: “High quality, consistent ward rounds in every hospital would contribute to a more patient centered culture in the NHS. This is crucial reading for the government and trusts [1].” A joint statement from the Royal College of Nursing and the Royal College of Physicians called for an improvement in the quality of ward rounds and to ensure they are truly patient centered [3]. Other than statements supporting this stance [4] specific guidelines from the respective surgical colleges have not been forthcoming. A systematic review of safety checklists found evidence of their use in the emergency department, critical care, acute medicine and operating theatre but none relating to planned care [5]. The members of the urology ward round varies depending on the availability of the different team members but is generally as follows. The round is led by the senior medically qualified member of ∗ Address for correspondence: Daniel Darbyshire, Accident and Emergency, The Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH, UK. Tel. : +44 07757 119141; E-mail: [email protected].
0924-6479/15/$35.00 © 2015 – IOS Press and the authors. All rights reserved
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staff, either a consultant urological surgeon (equivalent to an attending in the United States) or a urology registrar or senior clinical fellow (equivalent to post graduate year 5 or beyond residents or fellows). They will be supported by one or more junior medical staff, foundation doctors or core surgical trainees (interns or early years attending’s) and both the nurse looking after the patient and a senior nurse coordinating the ward. 1.1. Measuring ward round quality The literature reveals several aspects of a ward round that appear to be related to quality in the broadest sense. Prescribing of fluids for post operative patient is often left to the most junior members of the surgical team and many consultants believe it is not done well [6], indeed knowledge gaps and poor practice have been identified [7]. The ward round would seem to be the ideal opportunity to review this and to improve practice through bedside teaching, though it would seem that this practice is far from widespread [8, 9]. 1.2. Improving ward round quality Following the introduction of the World Health Organization safe surgery checklist [10] several authors have discussed their experience introducing a checklist into the ward round [11, 12]. While the evidence
Fig. 1. University College London Hospital Ward Round Safety Checklist.
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base for the effectiveness of such an approach within healthcare is still developing [5] a strong argument for their use comes from successful application in transport [13], military and aerospace [14] industries [15] as well as specific examples from within the healthcare industry [16, 17]. The University College London Hospitals (UCLH) approach combined the implementation of a ward safety checklist (see Fig. 1) with targeted education [11]. While the evaluation of this initiative is still ongoing the authors report on emerging issues. The “disconnect between medical and nursing staff” is a theme which has presented itself in relation to operating room teamwork [18] and described from a sociological perspective as a negotiated order, “the result of continuous negotiation between doctors and nurses” [19]. The lack of ring fenced time for nurses to attend ward round may contribute to this [12, 20]. Work in medical ward rounds at Worthing Hospital, UK led to the development of the Caldwell Considerative Checklist [21]. Akin to the UCLH approach above this aimed to encourage documented evidence of safe and high quality medical care. While both approaches seem sensible and target many of the same areas, the evidence to support their efficacy is anecdotal [5, 12]. 2. Methods Twenty indicators were selected for their relation to quality and safety and practicalities of measurement (see Table 1). These were recorded for every weekday ward round by the urology team, on the urology ward, for one month. Data was collected by the nursing staff for the first, last and middle 2 patients on the round. The rationale for this was that collecting data for all patients would be overly burdensome, that patient complexity may vary as the first 12 beds on the ward are side rooms and that clinicians may spend less time on patients at the end of a ward round [22]. Data was collected without the knowledge of the urology team aiming to reduce the change of behavior that may occur if team members knew they were being audited [23]. The results have been compared with a similar set of data collected in 2011. The methodology was similar though the number of domains was fewer. 2.1. Limitations Data was collected by several different members of the nursing team so inconsistencies in recording may be evident. The single time period and small sample size limit interpretation and generalizability. Results and trends may be due to outliers. Statistical tests could be used but have been avoided; as an a priori hypothesis was not in place so statistical significance of answers to questions asked would be misleading. Measures of frequency of actions or interactions says nothing of their quality. So, for example, while test results may have been reviewed nothing is recorded of the quality of the decisions made from this information. 3. Results Twenty ward rounds covering 4 periods of Monday to Friday in a single calendar month in 2013 were audited. Data was collected for all ward rounds but 4 had incomplete data. A total of 93 patient encounters had sufficient data for analysis. Complete results are available in Table 2.
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D. Darbyshire et al. / Measuring ward round quality Table 1 Domains measured and rationale for their inclusion
Indicator
Description
Rationale
Start time
Time at which the ward round starts, it is scheduled to start at 08:00
A consistent start time allows member of the multi-disciplinary team to plan their work [3] Allows calculation of ward round length Allows calculation of mean time per patient Associated with shorter length of stay and more same day discharges [38] Associated with reduction in nosocomial infection and MRSA transmission [39, 40] Isolation and barrier nursing are currently recommended though the evidence is inconclusive [25, 26] Trends in early warning score can lead to early recognition of clinical deterioration [41]. Thought to be performed poorly when left to the most junior staff [7]. To review for drug errors and non-therapeutic omissions [34], should be performed daily [3]. Accurate risk assessment with appropriate interventions reduces HAT [42]. Omission or errors in warfarin prescribing are of particular concern in pre or post op patients and such errors are common [35, 36]. Vascular access lines are associated with hospital acquired infection so prompt removal when no longer clinically indicated is important [43]. Drains are associated with surgical site infections and should be removed when no longer indicated [44]. Urinary catheters should be removed once no longer indicated [45]. Antibiotic resistance is a developing challenge [46] and rational prescribing is a key part of this [47]. Should be reviewed on all ward rounds [3], failure to do so is an increasingly recognized issue [48].
Ward round finish time Number of patients seen Consultant present Hand washing
Infection status clarified
Whether or not a consultant was present for that patient review Was hand washing performed in line with infection control policy
Observation chart
Were infection control restrictions clarified before entering the patients room Was the observation chart reviewed
Fluid balance
Was the fluid balance chart reviewed
Medication chart
Was the prescription chart reviewed
Hospital acquired thrombosis (HAT) risk
Was the HAT assessment reviewed
Warfarin
If the patient was on warfarin was its dosing and monitoring reviewed
Lines
Were venous and/or arterial access lines reviewed and their ongoing use rationalized
Drains
Were drains reviewed and plans for there removal in place
Catheter
If applicable, was the catheter reviewed and removal considered Was the antibiotic prescription reviewed and rationalized
Antibiotics
Tests in previous 24 hours
Were all tests performed in the previous 24 hours reviewed
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Table 1 (Continued) Indicator
Description
Rationale
Plan to nurse
Was the plan relayed to the nursing staff
Plan to patient
Was the plan discussed with the patient
Plan to doctors
Was the plan relayed to other members of the medical team
Expected discharge date (EDD) Follow up
Was an EDD in place and up to date
Typed directly
Were notes typed directly into the electronic record
Checked
Were the notes checked by the senior clinician leading the ward round
Vital to ensure collaborative patient care [49]. Vital to ensure collaborative patient care [49]. Poor communication obstructs task understanding, prioritization and completion [50] Early multidisciplinary involvement can reduce length of stay [51]. Patients lost to follow up have worse outcomes than those who continue to be assessed [52]. Notes entered at a later time are not contemporary and may be less accurate. Requires prioritized access to IT facilities [3] Documentation by junior doctors often does not meet GMC requirements [53].
Were plans for follow up clarified
The mean time for a ward round was 1 hour 24 minutes (range 35 minutes to 2 hours 45 minutes) with the mean number patients seen of 14 (range 6 to 22). This gives an average time per patient of 6 minutes 1 second. Consultant presence of the ward round varied between the beginning, middle and end of the round as shown in Fig. 2. Mean time per patient was 5 minutes with a consultant present and 6 minutes without. Comparing patient encounters with a consultant present and not, results were very similar. Notable differences were 56% of consultant encounters checked the VTE/HAT status versus 70% without. 57% of consultant encounters discussed the patients’ lines versus 14% without. 5% of consultant encounters checked the ward round documentation versus 28% of trainee led ward rounds. Comparing these results with a similar audit from July 2011, which included 74 patients and fewer recorded domains, reveals similarities and differences (see Fig. 3 and Fig. 4). 3.1. Analysis of results The time spent conducting the ward round is difficult to interpret and to the best of our knowledge no papers discussing this in the surgical context are available, with a single paper relating to inpatient medical ward rounds following the introduction of a ‘considerative checklist’. The means in this instance were 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds) [12]. The 1-minute mean difference between consultant and non-consultant led ward rounds could be due to any number of reasons, its clinical significance is not clear.
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D. Darbyshire et al. / Measuring ward round quality Table 2 Audit results
Consultant Present Hand washing Infection control status Observation chart Fluid balance Drug chart HAT Status Warfarin Lines Drains Urinary catheter Antibiotics Test in previous 24 hours Plan to nurses Plan to patient Plan to doctors Expected discharge date Follow up Typed directly Notes entry checked
Yes
No
Not recorded+ Not applicable
%
34 58 36 78 76 26 59 5 6 15 52 54 77 91 92 92 63 54 92 18
59 34 54 14 16 66 32 2 39 2 5 23 11 1 0 0 28 30 0 74
0 1 3 1 1 1 1 86 48 76 36 16 5 1 1 1 1 8 1 1
37 62 39 84 82 28 63 71 13 88 91 70 88 99 100 100 69 64 100 20
Fig. 2. Of the 10 ward rounds in which the consultant was present for any of the round the presence changed through the course of the round.
Consultant presence on the ward round fell between 2011 and 2013. The 62% figure for hand washing is 7% better than the 2011 figure and positive compared to work from Wales which found that surgeons washed their hands between patients 41% of the time on ward
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Fig. 3. Bar chart showing audit results from 2011 and 2013.
Fig. 4. Bar chart showing change between 2011 and 2013.
rounds [24]. However it is lower than local guidelines which state that clinicians should wash there hands between each patient contact. Despite incomplete evidence as to their efficacy [25, 26] barrier nursing, amongst other initiatives, is considered best practice when nursing patients with infection control issues. If the medical team is not
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aware of the patients infection control status then implementing these measures will be ineffective. The 39% review of infection control status improves to 50% if only those patients in side rooms are considered but this is still low. Review of the observation chart and fluid balance improved from 2011 but again the percentage figure is difficult to interpret. That review of the medication chart is so much lower warrants discussion. In the trust in question fluid balance and observation charts are paper documents located at the end of the bed. The medication prescription is electronic and accessed via the mobile computer used on the ward round. This presents particular challenges to the person making the ward round note as they cannot type and review the medications at the same time. The use of tablet computers to review the medications has been tried and while feasible the hardware was heavy and the interface not user friendly. Review of HAT status, warfarin and antibiotics suffers similar problems. Review of the ongoing clinical indication for vascular access lines, surgical drains and urinary catheters is important as they are potential sources of infection while they remain in situ. The high frequency of review for catheters and drains may reflect the specialty. The lower frequency of review of vascular access may paradoxically represent their almost universal use in hospital inpatients. Review of test results in the previous 24 hours improved by 20% and communication between ward round leader remains at or approaching 100%. This says nothing as to the quality of this communication but would seem a positive finding in a key tenant of ward round practice.
4. Discussion Measuring the quality of a ward round is difficult. The aspects of the ward round which impact on patient outcome and experience is essentially unknown and it is almost certain that many important domains have not been included in this work. However we believe that the domains selected are a good starting point. What levels reflect acceptable, good and excellent practice is unclear but it would seem, and the evidence in Fig. 2 would support, that higher levels are better. Improving ward rounds would seem to require a multi faceted approach. Checklists may be one facet to this with work from Caldwell and colleagues seemingly to show benefit in the medical context [12, 20, 21, 27]. However barriers to their implementation exist. Attempts were made to implement a ward round checklist for the urology ward round in 2011 following the first audit but its use was neither widespread nor lasting. Understanding barriers to successful implementation has been explored in terms of the WHO surgical checklist [28, 29] and relating this to the context of ward rounds will be paramount to any future attempts to implement them. Junior doctors are key members of the ward round, normally responsible for collating information, documenting the process and completing tasks generated. Despite this research suggests they are unprepared for active participation in ward rounds [30]. Efforts to rectify this include high fidelity training using simulated wards [31, 32] and role play using standardized patients [33]. With medication errors being such a key patient safety issue [34–36] every opportunity much be taken to recognize and prevent patient harm. Pharmacist involvement on ward rounds reduces error and saves money [37] and could be a more efficient way of working that the traditional medical reconciliation process. This work has looked at ward rounds from a specific surgical sub specialty perspective taking into account a broad research base relating to multiple factors. Targeting ward rounds as part of the development of a wider safety culture will involve quality improvement across specialty boundaries and buy in from all
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involved is paramount. By presenting the state of current practice we hope to facilitate active participation from all members of the multi disciplinary team. 5. Conclusion By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them. Conflict of interest The authors state that they have no conflicts of interest under headings 1 to 4 below (1) Associations with commercial entities that provided support for the work reported in the submitted manuscript (the timeframe for disclosure in this section of the form is the life span of the work being reported). (2) Associations with commercial entities that could be viewed as having an interest in the general area of the submitted manuscript (in the 36 months before submission of the manuscript). (3) Any similar financial associations involving authors’ spouses, partners, their children under 18 years. (4) Non-financial associations that may be relevant to the submitted manuscript. References [1] Triggle N. Call to make ward rounds ‘cornerstone of hospital care’. BBC News Website2012 [cited 2013 July]; Available from: http://www.bbc.co.uk/news/health-19816017. [2] Birtwistle L, Houghton J, Rostill H. A review of a surgical ward round in a large paediatric hospital: Does it achieve its aims? Medical Education. 2000;34(5):398-403. PubMed PMID: WOS:000086432800016. English. [3] RCN Ra. Ward rounds in medicine : Principles for best practice : A joint publication of the Royal College of Physicians and the Royal College of Nursing, October 2012. London: Royal College of Physicians; 2012. [4] RCSEd. RCSEd Welcomes RCP & RCN Statement on Ward Rounds. Royal College of Surgeons of Edinburgh website2012 [cited 2013 July]; Available from: http://www.rcsed.ac.uk/the-college/news/2012/october-2012/rcn-rcp-statement.aspx. [5] Ko H, Turner T, Finnigan M. Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness. Bmc Health Services Research. 2011;11. PubMed PMID: WOS:000295284200001. English. [6] Lobo D, Dube M, Neal K, Allison S, Rowlands B. Peri-operative fluid and electrolyte management: A survey of consultant surgeons in the UK. Annals of the Royal College of Surgeons of England. 2002;84(3):156-60. PubMed PMID: WOS:000176098300002. English. [7] Lobo D, Dube M, Neal K, Simpson J, Rowlands B, Allison S. Problems with solutions: Drowning in the brine of an inadequate knowledge base. Clinical Nutrition. 2001;20(2):125-30. PubMed PMID: WOS:000168416000005. English. [8] Chari A, Cooke J, Singh S, Findlay J. Peri-operative fluid and electrolyte management: Undergraduate preparation and awareness. e-SPEN. 2011;6(4):e207-e10. [9] Somasekar K, Somasekar A, Hayat G, Haray P. Fluid and electrolyte balance: How do junior doctors measure up? Hospital Medicine. 2003;64(6):369-70. PubMed PMID: WOS:000183638300015. English. [10] Gawande A. The checklist manifesto : How to get things right. 1st ed. ed. New York: Metropolitan Books; 2010. [11] Amin Y, Grewcock D, Andrews S, Halligan A. Why patients need leaders: Introducing a ward safety checklist. Journal of the Royal Society of Medicine. 2012;105(9):377-83. PubMed PMID: WOS:000309783900009. English. [12] Herring R, Desai T, Caldwell G. Quality and safety at the point of care: How long should a ward round take? Clinical Medicine. 2011;11(1):20-2. PubMed PMID: WOS:000288054200007. English.
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Measuring ward round quality in urology Daniel Darbyshirea,b,∗ , Charlotte Barrettc , David Rossc and David Shackleyc a
Health Education North West, Manchester, UK Accident and Emergency, The Royal Oldham Hospital, UK c Department of Urology, Salford Royal Hospital, UK b
Received 17 September 2014 Accepted 10 January 2015 Abstract. BACKGROUND: Ward rounds are the traditional process by which clinical information is interpreted and management plans made in the inpatient setting and the only time during which patient-doctor interaction can reliably occur. Efforts to improve quality and safety have started looking at the ward round but this has mainly been in the acute medical setting. OBJECTIVE: To begin the quality improvement process for Urological ward rounds. METHODS: Twenty indicators thought to relate to quality were recorded for every weekday ward round by the Urology team for one month. RESULTS: Twenty ward rounds, 93 patient encounters, were reviewed. A consultant was present for 37% of the patient encounters. 84% of observation charts were reviewed; drug charts 28% and antibiotics 70%. Plans were communicated to the doctors, patient and nursing staff. All notes were typed directly onto the electronic system, 20% of notes were checked by the lead clinician. Mean time per patient was 6 minutes. CONCLUSIONS: By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them. Keywords: Urology, quality improvement, audit, ward round, patient safety
1. Background Ward rounds are the daily point of contact between the patient and the clinical team caring for them. Despite a long held belief and public perception that ward rounds are vital for safe and effective patient care [1] they are often performed in a less than optimal fashion [2]. Katherine Murphy, chief executive of the Patients Association, said: “High quality, consistent ward rounds in every hospital would contribute to a more patient centered culture in the NHS. This is crucial reading for the government and trusts [1].” A joint statement from the Royal College of Nursing and the Royal College of Physicians called for an improvement in the quality of ward rounds and to ensure they are truly patient centered [3]. Other than statements supporting this stance [4] specific guidelines from the respective surgical colleges have not been forthcoming. A systematic review of safety checklists found evidence of their use in the emergency department, critical care, acute medicine and operating theatre but none relating to planned care [5]. The members of the urology ward round varies depending on the availability of the different team members but is generally as follows. The round is led by the senior medically qualified member of ∗ Address for correspondence: Daniel Darbyshire, Accident and Emergency, The Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH, UK. Tel. : +44 07757 119141; E-mail: [email protected].
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D. Darbyshire et al. / Measuring ward round quality
staff, either a consultant urological surgeon (equivalent to an attending in the United States) or a urology registrar or senior clinical fellow (equivalent to post graduate year 5 or beyond residents or fellows). They will be supported by one or more junior medical staff, foundation doctors or core surgical trainees (interns or early years attending’s) and both the nurse looking after the patient and a senior nurse coordinating the ward. 1.1. Measuring ward round quality The literature reveals several aspects of a ward round that appear to be related to quality in the broadest sense. Prescribing of fluids for post operative patient is often left to the most junior members of the surgical team and many consultants believe it is not done well [6], indeed knowledge gaps and poor practice have been identified [7]. The ward round would seem to be the ideal opportunity to review this and to improve practice through bedside teaching, though it would seem that this practice is far from widespread [8, 9]. 1.2. Improving ward round quality Following the introduction of the World Health Organization safe surgery checklist [10] several authors have discussed their experience introducing a checklist into the ward round [11, 12]. While the evidence
Fig. 1. University College London Hospital Ward Round Safety Checklist.
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base for the effectiveness of such an approach within healthcare is still developing [5] a strong argument for their use comes from successful application in transport [13], military and aerospace [14] industries [15] as well as specific examples from within the healthcare industry [16, 17]. The University College London Hospitals (UCLH) approach combined the implementation of a ward safety checklist (see Fig. 1) with targeted education [11]. While the evaluation of this initiative is still ongoing the authors report on emerging issues. The “disconnect between medical and nursing staff” is a theme which has presented itself in relation to operating room teamwork [18] and described from a sociological perspective as a negotiated order, “the result of continuous negotiation between doctors and nurses” [19]. The lack of ring fenced time for nurses to attend ward round may contribute to this [12, 20]. Work in medical ward rounds at Worthing Hospital, UK led to the development of the Caldwell Considerative Checklist [21]. Akin to the UCLH approach above this aimed to encourage documented evidence of safe and high quality medical care. While both approaches seem sensible and target many of the same areas, the evidence to support their efficacy is anecdotal [5, 12]. 2. Methods Twenty indicators were selected for their relation to quality and safety and practicalities of measurement (see Table 1). These were recorded for every weekday ward round by the urology team, on the urology ward, for one month. Data was collected by the nursing staff for the first, last and middle 2 patients on the round. The rationale for this was that collecting data for all patients would be overly burdensome, that patient complexity may vary as the first 12 beds on the ward are side rooms and that clinicians may spend less time on patients at the end of a ward round [22]. Data was collected without the knowledge of the urology team aiming to reduce the change of behavior that may occur if team members knew they were being audited [23]. The results have been compared with a similar set of data collected in 2011. The methodology was similar though the number of domains was fewer. 2.1. Limitations Data was collected by several different members of the nursing team so inconsistencies in recording may be evident. The single time period and small sample size limit interpretation and generalizability. Results and trends may be due to outliers. Statistical tests could be used but have been avoided; as an a priori hypothesis was not in place so statistical significance of answers to questions asked would be misleading. Measures of frequency of actions or interactions says nothing of their quality. So, for example, while test results may have been reviewed nothing is recorded of the quality of the decisions made from this information. 3. Results Twenty ward rounds covering 4 periods of Monday to Friday in a single calendar month in 2013 were audited. Data was collected for all ward rounds but 4 had incomplete data. A total of 93 patient encounters had sufficient data for analysis. Complete results are available in Table 2.
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D. Darbyshire et al. / Measuring ward round quality Table 1 Domains measured and rationale for their inclusion
Indicator
Description
Rationale
Start time
Time at which the ward round starts, it is scheduled to start at 08:00
A consistent start time allows member of the multi-disciplinary team to plan their work [3] Allows calculation of ward round length Allows calculation of mean time per patient Associated with shorter length of stay and more same day discharges [38] Associated with reduction in nosocomial infection and MRSA transmission [39, 40] Isolation and barrier nursing are currently recommended though the evidence is inconclusive [25, 26] Trends in early warning score can lead to early recognition of clinical deterioration [41]. Thought to be performed poorly when left to the most junior staff [7]. To review for drug errors and non-therapeutic omissions [34], should be performed daily [3]. Accurate risk assessment with appropriate interventions reduces HAT [42]. Omission or errors in warfarin prescribing are of particular concern in pre or post op patients and such errors are common [35, 36]. Vascular access lines are associated with hospital acquired infection so prompt removal when no longer clinically indicated is important [43]. Drains are associated with surgical site infections and should be removed when no longer indicated [44]. Urinary catheters should be removed once no longer indicated [45]. Antibiotic resistance is a developing challenge [46] and rational prescribing is a key part of this [47]. Should be reviewed on all ward rounds [3], failure to do so is an increasingly recognized issue [48].
Ward round finish time Number of patients seen Consultant present Hand washing
Infection status clarified
Whether or not a consultant was present for that patient review Was hand washing performed in line with infection control policy
Observation chart
Were infection control restrictions clarified before entering the patients room Was the observation chart reviewed
Fluid balance
Was the fluid balance chart reviewed
Medication chart
Was the prescription chart reviewed
Hospital acquired thrombosis (HAT) risk
Was the HAT assessment reviewed
Warfarin
If the patient was on warfarin was its dosing and monitoring reviewed
Lines
Were venous and/or arterial access lines reviewed and their ongoing use rationalized
Drains
Were drains reviewed and plans for there removal in place
Catheter
If applicable, was the catheter reviewed and removal considered Was the antibiotic prescription reviewed and rationalized
Antibiotics
Tests in previous 24 hours
Were all tests performed in the previous 24 hours reviewed
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Table 1 (Continued) Indicator
Description
Rationale
Plan to nurse
Was the plan relayed to the nursing staff
Plan to patient
Was the plan discussed with the patient
Plan to doctors
Was the plan relayed to other members of the medical team
Expected discharge date (EDD) Follow up
Was an EDD in place and up to date
Typed directly
Were notes typed directly into the electronic record
Checked
Were the notes checked by the senior clinician leading the ward round
Vital to ensure collaborative patient care [49]. Vital to ensure collaborative patient care [49]. Poor communication obstructs task understanding, prioritization and completion [50] Early multidisciplinary involvement can reduce length of stay [51]. Patients lost to follow up have worse outcomes than those who continue to be assessed [52]. Notes entered at a later time are not contemporary and may be less accurate. Requires prioritized access to IT facilities [3] Documentation by junior doctors often does not meet GMC requirements [53].
Were plans for follow up clarified
The mean time for a ward round was 1 hour 24 minutes (range 35 minutes to 2 hours 45 minutes) with the mean number patients seen of 14 (range 6 to 22). This gives an average time per patient of 6 minutes 1 second. Consultant presence of the ward round varied between the beginning, middle and end of the round as shown in Fig. 2. Mean time per patient was 5 minutes with a consultant present and 6 minutes without. Comparing patient encounters with a consultant present and not, results were very similar. Notable differences were 56% of consultant encounters checked the VTE/HAT status versus 70% without. 57% of consultant encounters discussed the patients’ lines versus 14% without. 5% of consultant encounters checked the ward round documentation versus 28% of trainee led ward rounds. Comparing these results with a similar audit from July 2011, which included 74 patients and fewer recorded domains, reveals similarities and differences (see Fig. 3 and Fig. 4). 3.1. Analysis of results The time spent conducting the ward round is difficult to interpret and to the best of our knowledge no papers discussing this in the surgical context are available, with a single paper relating to inpatient medical ward rounds following the introduction of a ‘considerative checklist’. The means in this instance were 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds) [12]. The 1-minute mean difference between consultant and non-consultant led ward rounds could be due to any number of reasons, its clinical significance is not clear.
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D. Darbyshire et al. / Measuring ward round quality Table 2 Audit results
Consultant Present Hand washing Infection control status Observation chart Fluid balance Drug chart HAT Status Warfarin Lines Drains Urinary catheter Antibiotics Test in previous 24 hours Plan to nurses Plan to patient Plan to doctors Expected discharge date Follow up Typed directly Notes entry checked
Yes
No
Not recorded+ Not applicable
%
34 58 36 78 76 26 59 5 6 15 52 54 77 91 92 92 63 54 92 18
59 34 54 14 16 66 32 2 39 2 5 23 11 1 0 0 28 30 0 74
0 1 3 1 1 1 1 86 48 76 36 16 5 1 1 1 1 8 1 1
37 62 39 84 82 28 63 71 13 88 91 70 88 99 100 100 69 64 100 20
Fig. 2. Of the 10 ward rounds in which the consultant was present for any of the round the presence changed through the course of the round.
Consultant presence on the ward round fell between 2011 and 2013. The 62% figure for hand washing is 7% better than the 2011 figure and positive compared to work from Wales which found that surgeons washed their hands between patients 41% of the time on ward
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Fig. 3. Bar chart showing audit results from 2011 and 2013.
Fig. 4. Bar chart showing change between 2011 and 2013.
rounds [24]. However it is lower than local guidelines which state that clinicians should wash there hands between each patient contact. Despite incomplete evidence as to their efficacy [25, 26] barrier nursing, amongst other initiatives, is considered best practice when nursing patients with infection control issues. If the medical team is not
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aware of the patients infection control status then implementing these measures will be ineffective. The 39% review of infection control status improves to 50% if only those patients in side rooms are considered but this is still low. Review of the observation chart and fluid balance improved from 2011 but again the percentage figure is difficult to interpret. That review of the medication chart is so much lower warrants discussion. In the trust in question fluid balance and observation charts are paper documents located at the end of the bed. The medication prescription is electronic and accessed via the mobile computer used on the ward round. This presents particular challenges to the person making the ward round note as they cannot type and review the medications at the same time. The use of tablet computers to review the medications has been tried and while feasible the hardware was heavy and the interface not user friendly. Review of HAT status, warfarin and antibiotics suffers similar problems. Review of the ongoing clinical indication for vascular access lines, surgical drains and urinary catheters is important as they are potential sources of infection while they remain in situ. The high frequency of review for catheters and drains may reflect the specialty. The lower frequency of review of vascular access may paradoxically represent their almost universal use in hospital inpatients. Review of test results in the previous 24 hours improved by 20% and communication between ward round leader remains at or approaching 100%. This says nothing as to the quality of this communication but would seem a positive finding in a key tenant of ward round practice.
4. Discussion Measuring the quality of a ward round is difficult. The aspects of the ward round which impact on patient outcome and experience is essentially unknown and it is almost certain that many important domains have not been included in this work. However we believe that the domains selected are a good starting point. What levels reflect acceptable, good and excellent practice is unclear but it would seem, and the evidence in Fig. 2 would support, that higher levels are better. Improving ward rounds would seem to require a multi faceted approach. Checklists may be one facet to this with work from Caldwell and colleagues seemingly to show benefit in the medical context [12, 20, 21, 27]. However barriers to their implementation exist. Attempts were made to implement a ward round checklist for the urology ward round in 2011 following the first audit but its use was neither widespread nor lasting. Understanding barriers to successful implementation has been explored in terms of the WHO surgical checklist [28, 29] and relating this to the context of ward rounds will be paramount to any future attempts to implement them. Junior doctors are key members of the ward round, normally responsible for collating information, documenting the process and completing tasks generated. Despite this research suggests they are unprepared for active participation in ward rounds [30]. Efforts to rectify this include high fidelity training using simulated wards [31, 32] and role play using standardized patients [33]. With medication errors being such a key patient safety issue [34–36] every opportunity much be taken to recognize and prevent patient harm. Pharmacist involvement on ward rounds reduces error and saves money [37] and could be a more efficient way of working that the traditional medical reconciliation process. This work has looked at ward rounds from a specific surgical sub specialty perspective taking into account a broad research base relating to multiple factors. Targeting ward rounds as part of the development of a wider safety culture will involve quality improvement across specialty boundaries and buy in from all
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involved is paramount. By presenting the state of current practice we hope to facilitate active participation from all members of the multi disciplinary team. 5. Conclusion By starting a discussion about ward rounds we aim to align the process with the broader values of the organisation. Ward rounds can be the cornerstone of delivering safe, clean and personal care and measuring this process is vital to understanding efforts to improve them. Conflict of interest The authors state that they have no conflicts of interest under headings 1 to 4 below (1) Associations with commercial entities that provided support for the work reported in the submitted manuscript (the timeframe for disclosure in this section of the form is the life span of the work being reported). (2) Associations with commercial entities that could be viewed as having an interest in the general area of the submitted manuscript (in the 36 months before submission of the manuscript). (3) Any similar financial associations involving authors’ spouses, partners, their children under 18 years. (4) Non-financial associations that may be relevant to the submitted manuscript. References [1] Triggle N. Call to make ward rounds ‘cornerstone of hospital care’. BBC News Website2012 [cited 2013 July]; Available from: http://www.bbc.co.uk/news/health-19816017. [2] Birtwistle L, Houghton J, Rostill H. A review of a surgical ward round in a large paediatric hospital: Does it achieve its aims? Medical Education. 2000;34(5):398-403. PubMed PMID: WOS:000086432800016. English. [3] RCN Ra. Ward rounds in medicine : Principles for best practice : A joint publication of the Royal College of Physicians and the Royal College of Nursing, October 2012. London: Royal College of Physicians; 2012. [4] RCSEd. RCSEd Welcomes RCP & RCN Statement on Ward Rounds. Royal College of Surgeons of Edinburgh website2012 [cited 2013 July]; Available from: http://www.rcsed.ac.uk/the-college/news/2012/october-2012/rcn-rcp-statement.aspx. [5] Ko H, Turner T, Finnigan M. Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness. Bmc Health Services Research. 2011;11. PubMed PMID: WOS:000295284200001. English. [6] Lobo D, Dube M, Neal K, Allison S, Rowlands B. Peri-operative fluid and electrolyte management: A survey of consultant surgeons in the UK. Annals of the Royal College of Surgeons of England. 2002;84(3):156-60. PubMed PMID: WOS:000176098300002. English. [7] Lobo D, Dube M, Neal K, Simpson J, Rowlands B, Allison S. Problems with solutions: Drowning in the brine of an inadequate knowledge base. Clinical Nutrition. 2001;20(2):125-30. PubMed PMID: WOS:000168416000005. English. [8] Chari A, Cooke J, Singh S, Findlay J. Peri-operative fluid and electrolyte management: Undergraduate preparation and awareness. e-SPEN. 2011;6(4):e207-e10. [9] Somasekar K, Somasekar A, Hayat G, Haray P. Fluid and electrolyte balance: How do junior doctors measure up? Hospital Medicine. 2003;64(6):369-70. PubMed PMID: WOS:000183638300015. English. [10] Gawande A. The checklist manifesto : How to get things right. 1st ed. ed. New York: Metropolitan Books; 2010. [11] Amin Y, Grewcock D, Andrews S, Halligan A. Why patients need leaders: Introducing a ward safety checklist. Journal of the Royal Society of Medicine. 2012;105(9):377-83. PubMed PMID: WOS:000309783900009. English. [12] Herring R, Desai T, Caldwell G. Quality and safety at the point of care: How long should a ward round take? Clinical Medicine. 2011;11(1):20-2. PubMed PMID: WOS:000288054200007. English.
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