LETTER TO Surgical Ward Round Quality and Impact on Variable Patient Outcomes To the Editor: e read with interest the recent article by Pucher et al1 that describes the relationship between surgical ward round (WR) quality in the high-dependency unit setting and clinical outcomes. This pragmatic observational study examined a vital aspect of inpatient care that had previously not been studied in detail. The association of poorquality WRs with delayed diagnoses and increased preventable complications is unsurprising. Simple, cheap, and easy-to-implement interventions such as WR checklists or proforma to improve the quality of patient review could lead to significant reductions in preventable morbidity. As such, the authors should be applauded for their efforts with this study. We would like, however, to point out a few significant limitations of this study. First, the subjects involved in this study were not blinded to the presence of the nonparticipating observer and as such an element of observer effect (the Hawthorne effect2) is likely to have been introduced. This source of bias could have led to participants modifying their behavior in direct response to being observed, leading to nonrepresentative WR quality being analyzed in this study. Presentation of the prestudy period patient complication rate would have been helpful to examine the influence that this source of bias had on the results presented. In addition, the authors did not make suitable comparison or adjustment for the type of surgery that patients received to help support their finding that preventable complications were higher in the poorer quality WR group. For example, a higher rate of pulmonary complications in the poorer quality WR groups could be explained if these patients underwent more thoracoabdominal procedures than those in the good-quality WR group. A more detailed comparison of patient characteristics between the high- and low-quality WR groups would have been desirable. Also, the use of a retrospective case note review to obtain data on patient complications is confounded by the likelihood that those performing a less thorough WR may also be less likely to record and document postoperative complications diligently. Furthermore, there was no mention in
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Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000779
THE
EDITOR
this article as to whether an increased frequency of formal WRs influenced patient outcomes. It would be interesting to assess whether an increased frequency of formal patient review (eg, twice daily) led to a reduction in preventable complications. Finally, the standard of inpatient hospital care delivered over the weekend is increasingly highlighted as an area for improvement.3 However, the influence and quality of weekend WRs were not discussed in this article. Weekend WRs are traditionally performed by the on-call surgical team members who may not be familiar with a particular patient’s case or progress. Time pressures and lack of continuity of care introduced as a result of traditional weekend hospital surgical cover could lead to poorer quality WRs and thus increased preventable complications. This could have a significant bearing on patients undergoing surgery toward the end of the working week who would therefore be more likely to receive high-dependency unit-level care at the weekend when poorer quality WRs may arguably be delivered. Further detailed studies of the influence of WR quality and development of strategies to improve postoperative clinical care are urgently required. Raymond Oliphant, MD Andrew Jackson, MD Susan Moug, PhD Robert Drummond, MRCS Vivienne Blackhall, MRCS Andrew Renwick, MD Department of General Surgery Royal Alexandra Hospital Paisley, Scotland, United Kingdom [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. Roesthlisberger FJ, Dickson WJ. Management and the Worker: An Account of a Research Program Conducted by the Western Electric Company, Hawthorne Works, Chicago. Cambridge, MA: Harvard University Press; 1939. 3. Kafetz A, Kilman A, Athanasiou T, et al, eds. Dr Foster Hospital Guide 2001-2011. Inside Your Hospital. London: Dr Foster Intelligence; 2011.
Reply:
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e thank Dr Oliphant and colleagues for taking the time to respond to our recently published article, in which we described the results of an observational study of variation in surgical ward round (WR) performance and its relationship to patient outcomes.1 Disclosure: The authors declare no conflicts of interest. All authors have seen and approved the final version of this manuscript. DOI: 10.1097/SLA.0000000000000846
Annals of Surgery Volume 262, Number 6, December 2015
In his letter, Dr Oliphant refers to both the limitations of our study, as well as potential sources of bias. In regard to the study’s results analysis, Dr Oliphant specifically raises concerns over a lack of adjustment for weekend WRs, or the types of procedure performed. Unfortunately, the relatively small sample size, given the exploratory nature of our study, precluded meaningful subgroup or multivariate analysis. Specifically, however, we can report that his concerns that a greater number of thoracoabdominal procedures may have accounted for greater pulmonary complications in the poor quality WR group are unfounded, as the majority of upper gastrointestinal procedures were in fact in the high-quality WR group (ratio 5:2). Regarding potential sources of bias, Dr Oliphant describes both observer (Hawthorne) effect, as well as a concern that with poorer quality WRs, poor documentation may also have resulted in a failure to document postoperative complications. Although these are valid concerns, applicable to any study of this nature, we feel it is unlikely that they have affected the validity of our results. First, in situ presence of an observer is an accepted method of process data collection2 and is the only way in which certain data, including WR quality, may be collected—as such the potential of an observer-induced effect is one which must be considered but cannot be avoided. However, any effect will have applied to all subjects (regardless of WR quality group), and the prolonged duration of observations, over 4 months, will have contributed to an amelioration of the Hawthorne effect. Second, complications were recorded not only from medical documentation but also through expert review of pathology results and other investigations. Bias through this mechanism, furthermore, would have acted to falsely weaken, rather than augment, our results—that is, any underreporting of complications in the poor WR group would mean that adverse event rates in this group were, in fact, higher still. We are fully in agreement that WRs represent a critical aspect of surgical care which have, to date, been overlooked as a target for process improvement. To improve care, checklists or proformas for WRs have been previously described,3 but it remains unclear whether these are suitable to the changing needs of surgical patients—a critically unwell postoperative patient, after all, is quite justifiably treated differently from a patient well into recovery and nearing discharge. Instead, we propose that WRs should be treated like any other surgical skill—just as trainees train to improve their various technical skills, such as to perform a hernia repair, they should also be taught the foundations of such nontechnical skills such as the conduct of www.annalsofsurgery.com | e105
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000779
THE
EDITOR
this article as to whether an increased frequency of formal WRs influenced patient outcomes. It would be interesting to assess whether an increased frequency of formal patient review (eg, twice daily) led to a reduction in preventable complications. Finally, the standard of inpatient hospital care delivered over the weekend is increasingly highlighted as an area for improvement.3 However, the influence and quality of weekend WRs were not discussed in this article. Weekend WRs are traditionally performed by the on-call surgical team members who may not be familiar with a particular patient’s case or progress. Time pressures and lack of continuity of care introduced as a result of traditional weekend hospital surgical cover could lead to poorer quality WRs and thus increased preventable complications. This could have a significant bearing on patients undergoing surgery toward the end of the working week who would therefore be more likely to receive high-dependency unit-level care at the weekend when poorer quality WRs may arguably be delivered. Further detailed studies of the influence of WR quality and development of strategies to improve postoperative clinical care are urgently required. Raymond Oliphant, MD Andrew Jackson, MD Susan Moug, PhD Robert Drummond, MRCS Vivienne Blackhall, MRCS Andrew Renwick, MD Department of General Surgery Royal Alexandra Hospital Paisley, Scotland, United Kingdom [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. Roesthlisberger FJ, Dickson WJ. Management and the Worker: An Account of a Research Program Conducted by the Western Electric Company, Hawthorne Works, Chicago. Cambridge, MA: Harvard University Press; 1939. 3. Kafetz A, Kilman A, Athanasiou T, et al, eds. Dr Foster Hospital Guide 2001-2011. Inside Your Hospital. London: Dr Foster Intelligence; 2011.
Reply:
W
e thank Dr Oliphant and colleagues for taking the time to respond to our recently published article, in which we described the results of an observational study of variation in surgical ward round (WR) performance and its relationship to patient outcomes.1 Disclosure: The authors declare no conflicts of interest. All authors have seen and approved the final version of this manuscript. DOI: 10.1097/SLA.0000000000000846
Annals of Surgery Volume 262, Number 6, December 2015
In his letter, Dr Oliphant refers to both the limitations of our study, as well as potential sources of bias. In regard to the study’s results analysis, Dr Oliphant specifically raises concerns over a lack of adjustment for weekend WRs, or the types of procedure performed. Unfortunately, the relatively small sample size, given the exploratory nature of our study, precluded meaningful subgroup or multivariate analysis. Specifically, however, we can report that his concerns that a greater number of thoracoabdominal procedures may have accounted for greater pulmonary complications in the poor quality WR group are unfounded, as the majority of upper gastrointestinal procedures were in fact in the high-quality WR group (ratio 5:2). Regarding potential sources of bias, Dr Oliphant describes both observer (Hawthorne) effect, as well as a concern that with poorer quality WRs, poor documentation may also have resulted in a failure to document postoperative complications. Although these are valid concerns, applicable to any study of this nature, we feel it is unlikely that they have affected the validity of our results. First, in situ presence of an observer is an accepted method of process data collection2 and is the only way in which certain data, including WR quality, may be collected—as such the potential of an observer-induced effect is one which must be considered but cannot be avoided. However, any effect will have applied to all subjects (regardless of WR quality group), and the prolonged duration of observations, over 4 months, will have contributed to an amelioration of the Hawthorne effect. Second, complications were recorded not only from medical documentation but also through expert review of pathology results and other investigations. Bias through this mechanism, furthermore, would have acted to falsely weaken, rather than augment, our results—that is, any underreporting of complications in the poor WR group would mean that adverse event rates in this group were, in fact, higher still. We are fully in agreement that WRs represent a critical aspect of surgical care which have, to date, been overlooked as a target for process improvement. To improve care, checklists or proformas for WRs have been previously described,3 but it remains unclear whether these are suitable to the changing needs of surgical patients—a critically unwell postoperative patient, after all, is quite justifiably treated differently from a patient well into recovery and nearing discharge. Instead, we propose that WRs should be treated like any other surgical skill—just as trainees train to improve their various technical skills, such as to perform a hernia repair, they should also be taught the foundations of such nontechnical skills such as the conduct of www.annalsofsurgery.com | e105
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
