Issue 31 / 19 August 2013

WARD rounds are central to care in hospitals. They are a sensible way for a team of carers to look after a group of patients methodically.

Ideally, relevant health professionals review patients and discuss problems, investigations, diagnoses, care and discharge plans as a team, and with the patient and family. The round should guide the provision of care in a safe environment based on the best evidence.

It is also a forum for education.  

What really happens is quite different. In a US observational study of general medicine ward teams, a median of 9 patients (range, 2–18) were seen in a median time of 120 minutes (range, 25–241 minutes) — about 13 minutes per patient.

There was much discussion about the patient. However, impacting on that communication were the facts that, on average, only 66% of team members were present at the beginning of each patient presentation, the majority of time was spent away from the bedside and nurses were not present. Medications charts were discussed in 69% of cases, invasive lines in 9% and prophylaxis for deep vein thrombosis in 16%. Education was not prominent.

What about in Australia? I am sure we do better and worse.

Competing demands, high turnover, sicker patients and more students and trainees are challenges. But these realities do not excuse potential compromises in safe care, because evidence shows we can do better.

What guides can we use to ensure our rounds are safe, constructive and educational?

From a communication and safety viewpoint, all members should take part in ward rounds and work together as a team. Nurses are essential, contributing knowledge from their 24-hours-a-day of interaction with the patient.

The use of checklists has been shown in surgery to contribute to safer care. Why not on ward rounds?

Examples of ward round checklists can be adapted for local need and to improve adherence to safe care and interprofessional communication. Students can be given the role to ensure all areas are covered — as long as you give them the authority to speak up on areas missed.

NSW Health is rolling out a new model for multidisciplinary ward rounds, in response to the Garling Report, which should address safety and communication, as well as outlining team members, round structure and the checklist for different clinical areas (such as psychiatry and the acute care).

As much as possible ward rounds should be done at the bedside. When patients are involved in bedside teaching, they leave hospital understanding more about their disease and are more satisfied with care.

Lack of communication is one of most frequent complaints from patients, so allow patients to listen and be part of the discussion. When done sensitively, appropriately and with clarity, most will appreciate it.

What about education? I think we should stop trying to “teach”. Rather we need to look at ways to integrate clinical care and education more closely.

Involve everyone in the case discussion, not by asking knowledge-based questions but by inviting input to thinking and analysis. Ask the resident to summarise their understanding and plan before completing the notes; get everyone to take turns being the lead in interacting with the patient.

You will always be there to intervene if the dialogue is not going well, but you get a chance to observe your students and trainees. As the provision of care is in their hands most of the time, you can gauge whether they are safe. Feedback is essential and you can model this by inviting reflection on your performance.

One resource includes two points for pausing — the first to check team understanding and the second patient understanding.

I suggest a third — reflection on the interaction and provision of feedback. Then we can feel more confident that we have communication, safety and education back into patient care.

Professor Fiona Lake is a respiratory physician and professor of medicine in the School of Medicine and Pharmacology, University of WA.
 

5 thoughts on “Fiona Lake: Value in rounds

  1. Stephen Langford says:

    Great article. I believe one of the most backward steps in quality clinical care was in the 1980s when nurses decided not to accompany doctors on ward rounds.  When you look at it, how nonsensical can that be?  The individuals who are caring for the patient during the day exclude themselves from participation in discussion about patient care plans and miss the opportunity to contribute information or clarify concerns.   Instead doctors then have to write stuff down and hope nurses will read it which they easily miss.  No wonder the system is so inefficient and flawed.  If you were designing any other business you would not allow it to run this way.

  2. Dr Kevin B ORR says:

    Yes, good stuff but the problem here is T-I-M-E! Specialists are so busy that they need to find time somewhere- why not the ward round? When I was s student at Prince Alfred in the late 40’s, ward rounds were a great learnig experience – students, nurses, RMO”S and registrars and the boss himself – depending on which boss! Fiona Lake’s ideas are great but isn’t this teaching? 

     

  3. Joan Benjamin says:

    Fiona’s ideas are spot on.  Its not teaching that matters, its allowing juniors the opportunity to contribute ideas, have them respectfully modified when needed, and contribute to patient care decision making.  Ward rounds should be about collaboratve decision making and that includes the patient, with opportunities for contribution, awareness, reflection and education (CARE).

  4. mohamedharoon says:

    Great Article by Professor Lake. One could not agree more with the contention that relevant health professionals reviewing patients and discussing problems, investigations, diagnoses, care and discharge plans as a team, and with the patient and family could only enhance the educational experience of the team. In today’s age of sub and super specialisation, our specialists and super specialists find themselves poorly placed to address patient issues outside their own speciality. This results in referrals and disjointed care which does little to address the patient’s concerns. Further it adversely impacts on a seamless patient journey within the healthcare system adding to our already overburdened health budget

    Whilst competing demands, high turnover, sicker patients and more students and trainees are indeed challenges – the current workforce model does little to address those concerns. Under the current workforce model patients come in contact with consultants for less than 25 % of their entire journey within the acute health care setting as pointed out by the Garling Report. This calls for an urgent rethink of the current workforce models in place.

    The Senior Hospitalist Initiative by the NSW Health addresses these concerns by promoting a highly skilled resident generalist workforce to pander to the educational, patient care needs within the acute healthcare setting.  What we need, I suspect is a greater recognition of the value proposition such roles provide to the acute health care setting at large. This would be an essential pre-requisite towards incentivization and greater adoption of such roles

  5. Joseph Moloney says:

    I’m wondering if Fiona Lake has EVER been up all night; covering a busy private hospital as well as a busy public one; had several mobile calls throughout a round – all important information about coming crises via road or in labour ward; and meanwhile trying to communcate with overstressed nursing staff often on double shifts, who are RUNNING to sundry responsibilities during the round??? What world of ENDLESS time for rounds, does she live in? Perhaps a cocoon of luxury at a well-resourced tertiary institution?

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