Daily Ward Rounds Research Articles

Antibiotic Stewardship-Visiten: Zeitverschwendung oder Qualitätssteigerung?

One of the core strategies to optimize antiinfective therapy is to review antibiotic prescriptions. Therefore, Antibiotic Stewardship (ABS) team members either attend ward rounds or perform a chart review to provide feedback to and discuss with the attending physician. Acceptance and effectiveness of both options are discussed in this article. Attending physicians were asked to complete a questionnaire evaluating ABS activities. The modality of the reviewing process and its effectiveness, as well as the feasibility of recommendations was assessed. As the degree of implementation of ABS recommendations decreased on a trauma ward, the reviewing process was changed from chart review to attending the daily ward rounds. In this setting, the duration of the reviewing process and the consumption of antiinfectives in recommended daily doses/100 patient days (RDD/100PT) were assessed, comparing the two intervention modalities. Attending physicians predominantly appreciated the modality and extent of ABS currently offered to them by the ABS team, rating it relevant and effective. Implementation of ABS recommendations was increased on the trauma ward by academic detailing during the daily ward round; the consumption of broad spectrum antibiotics was reduced. ABS team members with formal authority and dedicated time for antibiotic stewardship activities effectively optimize antiinfective therapies by reviewing antibiotic prescriptions. The interaction of ABS experts and attending physicians contributes fundamentally to the effectiveness and degree of implementation of ABS interventions.

Delivery of Enteral Nutrition after the Introduction of Practice Guidelines and Participation of Dietitians in Pediatric Critical Care Clinical Teams

Provision of optimal nutrition is often difficult to achieve in the critically ill child, but can improve with better nutritional support practices. This study evaluated the joint impact of the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds on enteral nutrition (EN) intake and practices in children in intensive care. Nutritional intake and EN practices were audited before (period A) and after (period B) the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds in a pediatric intensive care unit. Information was collected on a daily basis and nutritional intake was compared with predefined targets and the United Kingdom dietary reference values. There were 65 patients and 477 nutritional support days in period A and 65 patients and 410 nutritional support days in period B. Basal metabolic rate (BMR) energy requirements were achieved in a larger proportion of nutritional support days in period B (BMR achieved [% nutritional support days]; period A: 27% vs period B: 48.9%; P<0.001). In patients admitted for nonsurgical reasons, median energy, protein, and micronutrient intake improved significantly. In the same group, the percentage of daily fluid intake delivered as EN increased post implementation (period A: median=66.8%; interquartile range=40.9 vs period B: median=79.6%; interquartile range=35.2; P<0.001). No significant changes were seen in patients admitted for corrective heart surgery. Implementation of better EN support practice can improve nutritional intake in some patients in critical care, but can have limited benefit for children admitted for corrective heart surgery.

G317(P) Use of Clinical Audit to Improve Neonatal Thermoregulation at a University Hospital in Ethiopia

AimsTo use the audit cycle to assess and improve the standard of neonatal thermoregulatory care.To demonstrate the usefulness of clinical audit in a resource-limited setting.MethodsA prospective audit was undertaken on...

G223(P) A Novel Neonatal Hospital Record System to improve note keeping for infants admitted to a neonatal unit in a low resource country

AimTraining and knowledge of specialist neonatal care is frequently limited in low resource countries. We aimed to assess if the introduction of a standardised medical record could improve documentation, assisting...

Surgical ward rounds in England: a trainee-led multi-centre study of current practice

BackgroundRecent guidance advocates daily consultant-led ward rounds, conducted in the morning with the presence of senior nursing staff and minimising patients on outlying wards. These recommendations aim to improve patient management through timely investigations, treatment and discharge. This study sought to evaluate the current surgical ward round practices in England.MethodsInformation regarding timing and staffing levels of surgical ward rounds was collected prospectively over a one-week period. The location of each patient was also documented. Two surgical trainee research collaboratives coordinated data collection from 19 hospitals and 13 surgical subspecialties.ResultsData from 471 ward rounds involving 5622 patient encounters was obtained. 367 (77.9%) ward rounds commenced before 9am. Of 422 weekday rounds, 190 (45%) were consultant-led compared with 33 of the 49 (67%) weekend rounds. 2474 (44%) patients were seen with a nurse present. 1518 patients (27%) were classified as outliers, with 361 ward rounds (67%) reporting at least one outlying patient.ConclusionRecommendations for daily consultant-led multi disciplinary ward rounds are poorly implemented in surgical practice, and patients continue to be managed on outlying wards. Although strategies may be employed to improve nursing attendance on ward rounds, substantial changes to workforce planning would be required to deliver daily consultant-led care. An increasing political focus on patient outcomes at weekends may prompt changes in these areas.

Evaluating the effects of combination antiretroviral therapy regimens and the development of adverse drug reactions in Indian human immunodeficiency virus positive patients

Background: In India, adverse drug reactions (ADRs) occur frequently with combination antiretroviral therapy (cART) leading to switching or discontinuing cART intentionally. Objective: The study was conducted to characterize the effects of cART regimen and the development of ADRs in human immunodeficiency virus positive patients (HIV) in a tertiary care teaching hospital. Materials and Methods: A prospective observational study was conducted from August 2009 to May 2012 to characterize the pattern of ADRs to cART at Kasturba Hospital, Manipal in South India. Collection of the data was done by a clinical pharmacist during daily ward rounds to identify the suspected ADRs associated with the use of cART for various parameters which included patient demographics, cART with its adverse reaction characteristics. Assessment was also done for preventability, predictability and seriousness of ADRs, system organ classes affected and causality of the suspected ADRs using the World Health Organization (WHO) Probability Scale. Results: Among 450 patients enrolled, 230 suspected ADRs to cART were reported. By Pearson Chi-square test, higher occurrence of ADRs (P < 0.001) was noted in females, age 41-60 years, CD4 + T-cell counts 350-500 cells/μl, 5 years use of cART. ADRs were highest with zidovudine + lamivudine + nevirapine (42.3%) and tenofovir + emtricitabine + efavirenz (14.2%). On bivariate analysis, (P < 0.001) were identified in 1) Anemia with zidovudine use, 2) Pancytopenia with zidovudine, lamivudine use 3) Hepatotoxicity with nevirapine, efavirenz use, 4) Peripheral neuropathy with stavudine use, 5) Renal failure with tenofovir use and 6) Maculopapular rash with emtricitabine, tenofovir, efavirenz use. The system organ class most affected with ADRs to cART was red blood cell disorders (30.9%) followed by skin and appendages disorders (16.5%). Conclusion: With increasing reports of ADRs in India, clinicians need to select a safe cART regimen with underlying illness, medicines and drug intolerances.

Ward safety checklist in the acute surgical unit

Deficiencies in daily ward rounds are increasingly identified. A ward safety checklist has recently been devised to improve the fast-paced surgical ward round. Over 2 weeks the morning post-take surgical ward round was evaluated using the ward safety checklist. In order to avoid the Hawthorne effect, doctors involved were not aware their performance was being observed. One hundred patient encounters were evaluated. The three phases of the card safety checklist showed statistically significant improvement but for many components compliance was below 100%. Implementing this simple checklist has provided our unit with a starting point in how to overcome some of the deficiencies of the post-take surgical ward round.

Audit of Co-Management and Critical Care Outreach for High Risk Postoperative Patients (The POST Audit)

Co-management and critical care outreach for high risk surgical patients have been proposed to decrease postoperative complications and mortality. We proposed that a clinical project with postoperative comanagement and critical care outreach, the Post Operative Surveillance Team: (POST), would be associated with decreased hospital length of stay. We conducted a retrospective before (control group) and after (POST group) audit of this hospital program. POST was staffed for four months in 2010 by two intensive care nurses and two senior registrars who conducted daily ward rounds for the first five postoperative days on high risk patients undergoing inpatient general or urological surgery. The primary endpoint was length of hospital stay and secondary endpoints were Medical Emergency Team (MET) calls, cardiac arrests and in-hospital mortality. There were 194 patients in the POST group and 1,185 in the control group. The length of stay in the POST group, median nine days (Inter-quartile range [IQR]: 5 to 17 days), was longer than the control group, median seven days (IQR: 4 to 13 days): difference two days longer (95.0% confidence interval [95.0% CI]: 1 to 3 days longer, P <0.001). There were no important differences in the proportion of patients having MET calls (16.0% POST versus. 13% control (P=0.25)) or mortality (2.1% POST versus 2.8% Control (P=0.82)). Our audit found that the POST service was not associated with reduced length of stay. Models of co-management, different to POST, or with different performance metrics, could be tested.

Introduction of a heart failure nurse for the support of in-hospital management of mainly elderly patients with acute HF results in a better outcome after 1 year follow-up

Purpose: The optimal in-hospital and pre-discharge management of the mainly elderly patients hospitalised for acute Heart Failure (HF) is still a matter of debate. We evaluated the short and long-term effects of the introduction of a HF nurse for the support of the in-hospital management of these patients. The specific tasks of the HF nurse included participation in daily ward rounds, patient counseling and a pre-discharge medication check. Methods: We performed a sequential comparison of all consecutive patients admitted with HF at the department of cardiology during 2 study periods: group 1 (2008-2009) before introduction of the HF nurse (n=388 pts, mean age 78±11 years, 44% women, 43% HFPEF) and group 2 (2010-2011) after introduction of the HF nurse (n=450 pts, mean age 78±11 years, 46% women, 40% HFPEF). Baseline clinical characteristics, hospitalisation duration and in-hospital mortality as well as pre-discharge medication were compared between the 2 groups. All patients were followed for 1 year for the combined end-point of all-cause mortality and rehospitalisation for HF. Results: Baseline characteristics including clinical characteristics, severity of HF and comorbidities were comparable between the two groups. Although in-hospital mortality was comparable (6.7% vs 8.7%, p=0.30) hospitalisation duration was shorter for group 2 (8 days for group 1 (IQ range 6-14) vs 7 days for group 2 (IQ range 5-13), p=0.034). Introduction of the HF nurse resulted also in a significantly higher use of beta-blockers and mineralocorticoid receptor antagonists at discharge (both for all patients as for the HFREF patients in group 2). After 1 year FU, 156 pts (44%) had died or were rehospitalised for HF in group 1 and 88 patients in group 2 (23%, p<0.01). In multivariate Cox regression analysis, introduction of a HF nurse was associated with a 33% (95% CI 11%-50%, p<0.01) reduction of all cause-mortality or rehospitalisation for HF. Conclusion: The introduction of a HF nurse for the support of the in-hospital management of mainly elderly patients admitted with acute HF, was associated with a shorter in-hospital stay, a more frequent use of evidence-based medication at discharge and a significant reduction of the combined endpoint of all-cause mortality and rehospitalisation for HF after 1 year follow-up.

The German quality indicators in intensive care medicine 2013--second edition.

Quality indicators are key elements of quality management. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2010 were recently evaluated when their validity time expired after two years. Overall one indicator was replaced and further three were in part changed. The former indicator I “elevation of head of bed” was replaced by the indicator “Daily multi-professional ward rounds with the documentation of daily therapy goals” and added to the indicator IV “Weaning and other measures to prevent ventilator associated pneumonias (short: Weaning/VAP Bundle)” (VAP = ventilator-associated pneumonia) which aims at the reduction of VAP incidence. The indicator VIII “Documentation of structured relative-/next-of-kin communication” was refined. The indicator X “Direction of the ICU by a specially trained certified intensivist with no other clinical duties in a department” was also updated according to recent study results. These updated quality indicators are part of the Peer Review in intensive care medicine. The next update of the quality indicators is due in 2016.

The ward round – patient experiences and barriers to participation

Patients' participation is essential to their well-being and sense of coherence, as well as to their understanding of and adherence to prescribed treatments. Ward rounds serve as a forum for sharing information between patient and caregiver. The purpose of the ward round is to obtain information and plan medical and nursing care through staff-patient communication. The aim and objective of this study was to investigate patients' experiences during the ward round and their ability to participate in their care. The study was qualitative and descriptive in design. Fourteen inpatients at a cardiovascular ward were interviewed. Qualitative content analysis was used for the analysis. The ethics of scientific work were adhered to. Each study participant gave his/her informed consent based on verbal and written information. The study was approved by the Research Ethics Committee at Uppsala University. The analysis revealed one theme and three subthemes related to patients' experiences of ward rounds. The main theme was handling of information from the daily ward round while waiting for private consultation. The subthemes were making the best of the short time spent on ward rounds; encountering traditional roles and taking comfort in staff competency; and being able to choose the degree to which one participates in the decision-making process. Several aspects of traditional ward round routines could be improved in regard to the two-way information exchange process between caregivers and patient. Patients' and caregivers' ability to communicate their goals and the environment in which the communication occurs are of great importance. The information provided by nurses is easier to understand than that provided by physicians. The atmosphere must be open; the patient should be treated with empathy by staff; and patients' right to participate must be acknowledged by all healthcare professionals involved.

PMO-254 Comparison of IBDQIP scores for two services within one trust

IntroductionThe Heart of England NHS Foundation Trust is one of the largest in England, with over 1200 beds and serves over a million people throughout north and east Birmingham and...

Mass realism? Developing a virtual ward round for medical students

Aims Undergraduate paediatric attachments are typically 5-9 weeks long. As a result of changes in service delivery, it is an increasing challenge to expose students to the process of healthcare delivery and practical management of the unwell child. We sought to develop, use and evaluate a web-based tool to mimic aspects of a daily ward round, so that students could see how a child is assessed and managed over the course of an admission in an interactive and supportive environment. Methods A virtual ward round (VWR), written in html, was delivered through a web browser by a facilitator.[1][1] The VWR consisted of daily 30 minute sessions during the first week of a 4th year paediatric attachment. Participants were shown a virtual ward, and jointly conducted a ward round of 4 patients. Led by the facilitator, groups perused clinical information, discussed investigation results, considered disease processes and planned management. Developments were reviewed the following day. If patients were discharged, a new patient occupying the same bed would be introduced. Feedback was collected at the end of 6 separate attachments. Students rated sessions for content and presentation on a Likert scale from 1-5, chose appropriate adjectives and gave free text comments. Results 28 VWR sessions were delivered over 6 attachments to a total of 221 students. The VWR mean content score was higher than the course mean (4.52 v 4.42). VWR presentation was rated higher than course mean: (4.41 v 4.17). The commonest adjectives chosen for VWR sessions were Interactive, Interesting, Engaging, Useful and Fun. Free text comments indicated that many students found the VWR the most valuable part of the week, and highlighted its breadth, realism and interactivity. Conclusions The VWR successfully introduced students to paediatric clinical decision making, was well received and deemed particularly valuable. A web-based VWR enables students to experience common ward scenarios and is an effective adjunct to the teaching of clinical medicine. [1]: #ref-1

Pharmacist's contribution on the wards†

BackgroundDuring the fourth year of training, pharmacy residents perform a rotation with the team doctor on various wards.PurposeTo describe and to classify the interventions made during the rotation through the...

Daily consultant gastroenterologist ward rounds: reduced length of stay and improved inpatient mortality

BackgroundFor gastroenterology, The Royal College of Physicians reiterates the common practice of two to three consultant ward rounds per week. The Royal Bolton Hospital NHS Foundation Trust operated a 26-bed...

Republished: Daily consultant gastroenterologist ward rounds: reduced length of stay and improved inpatient mortality

BackgroundFor gastroenterology, The Royal College of Physicians reiterates the common practice of two to three consultant ward rounds per week. The Royal Bolton Hospital NHS Foundation Trust operated a 26-bed...

POC09 Effects of an attending physician system on acute neurology provision in Plymouth

IntroductionWe admit around 2500 patients per year with neurological emergencies including stroke directly under our care. In 2006 we introduced an attending physician model for inpatient care. Since then, we...

Reduction in prescription and administration errors on paediatric intensive care with “zero-tolerance prescription”

Prescription errors are frequent on intensive care units. The perception of prescribing as a low status task rather than an essential element of therapy, perceived time pressure and distractions may all be contributory factors. The authors altered practice on our tertiary paediatric intensive care unit in two stages: formal consultant review of prescription charts on daily ward rounds and requesting re-write for any errors was introduced with the aim of raising the status and visibility of prescription as a task. Subsequently, a dedicated prescription desk was provided and prescription elsewhere was not permitted. Staff were not permitted to interrupt a prescriber at this desk. The authors termed these combined interventions “zero-tolerance prescription” (ZTP) following a similar approach in Cardiff. The authors undertook an observational study of the impact of these on prescription error rates over 6 months in a tertiary paediatric intensive care unit. <h3>Methods</h3> Prescription and administration errors have been recorded prospectively on a daily basis by our ward pharmacist against 44 criteria. These include “clinical errors” (dosage, route of administration, frequency) and non-clinical errors (signature illegible, unapproved names or abbreviations etc). Total errors adjusted for ICU occupancy (errors per occupied PICU day) are presented for three periods: (A) baseline, (B) consultant checking prescription charts and (C) full ZTP. Comparisons are made between mean error rates with t-tests. <h3>Results</h3> (A) Baseline mean error rate over 12 weeks was 1.8 errors per occupied PICU bed day (95% CI 1.5 to 2.1), (B) In the 20 weeks following formalised consultant checking of charts, this was reduced to 1.4, errors per occupied PICU bed day (1.1–1.6) (p=0.0035 vs A). (C) Following the introduction of the full ZTP, protocol error rate was 1.1 (0.8–1.3) (p=0.001 vs A, and p&lt;0.05 vs B) over a 10-week period. This constitutes relative risk 0.59 for error. Infusion prescriptions errors were most improved A) 0.3 day (0.2–0.4) per occupied PICU bed vs C) 0.1 (0–0.2), p=0.02 (relative risk 0.45). <h3>Comment</h3> In this unblinded study, the ZTP package was associated with a significant and prolonged reduction in errors. The impact of these changes is likely to be highly influenced by local factors but merit consideration on PICU.

How effective is your ICU's daily ward round?

How effective is your ICU's daily ward round?

Randomised trial comparing ocular lubricants and polyacrylamide hydrogel dressings in the prevention of exposure keratopathy in the critically ill

To compare the cost and effectiveness of the two most popular forms of eye care in intensive care, ocular lubricant (Lacrilube) and polyacrylamide hydrogel dressings (Geliperm); for the prevention of exposure keratopathy in the critically ill. A prospective randomised contralateral eye study was conducted at the Intensive Care Unit (ICU), Royal London Hospital, London, UK. Eighty eyes of 40 patients were recruited. Each patient received both Lacrilube and Geliperm allocated at random to different sides. A daily ophthalmology ward round was conducted. The outcome measures included the greatest palpebral aperture length, conjunctival oedema, and any exposure keratopathy. There was no statistically significant difference in the maximum corneal exposure score between the eyes treated with Lacrilube and Geliperm (P = 0.38). No significant difference in degree of chemosis or palpebral aperture was identified. Our data suggest that Geliperm is as effective as Lacrilube in the prevention of exposure keratopathy in the critically ill. We also note that nursing staff must be fully trained in its application for eye care.