Inpatient Ward Rounds Research Articles

Health service access and quality of care provided by the Western NSW Local Health District Virtual Rural Generalist Service: a retrospective analysis of linked administrative data.

To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS). Retrospective cohort study; analysis of emergency department and administrative hospital data. Twenty-nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds. All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022. Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality. During 2021-22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio-demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79-4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60-0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86-0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio-demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98-5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35-0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non-VRGS care (aOR, 0.78; 95% CI, 0.48-1.28) and when comparing combined (VRGS and non-VRGS) and non-VRGS care (aOR 1.21; 95% CI, 0.91-1.61). In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

1076 Staff Perceptions on Electronic Patient List Management: Introducing the General Surgery Care Teams to Improve Patient Safety

Abstract Aim Electronic patient lists are widely used across NHS England and commonly rely on staff manually updating lists to guide inpatient ward-rounds, creating potential for human errors. Locally, lists are extracted from Electronic Patient Record (EPR), whereby doctors are responsible for ‘coding’ patients under ‘general surgeon’ at admission. Errors in this process lead to “missed” patients, raising concerns for patient safety. This study aimed to assess staff perceptions surrounding this system to help implement the new EPR General Surgery Care Team. Method Perceptions were analysed using an online anonymous questionnaire, distributed via a messaging group. Questions were categorised into ‘ease of use’, ‘time-efficiency’ and ‘safety’, and assessed using a Likert Scale (1-5). Open questions screened for list-related examples of poor patient care and areas for improvement. Results Twelve responses were analysed: 7 (58.3%) Foundation Year 1, 4 (33.4%) Senior House Officers and 1 (8.3%) Registrar. Eleven (91.7%) responses reported the system to be inefficient and 7/12 (58.3%) difficult to use (scoring Likert 4-5). 100% believed the system disturbed patient care (Likert 3-5), describing it as “complicated”, “time-consuming” and “messy to use”. This “compromises patient safety” and “increases junior workload”. Nine (75%) responses identified specific examples where the system directly affected care, including patients “missed” from ward-rounds, delayed management, and adverse outcomes. Conclusions The ‘old’ list management system was complex and slow to use, directly compromising patient care. Further qualitative data is required to continue improving the General Surgery Care Team List, implemented using this feedback, to optimise patient safety.

1016 USING VIDEO TELEMEDICINE FOR INPATIENT WORKING: A NOVEL APPROACH TO REMOTE WORKING DURING THE COVID-19 PANDEMIC

BackgroundOrthogeriatrics inpatient ward.IntroductionThe COVID-19 pandemic changed working patterns for many trainees. Remote telephone or video outpatient consultations became established practice, with clinically vulnerable staff able to support this provision. We adapted the use of telemedicine to provide remote clinical working for inpatient care and continued speciality training opportunities.MethodMicrosoft Teams video conferencing facilitated interaction between the specialist registrar working remotely and the on-site multidisciplinary team (MDT). Daily activities included virtual handover attendance, inpatient ward round consultations and MDT discussions. A portable computer enabled the clinician to see and interact with inpatients remotely. Access to electronic patient records facilitated timely decision making and enactment of management plans. Anonymous MDT feedback was collected via online questionnaires. This project conformed to service evaluation guidelines and ethical approval was not required.ResultsFourteen staff members completed the feedback survey. Results were overwhelmingly positive, with 78.6% of respondents strongly agreeing that the senior doctor working remotely supported the MDT, facilitated complex clinical decision making and was beneficial to patient care. Feedback noted that some patients praised the ‘clever’ and ‘innovative’ method. Limitations included technical difficulties due to Wi-Fi connection, which contributed to communication not being as fluid as face-to-face consultations and increased ward round duration. Patient factors, namely hearing and cognitive impairment, limited the interaction that patients were able to have with the clinician via video link.ConclusionVideo inpatient ward round consultations offer an effective opportunity for physicians to continue clinical patient-facing roles whilst working remotely. Furthermore, this minimises the impact of COVID-19 on specialty trainees, by providing continued training and assessment opportunities for individuals required to shield. This novel method affords a framework transferrable to clinicians from other hospital specialties who may be required to work remotely. Future reviews of patient and relative satisfaction with this process are required.

Improving the Quality of Old Age Inpatient Ward Rounds During COVID-19 in NHS Lanarkshire, Scotland

AimsTo provide a structured Multidisciplinary team (MDT) checklist to improve the quality of ward rounds in Ward 3, Wishaw General hospital. Ward rounds normally involved patient and electronic documentation review during MDT. Feedback from medical and nursing staff indicated inconsistencies in finding up to date Do not resuscitate cardiopulmonary resuscitation (DNACPR)forms/Treatment escalation plans, treatment forms, care plans, thromboembolism prophylaxis during ward rounds. Discussions about who will update the family, make social work referrals needed clear documentation in order to follow up efficiently post MDT. Food, fluid, and weight charts although done regularly there was no single place to keep them together. These charts to be kept in a separate folder for finding easily during ward rounds. The Royal College of Psychiatrists sets standards that managers and practitioners have agreed standards for ward rounds. Structured ward rounds and check lists have shown to prevent omissions in care and improve patient safety.MethodsDiscussions with Ward 3 team, nursing colleagues and ward Quality improvement group were held. A Standard MDT Quality improvement Checklist was devised and used as a Pilot in W3, WGH.This was first introduced in August 2021. Plan, do, study, act (PDSA) cycle was carried out.Plan: Trial MDT checklist at Ward 3 ward RoundDo: Use Initially for two Consultant ward roundsStudy: Ask all MDT staff members for feedback on the formAct: Reformat the checklist for the following ward rounds and distribute among all consultants.Repeated Revisions of MDT checklist done after feedback from ward staff and final version devised and results audited in Nov 2021 and Jan 2022.Food, Fluid, and weight charts were put in separate folders.ResultsBefore MDT Checklist nil up to date MDT checklist information available, 10% individual food and fluid charts and 0% folders.After MDT checklist in November 2021, 73% increase in up-to-date checklist items, 100% increase in finding charts in folders.In January 2022 decrease to 44% of up-to-date MDT checklist items, 100% food and fluid charts in folders.ConclusionMDT Checklist provided robust structure to our Ward rounds along with the regular electronic record and has been incorporated in our shared drive. The results in January for up-to-date checklist were down because of staff sickness due to new Omicron variant and less people available to keep documentation up-to-date.

Cognitive-Behaviourism, Constructivism and Humanism in Paediatrics Specialty Training: From theory to practice.

The study of human learning is constantly changing and developing facilitated using learning theories like cognitive-behaviourism, constructivism and humanism which are the main guide for both academic and clinical training including paediatrics. Current advances in medical education in postgraduate medical training suggests that trainees, educational and clinical supervisors can hugely benefit from robust understanding of learning theory and its right application in clinical practice in outpatient clinics, inpatient ward rounds, clinical skills teaching and multidisciplinary meetings. Consultants and senior medical staff involved in teaching and training of postgraduate doctors in paediatrics can review these theories and their approaches to targeted learning goals to increase skill set to cope with present demand and to produces sound and skilled paediatricians. The aim of this narrative review is to provide paediatricians clinical and educational supervisors opportunities to be theoretically grounded in the dynamics of selected learning theories leveraging on their right application to achieve the learning goals of paediatric specialty training and inform excellent medical scholarship. The combination of these theories in the raising of next generation of paediatrician is a viable pathway in postgraduate medical training.

Patient participation in inpatient ward rounds on acute inpatient medical wards: a descriptive study.

BackgroundMeaningful partnering with patients is advocated to enhance care delivery. Little is known about how this is operationalised at the point of care during hospital ward rounds, where decision-making concerning patient care frequently occurs.ObjectiveDescribe participation of patients, with differing preferences for participation, during ward rounds in acute medical inpatient services.MethodsNaturalistic, multimethod design. Data were collected using surveys and observations of ward rounds at two hospitals in Melbourne, Australia. Using convenience sampling, a stratified sample of acute general medical patients were recruited. Prior to observation and interview, patient responses to the Control Preference Scale were used to stratify them into three groups representing diverse participation preferences: active control where the patient makes decisions; shared control where the patient prefers to make decisions jointly with clinicians; and passive control where the patient prefers clinicians make decisions.ResultsOf the 52 patients observed over 133 ward rounds, 30.8% (n=16) reported an active control preference for participation in decision-making during ward rounds, 25% (n=13) expressed shared control preference and 44.2% (n=23) expressed low control preference. Patients’ participation was observed in 75% (n=85) of ward rounds, but few rounds (18%, n=20) involved patient contribution to decisions about their care. Clinicians prompted patient participation in 54% of rounds; and in 15% patients initiated their own participation. Thematic analysis of qualitative observation and patient interview data revealed two themes, supporting patient capability and clinician-led opportunity, that contributed to patient participation or non-participation in ward rounds.ConclusionsParticipation in ward rounds was similar for patients irrespective of control preference. This study demonstrates the need to better understand clinician roles in supporting strategies that promote patient participation in day-to-day hospital care.

398 Exploring experiences of the in-patient ward round with young people with CF

Objectives: The in-patient ward round, which involves a bedside visit by members of the multidisciplinary team to discuss treatment, progress and discharge plans, is central to the patient experience. However, its impact upon patients is often underestimated [1]. Research suggests that patients can feel anxious or dissatisfied with this vital clinical activity, as echoed by some patients in our Cystic Fibrosis (CF) Service. Our aim was to gain a better understanding of patient perspectives of our in-house ward round with a view to service improvement, if needed.

A ward round proforma improves documentation and communication.

This article present the results of an audit cycle which evaluated the quality of inpatient ward round documentation in a busy district general hospital before and after the implementation of a standardized proforma which was specifically designed for trauma and orthopaedic patients. In each cycle, 20 case notes were examined and the data analysed to examine three main areas: Diagnosis, management and/or discharge plan Objective assessments including neurovascular status, weight-bearing status, surgical wound review, observations, results of investigations and decision from the daily trauma meeting Logistics of the documentation such as legibility, date and time, name and grade of the doctor and contact number. This audit demonstrated that using a ward round proforma can significantly enhance the quality of documentation and improve communication between multidisciplinary team members.

Paediatric trainee supervision: Management changes and perceived education value

Supervision in postgraduate training is an under-researched area. We measured the amount, type and effect of supervision on patient care and perceived education value in a general paediatric service. We designed a structured observation form and questionnaire to document the type, duration and effect of supervision on patient management and perceived education value. Most supervision occurred without the paediatrician confirming the trainee's findings. Direct observation of the trainee was rare. Management was changed in 30% of patients seen on the inpatient ward round and in 42% of the patients discussed during the chart reviews but not seen by the paediatrician. Management was changed in 48% of the cases when the paediatrician saw the patient with the trainee in outpatients but in only 21% of patients when the patient was but not seen. Changes made to patient management, understanding and perceived education value, differed between inpatient and out patient settings. There was more impact when the paediatrician saw the patient with the trainee in outpatients; while for inpatients, the opposite was true. Trainees rated the value of the supervision more highly than their supervisors did. Trainees' comments on what they learnt from their supervisor related almost exclusively to clinical knowledge rather than professional behaviours. We observed little evidence of supervisors directly observing trainees and trainees learning professional behaviours. A review of supervisory practices to promote more effective learning is needed. Communicating to paediatricians the value their trainees place on their input could have a positive effect on their engagement in supervision.

The informationist: a prospective uncontrolled study

To determine whether doctors in an Australian tertiary hospital would use an informationist service, and to identify how the service would influence care. A prospective uncontrolled pilot study July 2002-January 2003. A teaching hospital in South Australia. Fourteen doctors working in the selected units. An informationist attended specified medical in-patient ward rounds and clinical meetings in the Respiratory Medicine, Sleep Disorders, and Rheumatology units. Main outcomes measures. Clinician self-assessed impact of information on a range of outcomes relating to clinical decision-making, clinician education, and avoidance of adverse events. In 23 weeks, 52 questions were generated by nine of 14 eligible doctors. Forty-eight of 52 (92%) feedback forms were completed, indicating an average of 5.7 impacted outcomes per response. Twenty-five of 48 (52%) provided new information to doctors, and 24/48 (50%) provided at least some information that could be used immediately. Most common contributions of the service to patient care were revision of treatment plan (21/48, 44%) and confirmation of proposed therapy (18/48, 38%). Thirteen of 48 (27%) contributed to avoiding adverse events, and 10/48 (21%) contributed to avoiding additional tests and procedures. Eleven of 11 (100%) doctors who used the service assessed that it contributed or probably contributed to their professional development, with 8/10 (80%) indicating a similar impact on improving clinical outcomes. Medical staff will use an informationist service, which contributes substantially to a multiplicity of outcomes relating to medical decision-making, clinician education, and clinical outcomes.

Carers of people with dementia: Their experience of ward rounds

This study examined the experience carers of people with dementia have of inpatient ward rounds in an old age psychiatry service and looked at whether the experience was more stressful for spouses than other carers. Questionnaires were administered over the telephone to 67 carers of dementia sufferers who had attended an inpatient ward round in a district general hospital. The mean time between attendance at a ward round and telephone interview was 29 weeks. Telephone administration of questionnaires resulted in a high response rate and was acceptable to carers. Most carers found that attending the ward round was a positive experience. However, carers needed to know more about the purpose and composition of the ward round in advance. Routine enquiry as to carers' views is important in advance and using telephone questionnaires was a useful way to gather this information.

Attending rounds on in-patient units: differences between medical and non-medical services

The objective of this cross-sectional observational study was to quantify communication patterns between teachers and trainees on in-patient attending ward rounds and assess trainees' perceptions of the effectiveness of teaching interactions. Sixty-nine in-patient ward rounds on medical and non-medical teaching services at a university hospital and its affiliated VA Medical Center were studied. Teaching rounds were observed and audiotaped, and trained raters coded verbal interchange for its location, speaker identity and topic of the exchange. One to three days following the teaching rounds, residents and students were interviewed and completed a questionnaire concerning recollections of the content of the session. Medical rounds lasted a mean of 90 minutes, while non-medical rounds averaged 38 minutes. Medical teams spent more time than non-medical teams on case presentations and discussions of diseases not directly related to patient care. Both groups averaged approximately 10 minutes directly interacting with patients, and equal times were spent speaking by the teacher and trainees. The role of postgraduate year 1 residents and medical students primarily was to recite details of patients' clinical condition. Twenty-nine per cent of trainees were unable to recall a specific teaching point from rounds when interviewed 1-3 days later. Duration and content of in-patient rounds differed on medical and non-medical services. For both, discourse tended to be hierarchical, with those at different training levels adhering to specific roles. Bedside patient interactions were limited. The content recalled by students and house staff suggests that new, more effective educational paradigms are needed.