Morning Ward Round Research Articles

Team situation awareness and the anticipation of patient progress during ICU rounds

BackgroundThe ability of medical teams to develop and maintain team situation awareness (team SA) is crucial for patient safety. Limited research has investigated team SA within clinical environments. This study...

PICU pharmacist interventions: what can they tell us?

ObjectiveThe Pharmacy Paediatric Intensive Care (PICU) team record interventions that affect a patient's episode on PICU. These interventions are not always reported via the hospital's incident reporting route. The aim...

Wastage factor of intravenous infusions in a regional intensive care unit

Abstract The use and wastage of infusions of propofol and atracurium were studied over an eight-week period in an intensive care unit. Four sources of wastage were apparent, three of which were avoidable. Cessation of therapy, often as a result of decisions made by medical staff on morning ward rounds, was the most important source of wastage (75.7 and 74.6 per cent of wastage of propofol and atracurium, respectively). Advance preparation of syringes was another source, particularly for atracurium, and intermittent short infusions accounted for 8.5 per cent of wastage of propofol. Alterations in unit practice for administration of propofol and atracurium could lead to financial savings (approximately 1.5 per cent of the annual expenditure on drugs by this unit) and greater financial savings would be expected if wastage reduction policies were applied to all infusions.

Arbeitszeitkonformes Visitenmodell und Patientenzufriedenheit

The introduction in 2006 of the European legislation restricting physicians work-ing hours has had a dramatic impact on working conditions. This restriction called for a marked improvement in hospital workflow, leading to a reduction of time spent on ward rounds. We conducted an opinion survey assessing patient satisfaction in the area of markedly reduced ward rounds. By January 2009, the time-frame allowed for morning ward rounds had been reduced by 33 % from 45 to 30 min. At the same time, the attendance of the senior staff surgeon was declared mandatory on each ward round. We conducted a prospective study, assessing patient satisfaction over a period of 3 months. 86 patients with an average age of 56.7 years were repeatedly questioned by a single investigator. Average length of hospital stay was 7.2 days. Patients expected ward rounds to average 5.3 min, which was significantly higher than actually observed. However, an overall patient satisfaction of above 80 % could be measured. In spite of the reduced time spent on ward rounds, a high level of overall patient satisfaction can be obtained due to the regular attendance of a senior staff surgeon. Process management is furthermore endorsed by the routine -application of clinical pathways in patient management.

Anatomy of the ward round: the time spent in different activities

The ward round, central to inpatient care, has not been well studied. One recent trend is for hospitals to run at capacity by placing 'overflow' patients into 'outlying' beds. Bed occupancy rates are increased and ward rounds may require visits to many wards. The present study aims to identify the time spent in different activities on general surgical ward rounds, with particular reference to the impact of outlying patients. For 4 days, the morning ward round was observed. Activity was timed to the second. The resulting data were analysed to compare outlying wards, acute wards and home ward patients. Seven hours and 7 min of ward rounds were documented. One hundred ten consultations were observed. Four hours and 4 min were spent at the bedside (58%). Sixty-six minutes were spent in transit between wards. The average times spent at the bedside and in patient discussion were similar for the different ward types. The mean average time per patient was nearly doubled for outlying patients compared with home wards (5:40 min versus 2:57 min, respectively). Although patient discussion and consultation were longer for outlying patients, most of the increased time was related to time travelling between wards (2:16 min average per patient consultation). Most of the time spent on surgical ward rounds is in patient contact. Travel time to outlying patients for morning ward rounds is more than an hour per week.

Andrew Philip Thomas

When first appointed to the Royal Wolverhampton Hospital as a consultant in 1990, Andrew Philip Thomas made it clear from the outset that he intended to deliver the highest quality...

Lung sounds online

“Can you auscultate this man’s lung?” A doctor points at you in the early morning ward round. What if this happens to you in your first clinical year? As you put your new stethoscope diaphragm to your patient’s chest, you might struggle to differentiate vesicular from bronchial breathing, stridor, wheezing, pleural friction rub, or crackles. It is hard to appreciate the variation in breathing sounds especially when you have never heard them clearly …

Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography

In this article, we outline a study method with which structural changes to clinical communication were achieved within a local intensive care unit (ICU). The study method involved in-depth, round-the-clock observation, interviewing, and video filming of how intensivists conducted their practices, as well as showing selected footage to the clinicians for feedback. This feedback component iteratively engaged clinicians in problem-solving their own communication difficulties. The article focuses on one such feedback meeting and describes changes to the morning ward round and planning meeting that this feedback process catalyzed: greater time efficiency, a greater presence of intensivists in the ICU, more satisfied nursing staff, and a handover sheet to improve the structure of clinical information exchanges. We argue that in embodying not a descriptive but an interventionist approach to health service provision, this video-ethnographic method has great significance for enhancing clinicians' and researchers' understanding of the rising complexity of in-hospital practices, and for enabling them to intervene in these practices.

Electronic patient record use during ward rounds: a qualitative study of interaction between medical staff

IntroductionElectronic patient records are becoming more common in critical care. As their design and implementation are optimized for single users rather than for groups, we aimed to understand the differences in interaction between members of a multidisciplinary team during ward rounds using an electronic, as opposed to paper, patient medical record.MethodsA qualitative study of morning ward rounds of an intensive care unit that triangulates data from video-based interaction analysis, observation, and interviews.ResultsOur analysis demonstrates several difficulties the ward round team faced when interacting with each other using the electronic record compared with the paper one. The physical setup of the technology may impede the consultant's ability to lead the ward round and may prevent other clinical staff from contributing to discussions.ConclusionsWe discuss technical and social solutions for minimizing the impact of introducing an electronic patient record, emphasizing the need to balance both. We note that awareness of the effects of technology can enable ward-round teams to adapt their formations and information sources to facilitate multidisciplinary communication during the ward round.

Orthopedic fast track: An efficient patient-care service

Study objectives: Previously, patients who presented to our emergency department (ED) with minor hand injuries requiring specialist operative care were all admitted to the wards. They waited an average of 10 hours 14 minutes before surgery. Postoperatively, they returned to the wards and waited for the next morning's ward round, after which most of them were discharged. They spent an average of 26 hours 22 minutes in hospital. We analyzed our traditional ED workflow, streamlined our processes, and aimed to provide a more efficient service to our patients. We attempt to get patients with minor hand injuries requiring specialist intervention to surgery and eventually discharged in the shortest possible time. Methods: We collaborated with the orthopedic and anesthesiology departments and identified a group of patients who could be fast-tracked directly to the operating room instead of being admitted to the wards. Criteria for fast track were fingertip injuries, cut flexor tendons, cut digital nerves, single-digit fractures, and cut extensor tendon of the hands. Postoperatively, most of these patients were discharged directly from the recovery room. Results: Thirty-three patients were fast tracked. The average time taken to reach the operating room was 3 hours 47 minutes. Of the 21 patients who were discharged on the same postoperative day, the average length of hospital stay was 6 hours 3 minutes. The door-to-surgery time was reduced by 63.0%, whereas door-to-discharge time was cut down by 77.1%. In addition, the average patient bill size was halved. Conclusion: Close cooperation between the ED and inpatient disciplines can improve services and increase efficiency dramatically, which will benefit patients and the institution. Such fast tracking may be extended to other minor surgical conditions. It challenges traditional, often inefficient, ED processes.

Ambulatory rounds: a venue for evidence-based medicine.

The format of inpatient morning reports and ward rounds is infrequently applied in ambulatory medical education. Published reports, however, suggest that this format provides for learner-centered, case-based discussions rather than topic-based lectures in the ambulatory setting.(1) We developed an ambulatory morning report with the specific objective of enhancing evidence-based medical inquiry among our pediatrics housestaff. We developed a pediatric encounter form (PEF) by adapting and modifying an instrument described by Paccione et al.(2) The PEF was to be used by residents to document pertinent information and unanswered questions about patients seen during each ambulatory clinic session. Prompts were provided for documenting the patient's primary complaints, the patient's disposition, and questions that the resident needed answered. The PEF was piloted among a group of residents and faculty. The final version incorporated both resident and faculty input. Each resident was asked to complete a PEF for a maximum of two patients per clinic session. We did not direct residents as to what types of questions to formulate. All completed forms were maintained in a central folder. Next, we instituted a one-hour "Ambulatory Rounds" seminar once a week at lunch-time. During these seminars, faculty selected PEF cases from the previous week for discussion. Residents presented the cases and discussed the reasons behind the formulation of their questions. Faculty facilitated and guided residents toward resources for answering their questions. Faculty also helped residents to reformulate their questions to reflect an evidence-based medicine approach. At the end of each seminar, residents elected to research specific questions and present brief reports at the next seminar. To test the hypothesis that residents will formulate a higher proportion of evidence-based medicine (EBM) questions over time, we collected and analyzed 445 questions asked by 12 residents between July 2000 and August 2001. We categorized questions into EBM and non-EBM questions based on faculty assessment. We performed a trend analysis using chi-square to compare questions from July 2000 (as reference value) with the six-month periods of August 2000 to January 2001 and February to August 2001. By the end of the observation period, the proportion of EBM questions had significantly increased from 13% in July 2000 to 28% in the first six-month period and 59% in the second six-month period (p < 0.001). We describe a new application of outpatient morning reports. This format has been very well received. Housestaff gave the ambulatory rounds an average rating of 4.3 (out of 5) on a Likert scale. Our experience suggests that this format not only provides a forum for case-based learning but can be successfully used to enhance the principles of evidence-based medicine among residents.

Problems with solutions: drowning in the brine of an inadequate knowledge base

Background & aims: We undertook a telephone questionnaire to determine current fluid prescribing practices and relevant knowledge among surgical preregistration house officers (PRHOs) and senior house officers (SHOs) working in 25 British hospitals.Methods: One hundred PRHOs were surveyed within 10 days of starting their first job (Group A). Fifty other PRHOs were surveyed 6–8 weeks after starting their first job(Group B) along with 50 surgical SHOs (Group C). Outcome measures included responsibility for prescribing, knowledge of the composition of common intravenous fluids and the principles governing their use.Results: PRHOs were responsible for prescribing in 89% of instances. Only 56% of respondents stated that fluid balance charts were checked on morning ward rounds. Less than half were aware of the sodium content of 0.9% saline or the daily sodium requirement. Although potassium supplements were usually correct, 25% of respondents prescribed two or more litres of 0.9% saline per day, which is far in excess of normal requirements. Although SHOs were more confident (P<0.0001), there was no significant difference between the three groups for most responses.Conclusions: Inadequate knowledge and suboptimal prescribing of fluid and electrolytes is common. Undergraduate and postgraduate training in this basic patient management skill needs improvement, with particular emphasis on the practical aspects.

System ergonomic analysis of the morning ward round in an intensive care unit.

Our objective was to find out what is discussed during a bedside morning ward round (MWR), whether there are any weak points, and if a standard work process structure can be recommended. An intensive care unit (ICU) consultant recorded in a predefined form the topics that were discussed in 225 bedside discussions. The median length of discussions was 5 min. In more than 60% of the discussions, items were considered related to the respiratory, neurological, and cardiovascular systems, as well as to surgical and nursing problems. Specific variables relating to organ system conditions were seldom used (e.g., inspired O2 concentration, 35%; temperature, 28%; ventilation mode, 25%). We recorded two interruptions per MWR; only 17% of them were related to urgent decisions. Information that could not be found in the patient's file usually concerned microbiology findings (10%) or surgical procedures (6%). We recommend the following structure: (1) Addressing the patient by saying "hello"; (2) presentation of information related to case history, acute status (findings and strategy) (including the function of the main organ systems), infection status, and nursing problems; (3) patient-related discussion; and (4) discussion of general treatment rules, triggered by individual patient condition.

Working cultures matter in care

Some weeks ago my wife gave birth to twins at 25 weeks' gestation. Tragically one of the boys was stillborn, while the other is soldiering on bravely in the special care baby unit at our local hospital. Throughout these traumatic proceedings the hospital staff have been superb - from accompanying us through that first awful night in a room especially designed for grieving parents of stillborn children through to their current daily dealings with us when we visit the unit for the morning ward round and the nappy change and mouth care in the afternoon or evening. But we encountered a different culture when, after four weeks, our baby was transferred for a week to the larger, regional unit for an operation to close his patent ductus arteriosus. I work in industry, which has seen the publication of many dull volumes about corporate culture. I have always been sceptical about dissecting a concept as nebulous as this, and it has taken my current, unsought exposure to hospital life to bring home the reality of how much working culture can matter. Please do not misinterpret this as any criticism of the standard of care in the larger unit. The professionalism …

The medicine of misery: A personal account

We spent part of this morning's ward round making a priority list; which of the five patients in need of admission was most acute, which could wait. There are two elderly ladies, both living alone, both very depressed. Edith is no longer taking care of herself, picking at her skin to the point where nasty sores have formed, and pulling her eyebrows out in her distress. Jonathan should have been admitted last week, we delayed and he took an overdose of Ativan. Alan is an elderly man who gets recurrent depressions. They seem to resolve of their own accord without medication if only he can be admitted for two or three days. Eleanor is a young mother of 28 who has been depressed for three months. Now she is completely preoccupied with ideas of killing both herself and her children.