Post-take Ward Rounds Research Articles

WP1.18 - A Surgical Post-Take Ward Round Checklist Proforma: A Prompt for Improved Documentation

Abstract Aims Surgical ward rounds are often swift, therefore documentation of diagnostic and management decisions is frequently incomplete. The Royal College of Surgeons of Edinburgh (RCSEd) devised a ward round checklist toolkit to improve documentation of surgical post-take ward rounds. Methods We conducted a baseline audit of our district general hospital general surgery post-take ward round documentation, based on the RCSEd checklist. Documentation in each domain was recorded for each ward round entry for both pre and post intervention groups. Control patients were identified from the surgical take list across 7 different days in a month. The checklist toolkit was then adapted into a proforma for our institution and used on post-take ward rounds for a trial period of 7 days. Results 40 patients were included in the pre-intervention group, 17 in the post intervention group. Following the introduction of the post take ward round proforma, documentation of most recent observations improved from 40% to 82%, admission blood results from 27.5% to 94%, and imaging results from 42% to 90%. Areas of existing good practice improved; history and examination findings were documented in 100% of patients, an improvement from 80% pre-intervention. Nil by mouth status was documented in 80% of cases, up from 50%, and IV fluid requirement in 58%, up from 10%. Conclusions A proforma for post take ward rounds improved documentation of key diagnostic and management information. As a result, we recommend a standardised approach to documentation to encourage consistency of recording key information in the patient record.

SP9.4 Improving time to initial consultant review for emergency general surgery admissions at a major trauma centre

Abstract NHS England’s Seven Day Services Clinical Standards and NCEPOD Guidance recommend 100% of emergency admissions to hospital should receive an initial consultant review within 14-hours of hospital admission. An audit of time for initial consultant review for emergency general surgery (EGS) admissions at a Major Trauma Centre revealed only 75% of patients were reviewed by a consultant surgeon within the 14-hour target, with longest time to review 20 hours and 56 minutes. Aim To assess and improve compliance of time to initial consultant review for EGS admissions with the recommended standard by implementing twice daily versus once daily post take ward rounds (PTWR). Standard 100% of EGS admissions should have a consultant review within 14-hours of hospital admission. Methods Retrospective review of admission data and progress notes on the electronic medical record for all patients admitted under EGS from 00:00 Monday 26/9/2022 – 23:59 Friday 30/9/22 (identified from general surgery take list) three weeks post intervention. Data inputted onto a single audit tool and analyzed in Microsoft Excel in comparison to initial audit data (one month prior to intervention). Results Twice daily compared to once daily PTWRs improved compliance with the audit standard by 25%; 100% of patients reviewed within 14-hours. Longest time for initial consultant review decreased by 11hr 04min (20hr 56min to 09hr 52min). Number of patients reviewed in the emergency department by a consultant increased from 25% to 50%. Conclusions 100% of EGS patients can receive an initial consultant review in line with the nationally recommended timeframe with the introduction of twice daily versus once daily PTWRs.

P05 Quality of surgical post take ward round documentation by on-call team

Abstract Introduction Documentation of clinical assessment and care plans is integral to patient safety, continuity of care and has medico legal implications. Methods A retrospective study of the quality of documentation of post take ward rounds (PTWR) by the on-call surgical team was performed. Results Among the key factors reviewed (18 randomly selected emergency admissions), history of presenting complaints, past history and medical history were recorded in 66%, 72% and 44% of the records respectively. National early warning score (NEWS) was recorded in 66% notes and clinical findings in 88% of patients. The key lab and imaging findings were entered in a subset of patients only (27% and 33% respectively). Based on the initial audit, the PTWR quality could be improved with increased compliance of NEWS score entry, medical history, key lab and imaging results. A standardised ward round template was designed and circulated. This was disseminated to the surgical team by email. Posters were displayed in the surgery office. A presentation was made during teaching session for the junior doctors. The re-audit (34 emergency admissions) showed that the quality had improved based improvement noted in all the key parameters. Documentation of presenting history improved from 66% to 100%. Similarly medical history (44% to 85%), vital signs (66% to 79%), key lab results (27% to 55%), and key imaging (33% to 78%), the management plan was documented in all patients (94% to 100%). Conclusion In summary, a standardised PTWR entry ensures better quality and compliance; this should be reiterated during junior doctor change over phase. Take-home message Standardised post take ward round entry ensures quality and better compliance during a busy surgical ward round.

75 Treatment Escalation Plan (TEP) Completion Rates in General Surgery

Abstract Background TEPs ensure every patient has a ceiling of care formally documented, including a DNACPR decision. This pre-empts complications and provides guidance on how to appropriately manage acutely unwell patients. There is no national standard for TEPs. Our aim: to formally document the incidence of TEP completion in general surgery at a local District General Hospital. Method A multi-phase, cross-sectional study of 1. Inpatients on three general surgical wards, 2. TEP completion at post-take after a typical on-call cycle. Results 15.4% of TEPs were completed, of which 75% had a DNARCPR form. For the two post-take ward rounds, 5% and 7.7% of admitted patients had a TEP. Elective surgical/Enhanced recovery patients (ERP) did not have a TEP. Findings were presented locally, and posters placed in the surgical offices. Cycle 2: 19.6% and 10% completion rate for ward and post-take patients, respectively. Conclusions TEPs are rarely completed. Minimal improvement in completion rate was noted at cycle 2. TEPs are more commonly completed for patients not for resuscitation. Future aims include editing the surgical clerking proforma and the elective surgery/ERP paperwork to encourage completion, improving patient care. Currently we are arranging similar audits across other NHS trusts to determine if this is a national problem.

Pharmacist contributions to consultant-led post-take ward rounds: a service evaluation

A study carried out at Imperial College Healthcare NHS Trust shows that pharmacists’ contributions on post-take ward rounds are highly valued, with their interventions leading to a reduction in prescribing errors and potential for harm.

A quality improvement project to improve the documentation of resuscitation and ceiling of care decisions in elderly patients at a large district general hospital

All elderly patients seen on post-take ward rounds should be assessed by the Gold Standards Framework (GSF), with resuscitation status and ceiling of care discussed and documented accordingly in the medical notes and discharge letters. We opportunistically reviewed the medical notes and discharge letters of all patients aged over 75 years immediately prior to discharge. We conducted three cycles of data collection, each lasting 1 week in duration, from November 2017 to January 2018. Data was recorded into an anonymised Excel template. We determined a pre-intervention …

The impact of a pharmacist on post-take ward round prescribing and medication appropriateness

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients’ medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

Prescribing and medication communication on the post-take ward round.

Gaps in communication between medical officers and poor planning are associated with prescribing errors and may result in patient harm. This study describes medication communication on post-take ward rounds (PTWR). Over 6 weeks on 24 PTWR, 130 patients, prescribed 1244 medications, were observed. Of these, 811 (65%) medications were discussed, with 249 discussions (relating to 126 medications) being 'in-depth'. Of 191 planned medication-related actions, 38 (20%) were not implemented by the end of the PTWR and 21 (11%) by time of discharge from hospital. This study suggests that the level of medication communication and subsequent actions are suboptimal. Processes to improve this situation should be explored.

‘The time it takes…’ How doctors spend their time admitting a patient during the acute medical take

Patient safety depends on adequate staffing but the number of doctors required for safe staffing for medical emergencies is not known. We measured the duration of the admission process for patients seen by medical teams in emergency departments (EDs) and acute medical units. History taking and examination by a core medical trainee took 22minutes for a patient referred from the ED and 21minutes for a patient referred from primary care. A complete admission clerking with prescription and ordering of investigations ranged from a mean of 15minutes for a consultant in acute medicine to a mean of 55minutes for a foundation year 1 trainee. The duration of post-take ward rounds also showed significant variability.Our data can be used to model staffing patterns if combined with information about admission numbers and local set up.

PWE-442 Balancing gastroenterology and general internal medicine training in the uk

<h3>Introduction</h3> The majority of UK Gastroenterology trainees undertake dual accreditation with General Internal Medicine (GIM). The aim of this study is to explore trainees’ views on dual accreditation training. <h3>Method</h3> Data was collected from the BSG online survey which was sent to all higher specialist gastroenterology trainees in the UK. The survey was open from July to September 2014. <h3>Results</h3> 263 out of 806 (32.6%) trainees across the UK completed the survey. 36% (95/263) of responders were female and all training grades were well represented. Almost all (97.6%) gastroenterology trainees are dual accrediting in GIM. The majority (81%) feel that GIM training is useful for their future work as a consultant. Trainees spend 20–40% of their time in GIM commitments. Only 37% agree that their GIM training is of a good quality. More than half (62%) of trainees feel GIM training has a negative impact on their gastroenterology training (Figure 1). This impact is commented upon more noticeably with seniority – 60% of junior trainees (ST3-ST5) and 70% of senior trainees (ST6 and above). Only 10.6% of trainees felt that GIM training met their educational competencies due to the role of the medical registrar being more one of service provision, due to less experienced juniors, an increased work load and difficulty in obtaining workplace-based assessments (Figure 2). Another common theme was the lack of opportunity to present patients on post-take ward rounds. 31.2% of trainees would stop their GIM training if given the opportunity. <h3>Conclusion</h3> Whilst the majority of trainees recognise the importance of dual accreditation for future consultant jobs, a large proportion of trainees feel that the quality of their GIM training does not satisfy their training needs and curriculum requirements. In addition, more than half of trainees feel that GIM training has a negative impact on their gastroenterology training and a third would give up GIM if possible. The workload in acute medicine and decreasing experience of junior doctors are clearly topical issues. A way to improve the quality of GIM training could be to encourage consultants to allow time to present patients and complete work-based assessments, either on the post-take ward round or at another agreed time. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Neale JR, Basford PJ; British Society of Gastroenterology Trainees Section. General medical training in gastroenterology: views from specialist trainees on the challenges of dual accreditation. Clin Med. 2015;15(1):35–9

Improving the quality of documentation of paediatric post-take ward rounds: the impact of an acrostic

BackgroundReview of patients’ notes while investigating clinical incidents showed a recurring problem of poor documentation of important aspects of the paediatric post-take ward round.Purpose of the studyTo evaluate the impact...

No substitute for experience: do consultants that have been practising for longer lead faster post-take medical ward rounds?

Aim: To ascertain whether consultants that have been practising for longer lead faster post-take medical ward rounds. Method: Single-centre observational study of nine consultant physicians at morning post-take medical ward rounds at a district general hospital in the North West of London. Results: Data were gathered from 25 post-take medical ward rounds. Multivariate regression analysis revealed that less time is spent per patient when consultants have been practising for longer (p&lt;0.01), or have spent more time on the specialist register (p&lt;0.01), with no discernible relation to the outcomes for the patients seen. This time is further reduced when a greater number of patients are seen on the ward round. Conclusion: More experienced consultant physicians conduct faster post-take medical ward rounds.

Is the post-take ward round standardised?

The importance of the post-take ward round to both patient safety and medical education cannot be overemphasised. Despite this, significant variation exists between consultants and senior doctors in the conduct and content of ward rounds. This discrepancy prompted the idea of using a checklist to audit whether essential components were being consistently addressed during post-take ward rounds. This would allow an exploration of whether introducing a checklist would benefit both patient safety and medical education. The post-take ward round was audited by a small group of medical students over a few months using a checklist. This checklist contained 17 evidence-based items that had been identified as important for patient safety. A number of different consultants were included in the audit. Results of the audit analysis confirmed that there was significant variability between consultants in both the approach and the content of the post-take ward round. Although some areas were completed most of the time, there were other areas in which inconsistent approaches were demonstrated. As such variability was demonstrated between consultants in their conduct of the ward rounds, it was concluded that the introduction of this checklist would provide a standardised approach that junior doctors could learn from. Therefore, the introduction of this checklist into clinical practice was identified as a worthwhile teaching resource for juniors in order to enhance patient safety and foundation doctor learning.

Acute palliative care in the assessment areas

AimTo describe the benefits of early review by the Hospital Palliative Care Team (HPCT) for acutely admitted palliative patients.BackgroundOver an 18 month period, the HPCT at a large University Hospital...

Learning safe prescribing during post-take ward rounds

As the main tool through which doctors treat the medically unwell, prescribing is a practice that is undervalued and under-taught within modern medicine. Paradoxically prescribing not only has the potential to cure, it also has the potential to cause great harm if carried out incorrectly and unsafely. Prescribing errors have remained an issue in patient safety for many years, yet education in safe prescribing at both undergraduate and postgraduate level appears to be lacking. 'Check and Correct' is an innovation developed at Worthing Hospital in West Sussex to educate both medical students and junior doctors on the importance of safe prescribing. As a final-year medical student I used 'Check and Correct' on busy post-take ward rounds for 2 weeks. The aim was to research the main areas where prescribing standards set by the hospital had not been met, whilst improving awareness in safe prescribing for both myself and the post-take team. The process involved checking the drug chart of every patient seen on the post-take round and addressing errors on the chart with the team for correction at the bedside. 'Check and Correct' reaffirms the assertion that further education is required in safe prescribing. The success of the process is highly dependent on the consultant leading the ward round ensuring that errors are vocalised and addressed. If conducted correctly, this exercise can educate doctors and medical students by addressing errors and emphasising the importance of prescribing, whilst ensuring the safety and care of patients.

Ward rounds: missed learning opportunities in diagnostic changes?

The introduction of the European Working Time Directive has resulted in the on-call general surgery junior doctor regularly missing consultant-led post-take ward rounds (PTWRs). This study aimed to determine the frequency with which the admission diagnosis was changed on the PTWR, and thus whether an educational opportunity for trainees is missed. Prospective observational study of consecutive admissions to a general surgery department over a 4-week period was conducted. Patients with exacerbations of known conditions were excluded. Fifty-two included patients were admitted by seven general surgery juniors, and 27 per cent (14/52) of diagnoses were changed on the PTWR. There were two 'major' diagnostic changes: peritonitis and ischaemic bowel. Patients whose diagnoses were changed by the consultant were no more likely to be older (p = 0.575) or have differing white cell counts (p = 0.471), C-reactive proteins (CRPs; p = 0.643) or amylase levels (p = 0.666) than those whose initial diagnosis was agreed with. Thirty-five per cent of patients (18/52) had further investigations ordered at the PTWR. These included nine ultrasound scans, four computed tomography scans, three abdominal or chest X-rays, two flexible sigmoidoscopies and one barium enema. In one case, a serum amylase was ordered. The rate of incorrect diagnoses by on-call surgical juniors is high, and educational feedback to these doctors is important. The PTWR represents a strong educational opportunity that is missed if admitting junior doctors are not present. These results should be taken into account for any specialty that uses junior doctors to admit patients who are then reviewed by a consultant on a PTWR.

Quality and safety at the point of care: how long should a ward round take?

In April 2009 a 'considerative checklist' was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.

Time for change: teaching and learning on busy post-take ward rounds

In the UK, patients admitted to hospital as acute medical emergencies are reviewed by a consultant physician within 12–24 hours of admission. This occurs on a post-take ward round where a problem list is identified, a provisional diagnosis made and a management plan outlined. They have usually

The value of the post-take ward round: are new working patterns compromising junior doctor education?

This prospective observational study assessed the impact of the changes in junior doctors' working hours and waiting-time initiatives on teaching and learning opportunities for junior doctors in acute medicine. An audit cycle of post-take ward rounds including all medical admissions to an urban teaching hospital was conducted. During two seven-day periods in July 2006 and 2008, 317 and 354 patients were admitted respectively. In the two-year interval a number of changes were implemented resulting in a significant increase in patients reviewed by a consultant within 24 hours of admission. Target waiting times were being met but there were many missed learning opportunities for junior staff. Senior doctors continue to perform the majority of post-take reviews in the absence of the doctors who had admitted the patient. Similar patterns are likely to be found in other hospitals attempting to balance training with government targets for waiting times and junior doctors' working hours.

Resource utilisation, length of hospital stay, and pattern of investigation during acute medical hospital admission

Objectives: To describe the patient demographic characteristics and organisational factors that influence length of stay (LOS) among emergency medical admissions. Also, to describe differences in investigation practice among consultant physicians...