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Improving Ward-based Patient Care: Prioritizing the Ward Round in Training and Practice

Pucher, Philip H. MD, PhD, MRCS; Aggarwal, Rajesh MBBS, MA, PhD, FRCS, FRCSC, FACS

doi: 10.1097/SLA.0000000000001627
SURGICAL PERSPECTIVES
Free

*Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK

Department of Surgery, Faculty of Medicine, McGill University, Montreal, Canada

Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine, McGill University, Montreal, Canada.

Reprints: Philip H. Pucher, Department of Surgery and Cancer, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, UK. E-mail: p.pucher@imperial.ac.uk.

Funding: No funding was received for this body of work.

Conflicts of interest: Rajesh Aggarwal is a consultant for Applied Medical. All other authors declare no conflicts of interest.

The clinician's visit to the bedside has for centuries represented the foundation of medical care and the primary point of interaction between doctor and patient. Despite the advances of 21st century medicine, the bedside visit continues largely unchanged today in the guise of the hospitalist's daily ward round. In a process which would have been familiar to Hippocrates and his acolytes, the ward round sees clinicians accompanied by a multitude of trainees and allied health professionals serially assess, diagnose, treat, and discuss often dozens of patients in turn, providing both clinical care and medical education. In addition to these myriad tasks, the modern clinician must now also contend with external regulatory and financial pressures, just as clinical care has gradually become ever more complex with a greater diagnostic and therapeutic armament than ever before. Medical knowledge is not enough; to lead an efficient ward round clinicians must be physicians, communicators, managers, and leaders. The Halstedian apprenticeship model in which trainees learn to conduct ward rounds through experience, trial, and error, belies the complexity of the task. The manner in which ward rounds are learned, taught, and performed must change.

For many clinical skills, ranging from breaking bad news to performing laparoscopic surgery, it is understood that a curricular approach of structured deliberate training results in better learning and improved clinical performance. It is therefore perhaps unsurprising that there has been growing interest in addressing the issue of training and assessment for ward rounds, as well. Particularly in surgery, which has traditionally focused on the operative aspects of care, there has been a paradigm shift in how patient care is perceived.

The concept of “failure to rescue” after surgery suggests that wide variations in surgical patient outcomes result overwhelmingly from failures in postoperative care.1,2 First described by Silber in 1992, failure to rescue is defined by the death of a patient from complications rather than from the primary diagnosis.3 Though initially restricted to postoperative complications in a surgical cohort, this concept has since been expanded to include medical patients also. Within surgery, a growing body of literature now suggests that failure to rescue is responsible for a significant large proportion of variability seen in patient outcomes, with postoperative care now increasingly the focus of efforts to improve outcomes.

This need to improve ward-based care, and specifically to improve ward rounds, is reflected in part by dedicated modules included in the American College of Surgeons’ most recent trainee curriculum. In the United Kingdom, the Royal College of Physicians and the Royal College of Nursing have issued a joint guidance document calling specifically for a renewed focus on ward rounds.4

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TRAINING AND ASSESSMENT

If ward round performance is to be improved, it must first be measureable. Whereas historically educators have lacked the means to do so, a growing body of evidence in this area now provides a variety of tools with which to objectively assess, and improve, ward round practice through objective and reliable means.

In seeking to quantify ward round quality, the design path of individual ward round assessment tools has been remarkably convergent. All studies to date have measured performance based on a “thoroughness of assessment” model, combined with an assessment of nontechnical skill.5 The completion, or omission, of tasks such as checking vital signs and prescription charts, physical examination of the patient, and articulation and documentation of a treatment plan, forms the basis for varied scoring frameworks, which may be used to assess clinicians’ ward round performance in conjunction with a rating of nontechnical skill or teamwork. Performance in this manner has also been linked to improved outcomes in at least one study,6 with improved ward round performance associated with a reduction in preventable postoperative complications.

Whereas numerous assessment tools, with varying levels of validity evidence, for ward rounds, are now available, interventions to improve practice remain at a more nascent stage. Simulation-based approaches have shown some promise in this role, as have already been successfully adopted in other areas of clinical training. Alternately, rather than formalized educational interventions or curricula, some have advocated the implementation of checklists to improve care quality.7 However, with the potential of such interventions to become “box-ticking” exercises lacking the flexibility needed in the care of differing patients and diagnoses, their efficacy remains less clear.

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MODERNIZING THE WARD ROUND

Though modern technologies and practices have moved beyond the historic origins of the bedside visit, this has not necessarily been reflected in current practice. In addition to improved training and assessment, organizational and technological modifications to the ward round may serve as synergistic adjuncts to improving care as well.

In the United Kingdom, clinician pay packages account for defined time blocks (programmed activities) for all clinical activity, including ward rounds. In surgical specialties, it is not unusual for this to be limited to the equivalent of half an hour a day or less. Beyond the detection and treatment of pathology, such time pressures also endanger the human element of the ward round. In the modern clinician's world of ever-competing priorities, too often, the compassion and empathy that embody the foundation of the doctor–patient relationship can be placed at risk. If the conduct of rounds is to be recognized as an area of priority, then top-down reorganization may be required to redesign both work patterns and remuneration.

Whereas patients were once the passive subjects of the round, they are increasingly now active participants in deciding the course of care. Direct involvement of patients and next-of-kin in care decisions is increasingly seen as vital to good practice. In a recent trial, medical ward rounds were conducted in both a standard fashion (patient and clinical staff only), and with family members invited to be present.8 Follow-up surveys of staff, patients, and family indicated an overwhelming preference for the latter format, despite concerns regarding potential limitations such as the increased time required for each round.

In modernizing practice, there is a need to balance greater transparency and communication with pre-existing clinical commitments and limited staff availability. Greater integration of modern technologies into routine practice may provide means for faster, more efficient communication between staff and patients alike. With intuitive software design and an increasingly tech-literate population, it is conceivable that patients in near future might link directly into their medical notes on the ward not only to understand, but also actively contribute to care decisions. Electronic communication tools integrated into routine care might in this manner provide information on progress, diagnosis, and treatment to patients (and relatives) just as they feed back “real time” information on symptoms and concerns to the clinical team.

Ongoing projects such as the OpenNotes trial, which has recruited some 25,000 patients who will be able to view their medical notes live via an online portal and seeks to assess impact on patient perceptions and outcomes, further exemplify the growing transparency of clinical practice which is likely to become the future norm.9 Though seemingly daunting, if patients are thus empowered to be more involved in their own recovery, and less inhibited in raising concerns, then this can only be of benefit.

Further study on the assessment of rounds, and the means to improve them, is undoubtedly required. Though improvements in ward round quality, whether through educational curricula or otherwise, must ultimately be assessed for impact on clinical outcomes to be truly meaningful, the need to drive improvement and reduce failure to rescue rates is clear.

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REFERENCES

1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361:1368–1375.
2. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011; 49:1076–1081.
3. Silber JH, Williams SV, Krakauer H, et al. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30:615–629.
4. Royal College of Physicians, Royal College of Nursing. Ward rounds in medicine: principles for best practice. London, UK: Royal College of Physicians; 2012.
5. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg 2014; 259:215–221.
6. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259:222–226.
7. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care 2003; 18:71–75.
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9. Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med 2010; 153:121–125.
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