Last Updated: 19/11/2014
Making Ward Rounds Count
Post take ward rounds are where a clinical diagnosis is obtained or revised, a clinical examination is undertaken, decisions about future investigations and treatment options are made, discharge plans are formulated and written and verbal communication is undertaken (Brown N, Webster A. (2004) New medical technologies and society: reordering life. Polity Pr.). Medical ward rounds are complex clinical activities, critical to providing high-quality, safe care for patients in a timely, relevant manner. They provide an opportunity for the multidisciplinary team to come together to review a patient’s condition and develop a coordinated plan of care, while facilitating full engagement of the patient and/or carers in making shared decisions about care. Additionally, ward rounds offer great opportunities for effective communication, information sharing and joint learning through active participation of all members of the multidisciplinary team (Royal College of Physicians and Royal College of Nursing (2012). Ward rounds in medicine: Principles for best practice).
It is clear that delivering safe, high quality care to patients depends on developing and using reliable processes. In 2014, care in hospital is the result of many linked processes, usually delivered by several teams of clinicians, allied health professionals and others. The co-ordination of these multiple inputs/processes is a central function of the clinical ward round. The task may be considered as analogous to a team assembling a very difficult jig-saw puzzle ‘against the clock’. It requires the development of an agreed plan of action (care), which records what is to be done - and by when. Such an approach can help deliver seamless, effective and efficient care in a compassionate manner.
The aim was to audit and review current practice in relation to Post Take Ward Rounds and Prescribing Standards, identifying aspects of good practice and areas for improvement to ensure that patients receive high quality care. The specific objectives within the audit were:
1. To improve team working on ward rounds
2. To improve the standard of care provided to patients and patient safety
3. To ensure drug charts meet minimum safe prescribing standards
Ward rounds are not solely the responsibility of doctors. According to a recent joint publication between the Royal College of Physicians and the Royal College of Nursing, a nurse should be present at every bedside during ward rounds to help improve the quality of ward rounds. Drug errors are among the leading causes of avoidable harm to hospital inpatients (Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M & Wass V. (2011) An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study) as such the administration of drugs should be regarded as a high risk procedure.
Two approaches were taken to capture the required information.
• Firstly an observation audit was undertaken to capture information regarding the standard of care provided to patients and patient safety.
• Secondly in order to ensure that drug charts met safe prescribing standards case note audits were conducted.
The audit showed that all the post-take ward round were initiated by the consultants and not carried out by junior doctors. There was also at least one junior doctor on 34 out of the 35 ward rounds audited, these ranged in grades from Foundation Year 1 doctors to Registrars.
Nurses were also present at the start of the post-take ward round in 77% of the audits.
Completion rate of the VTE Risk assessment were very good, with the overall completion rate of 97%.
Both the Royal College of Physicians and the Royal College of Nursing, state a nurse should be present at every bedside during ward rounds to help improve the quality of ward rounds1. In the audit it was shown that a nurse was present at 172 out of 232 patients bedside during the patient’s consultation. This represents 74%. With a nurse present at the bedside during the consultation, it helps to provide up to date information on the patient and how they have been doing since their admission. It is also a useful opportunity for information to be passed from the consultant to their nursing colleagues about changes required to the patients care.
A key component to planning is the estimated date of discharge for each patient. While it is recognised that this is an estimation and not fixed it is an extremely useful in determining the hospital resources. It is also recognised as good practice and also helps the patient to feel a little more in control during their stay in hospital. The audit showed that the EDD was recorded in 91.81% of patient’s notes.
Some medications require the patient’s weight to calculate the dosage, and while the weight may be recorded in the nursing notes, in an emergency situation there may not always be time to consult these. Recording of the patient’s weight on the medicine kardex was poor. Only 15% of patients had their weight recorded.
All the patients in the audit who were prescribed medication, whether regular or PRN medicines, were written in the recommended BNF format. All PRN drugs had the dose recorded and were appropriate the maximum dose recorded.
According to the Institute of Medicine, patient safety is “indistinguishable from the delivery of quality health care (Aspden P, Corrigan JM, Wolcott J, Erickson SM (2004). Patient safety: achieving a new standard for care. Washington, DC: National Academies Press). As stated at the start of this report medical ward rounds are complex clinical activities, critical to providing high-quality, safe care for patients in a timely, relevant manner.
The audit found care to be delivered to a high standard:
• The medical staff were very thorough in their consultations and in agreeing a management plan for each patient.
• Details of tests and all other information regarding the patient were checked before going to the patient’s bedside.
Some areas of improvement were identified in the audit:
• Not all patients had an identification wristband
• There was not always a nurse present at the patient’s bedside during the consultation.
• Not all patients should have a diagnosis or working diagnosis recorded in the notes following the consultation, the audit found that just over 94% had this recorded.
• Only 91% of patients had their estimated date of discharge recorded in their notes, this is essential when it comes to planning for a patient going home or about the availability of beds within the hospital.
To learn more contact:
Dr Marina Lupari
Assistant Director Nursing Research & Development
078 2781 3911