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| RESIDENTS CORNER |
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| Year : 2020 | Volume
: 13
| Issue : 1 | Page : 79-81 |
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How to conduct medical ward rounds
Vishnu Sharma Moleyar1, Anupama Noojibail2
1 Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore, Karnataka, India
2 Department of Physiology, Manipal Academy of Higher Education, Kasturba Medical College, Manipal, Karnataka, India
| Date of Submission | 22-Feb-2019 |
| Date of Decision | 03-Sep-2019 |
| Date of Acceptance | 03-Sep-2019 |
| Date of Web Publication | 16-Dec-2019 |
Correspondence Address:
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.mjdrdypu_65_19
How to cite this article:
Moleyar VS, Noojibail A. How to conduct medical ward rounds. Med J DY Patil Vidyapeeth 2020;13:79-81 |
Medical ward round is a complex clinical process during which the clinical care of hospital inpatient is reviewed.[1] Ward round is the key for coordinating inpatient care in any health-care setup. Ward round is conducted by a multidisciplinary team consisting of doctors, nurses, pharmacists, and allied health professionals. Ward round is an opportunity to inform and involve patients in health-care delivery. It also provides a joint learning opportunity for the health-care staff involved in patient care. It should be done daily preferably in the morning so that proper planning and execution of the plan can be carried out.
| Purpose of Ward Round | |  |
The main purpose of ward round is to establish, refine, or change the clinical diagnosis and execute proper inpatient management. During ward round, decisions about further investigations and options for treatment, including do not attempt resuscitation and any ceilings of care, are made.[2] Once the patient is stable, the arrangement for discharge is made during the ward round. Communicating all of the above with the multidisciplinary team, patient, relatives, and carers are also made during the ward round. Active safety checking is done during ward round to mitigate any avoidable harm to the patient.[3] An effective ward round is useful in the training of health-care professionals.[4] An effective ward round should enable all individuals involved in the health-care delivery process to express a shared aspiration to make the patient the center of attention empowered in his or her own care. This will help the patient to cooperate and develop confidence in health-care delivery system. Ward round should ensure the delivery of good quality, safe, efficient, and compassionate patient care. A successful ward round should enhance the patient's confidence in health-care delivery system. Ward round is the key for proper inpatient management, to facilitate speedy discharge, to avoid any harm to the patient during health-care delivery, and to improve team communication among the health-care delivery staff.[4]
| Preparation for Ward Round | | |
The steps involved in the preparation of ward round are bed allocation and preround and preparing and briefing the patient about the ward round.[5]
| Bed Allocation and Preround | | |
Preround should be done by the trainees or junior doctors.[5] Bed allocation should be done for trainees by the team leader who is the senior-most among the consultants. Trainees are interns and/or resident doctors. Trainees should see allotted patients in detail. Symptoms, physical findings, reports of investigations, and plan for further management of the patient should be assessed and noted in preround. The trainee should collect information regarding current problems of the patient, medications which are being received by the patient, response to treatment, any new-onset of symptoms/signs, any complications of the disease, and/or treatment. Information should be collected from the patient and/or family members and nurses. Trainees should note down all these information and should present them to the team leader during the ward round.[5],[6]
| Conducting the Ward Round | | |
Consultant should lead the ward round. At the bedside, the consultant should introduce the patient to the team. He should ensure that the patient's dignity is respected. He should review all information about the patient and update the patient and the team. He should review the drug chart. Using the “situation, background, assessment, recommendation” (SBAR) structure, the team should discuss the clinical scenario.[4]
SBAR was originally developed and used during submarine duty handoff by the US Navy. SBAR communication technique is as follows: Situation: What is the situation; why are you calling the physician? Background: What is the background information? Assessment: What is your assessment of the problem? Recommendation: How the problem should be corrected? In the health-care setting, SBAR protocol was first introduced at Kaiser Permanente in 2003 as a framework for structuring conversations between doctors and nurses about situations requiring immediate attention. SBAR was originally implemented in health-care settings with the intent of improving nurse–physician communication in acute care situations. SABR has also been shown to increase communication satisfaction among health-care providers as well as their perceptions so that communication is more precise.
| Example of Situation, Background, Assessment, Recommendation | | |
A 68-year-old male Mr. AM is admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD) into the ward. On admission from the emergency room, nasal oxygen 2 L/min was advised. After 1 h in the ward, the patient is found to be progressively drowsy with labored breathing. The ordering physician needs to be called to review the patient condition and clarify regarding oxygen administration.
- Situation: Dr. R, this is staff nurse from the ward. I have an order to administer 2 L oxygen to Mr. AM who was admitted 1 h ago. I would like to update you on his condition and clarify the order
- Background: Mr. AM was admitted with exacerbation of COPD. Nasal oxygen 2 L/min was advised on admission
- Assessment: Now, in the ward 1 h after admission Mr. AM is found to be progressively drowsy with labored breathing
- Recommendation: I think we need to shift him to intensive care unit and get immediate arterial blood gas (ABG) analysis and depending on the report of ABG we need to plan for noninvasive ventilation or invasive mechanical ventilation. I will be there in another 5 min to assess the patient.
Using safety checklists, the team members should review the clinical status and care according to their assigned tasks.[5] Ward round team should utilize locally adapted checklists as per the condition of the patient to reduce omissions, improve patient safety, and strengthen multidisciplinary communication. Drug charts must be reviewed by the consultant for each patient during the ward round. At the end, after discussion, the consultant should summarize the daily plan for the patient. During the ward round, an educational point may be highlighted. Consultant should use every opportunity to discuss and teach the team members. Consultant can ask questions to the team members and discuss the case. Team members should actively participate in discussion and should come out with ideas and suggestions regarding the management of the patient. Consultant should identify deficiencies if any in the delivery of health-care service to the patient and suggest how to rectify these.
| Duties of Nurse | | |
Senior nurse should update on the current status of the patient and perform safety checks. She has to assist the patients in communicating their needs and should coordinate inpatient care. Nurse should provide updates on vital signs, pain control, nutrition and hydration, elimination (urine and bowels), mobility of the patient, any confusion or delirium or behavioral problem in the patient.[7]
Duties of the nurse during ward round include quality and safety checks, checking urinary catheter, review of intravenous lines and venous thromboembolism prophylaxis, check and categorize pressure ulcers and check for vulnerability for falls/injury, check for infection control measures, and medication administration.[7]
| Role of Patient and Carers | | |
They should provide updates on current symptoms, problems, and concerns regarding the patient.[7] Patient and caregivers should co-operate with health-care professionals by giving proper detailed information regarding their present as well as past health problems. They should provide previous medical documents. Hiding vital information or neglecting or not reporting symptoms or adverse events may lead to errors in patient care and adverse outcome. They should discuss and try to understand and take responsibility for their health on discharge. They should follow the instructions from health-care providers properly.
| Summary by the Consultant | | |
At the end of the ward round, consultant should summarize the team inputs into the plan for the day and set daily goals.[5] He should clearly mention about further evaluation and treatment plan. If the patient is stable, discharge planning should be done. Anticipated discharge needs, place of discharge (e.g., to home or rehabilitation center), discharge date and time, follow-up arrangements should be planned. Consultant should provide the patient information relating to the plan of care and should check patient understanding.
| Recommendations for Protecting Confidentiality and Dignity of Patient | | |
Bedside curtains must be fully drawn before any physical examination of the patient during ward round. The patient should be appropriately exposed only for the duration of physical examination. Hospital authorities should ensure that clinical teams have appropriate facilities to ensure patient confidentiality.[5] Patient's records should be kept centrally to promote effective communication and team working. All key decisions and actions made on the ward round should be clearly documented in the inpatient record.
| Discharge Planning | | |
Patients and carers should be involved in discharge planning. A structured approach to discharge is essential (e.g., a predischarge board round). Medications and outstanding issues should be carefully reviewed using a checklist method. Hospital teams should ensure clear verbal and written communication of the discharge plan.[8] Postdischarge follow-up arrangements should be clearly communicated to the patient.
Explicit delineation of roles and responsibilities of patient care after discharge should be documented.[9] Caregiver should be identified and educated regarding postdischarge patient care. Patient and caregiver should be educated throughout the hospitalization, not only at the time of discharge. Properly structured information should be given to the patient and caregiver from the hospital team.[10]
Every discharge must have a written discharge plan which should be comprehensive and should address medications, therapies, dietary and other lifestyle modifications, follow-up care, patient education, and instructions about what the patient and caregivers should do if the condition worsens. This comprehensive discharge plan should be handed over to the patient with a detailed explanation before the patient leaves the hospital. Patients who are at high risk of rehospitalization should have the discharge plan reinforced by contact from the hospital team after discharge. All information about the admission and discharge and hospital course of events must be organized and delivered to the primary care physician within 24 h of discharge. All patients should preferably have access to their discharge information in their language and at their educational level.
| Following Ward Round | | |
The consultant should ensure tasks regarding further management of the patient are allocated to particular team members.[4] Providing written summaries of discussion may be helpful for patients (e.g., discharge planning, new diagnoses). Patient/carers may book a time with the consultant for in-depth discussion if needed. An evening board round can follow-up to discuss the issues arising from the ward round.
| References | | |
| 1. | Herring R, Desai T, Caldwell G. Quality and safety at the point of care: How long should a ward round take? Clin Med (Lond) 2011;11:20-2.  |
| 2. | Royal College of Physicians. National Early Warning Score: Standardising the Assessment of Acute-Illness Severity in the NHS. Report of a Working Party. London: Royal College of Physicians; 2012. |
| 3. | |
| 4. | O'Mahony S, Mazur E, Charney P, Wang Y, Fine J. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med 2007;22:1073-9. |
| 5. | Soong J, Bravis V, Smith D, LeBall K, Levy J. Improving Ward Round Processes: A Pilot Medical Checklist Improves Performance. Paris: International Forum on Quality and Safety in Healthcare; 2012. |
| 6. | Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care – A narrative review. Saf Health 2018;4:4-7. |
| 7. | Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ 2004;329:1017. |
| 8. | |
| 9. | Anthony D, Chetty VK, Kartha A, McKenna K, DePaoli MR, Jack B. Re-engineering the hospital discharge: An example of a multifaceted process evaluation. Advances in Patient Safety: Concepts and Methodology. Vol. 2. Rockville (MD): Agency for Healthcare Research and Quality (US); Advances in Patient Safety; 2005. 379-94. |
| 10. | Department of Health. Ready to Go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care. London: Department of Health; 2010. |
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