Ward rounds – what’s the point?

Opinion piece: Running the NICU ward round

Jess, ST6 Neonatal SPIN Trainee, Severn Deanery

Leadership is a key word that inevitably ends up on every trainee’s development plan as they reach the final years of training.  I had decided that this was an area I was keen to focus on, and agreed with a consultant that they would observe me running a high dependency and special care ward round.  My main worry as I stepped up to the task – would I actually be able to make all those clinical decisions?! The consultants seem to make them with ease, but what happens if I just chose to do the “wrong” thing?

Well, that was my main worry until we were about to begin.  Then the supervising consultant asked a thought provoking question –

“What is the point of a ward round?”

I had never really thought about this before.  I just accepted they were part of life. (Perhaps at a later date I should focus more on my lack of intellectual curiosity…)

We have all been on seemingly terrible ward rounds. Ones that have lasted until mid-afternoon so there is no time to enact any plans. Ones where there have been so many interruptions that the team has lost focus. Oh, and the ones where the whole team has been bleeped away so you are left holding the baby (literally). There are some people who feel that the whole concept of ward round needs an overhaul.1 From a healthcare economics perspective, there are hours of expensive, skilled-labour time being invested into these daily rituals – are they worth it?

The ward round is considered the backbone of hospital medicine. It is so ubiquitous that it is taken for granted by everyone.  Major clinical decisions – often quite complex in nature – are made during this process by senior doctors. It is paramount for patient safety that the most appropriate clinical decisions are made in a timely fashion. On the face of it, that might be all the ward round is for but actually there are many more aspects…

So it turns out ward rounds are important, and complicated! Then came my next question…

“How do I make my ward round successful?”

Considering the sheer amount of medical, nursing and allied health professionals’ time spent ward-rounding, there is a real paucity of evidence on the topic.  The content, process, and decision making are so heterogenous and difficult to measure – how would you even study it? A systematic review of factors influencing ward round quality in adult intensive care showed… 2

I concluded I probably need to start by proactively facilitating allocation of roles in the team, and perhaps have a discussion about the particular focus of the ward round that day.  But how about the other aspects?

Timing seems a huge factor.  In my experience, the longer rounds go on, the more likely it is to suffer from interruptions.  There are competing aspects to timing. On one hand you have the actual length of the round, with associated decision fatigue and physical fatigue of those in attendance.  On the other hand, there is equity of time allocation to each patient.  It is clearly a balance of high quality, safe patient care vs going-as-fast-as-possible.3  Royal College of Physicians guidance for adult physicians on ward round practice is that cognitive fatigue sets in after 120 minutes4 – so aiming for less than 2 hours, or having a break if this isn’t possible, seems sensible. 

Checklists are another factor to consider.  Safety checks have been widely introduced into NICU for the sickest patients, recognising that busy ward rounds are an area of clinical risk.  They are primarily to ensure that there has been comprehensive coverage of all aspects of patient care.  They aim to improve communication, teamwork, and to empower the nurse caring for the baby to fully participate in discussions.  In PICU, checklists have been shown to reduce adverse outcomes.5 Checklists only work if they are fully embraced by senior members of the team.  Then – and only then – would the most junior members feel empowered to speak up and complete the list.  It seems to me that it is more difficult to apply a checklist to the HDU/special care environment, as the most important aspects that require attention seem to vary between patients and the management is generally less acute.  Without a checklist, however, longer term or less acute issues risk being forgotten or drowned in volumes of long-stay patient notes. A team of adult physicians have attempted to tackle this problem.  A “considerative checklist” has been developed for use in adult acute general medicine, which shows that potentially even more heterogenous and complex ward round activities can have some standardisation.  It is named “considerative” because the idea is for areas to be contemplated and discussed, as opposed to a simple tick-box exercise.6

Finally, I am keen to make my ward round a success from the patient and their family’s perspective too. In other words, I am keen to make my round as family-centred as possible. But then I wondered…

“What do families want?”

Qualitative research undertaken after introduction of parent involvement in general paediatric ward rounds has found that parents find being present for their child’s ward round invaluable.7  They reported that the communication about their child’s condition and the plan was their main source of satisfaction, and the use of lay terminology to summarise this was valued.  Parents also felt included as part of the team if they were invited to participate.  They felt their views were valued, and they felt more comfortable voicing their opinions or concerns if explicitly asked to do so.  In addition, simply observing/witnessing the whole team working together to discuss and care for their child was important for the families involved.  Inclusion of the nurse caring for the patient was important, however, in facilitating parental involvement and improving their comfort.  There were some areas of dissatisfaction – feeling rushed and not knowing the times rounds were happening, which has been echoed in other research.8. I learnt that some NICUs have taken the concept of family-centred care further by offering parents the opportunity to “present” their babies on the ward rounds, with reported success.9, 10

So, what happened on my ward round? There were a few interruptions, we ran a little over time and there were multiple deliveries for my team members to attend.  However, I invited several parents to actively participate and we had some interesting educational discussions ranging from antenatal spina bifida surgery to growth optimisation. All in all, not a complete disaster!

Time for a coffee

As I paused over my post-ward round coffee (and cake – I had survived – time for celebration!), I reflected on what I had learnt.  Ward rounds are more complex and involve more skill in combining all their competing demands than I had given them credit for.  In addition to my concern about making safe clinical decisions, I am now focussing on a family-centred approach through which I can aim for holistic care.  

Next, I wonder what the future will bring for ward rounds as my career progresses.  The world is changing in its accessibility and technological advances – but can we become more virtual in our ward rounds without losing the personal touch?  And how much should we rely on technology to make some decisions on our behalf using algorithms rather than clinical acumen?  Somehow I feel that as we have ever increasing information and tools at our disposal to aid decisions, it may require even more refining of our skills to continue to deliver successful rounds in this new era of telemedicine.

References

  1. https://blogs.bmj.com/bmj/2017/08/15/matt-morgan-the-ward-round-is-broken/
  2. Lane, D., Ferri, M., Lemaire, J., MacLaughlin, K., Stelfox, H. A systematic review of evidence-informed practices for patient care rounds in the ICU. Critical Care Medicine. 2013. Volume 41
  3. Herring, R., Desai, R., Caldwell, G. Quality and safety at the point of care: how long should a ward round take? Clinical Medicine. 2011. Volume 11, No. 1: 20-22
  4. Modern Ward Rounds. Good practice for multidisciplinary inpatient review.  Royal College of Physicians and Royal College of Nursing. 2021 https://www.rcplondon.ac.uk/projects/outputs/modern-ward-rounds
  5. Sharma, S., Peters, M., PICU/NICU Risk action group. “Safety by DEFAULT”: introduction and impact of a paediatric ward round checklist. Critical Care. 2013. Volume 17
  6. Herring, R., Caldwell, G., Jackson, S. Implementation of a considerative checklist to improve productivity and team working on medical ward rounds. Clinical Governane: An International Journal. 2011.  Volume 16, No 2, p129-136
  7. Latta, L., Dick, R., Parry, C., Tamura, G. Parental Responses to Involvement in Rounds on a Pediatric Inpatient Unit at a Teaching Hospital: A Qualitative Study. Academic Medicine. 2008. Volume 83, No 3, p292-297
  8. Barrington, J., Polley, C., van Heerden, C., Gray, A. Descriptive study of parents’ perceptions of paediatric ward rounds. Arch Dis Child. 2021
  9. https://www.paediatricfoam.com/2019/07/parent-led-ward-rounds-on-a-neonatal-unit/
  10. https://fabnhsstuff.net/fab-stuff/patient-led-neonatal-ward-round

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