How to structure your ward round for maximum efficiency

In our latest blog, “The things all Doctors need to know about Ward Rounds”, we discussed the role of the ward round in the daily job of the junior doctor with potential issues and suggested solutions by applying medical leadership skills. Trainees might experience ward rounds as service orientated with little time for teaching. However, they are important in developing skills in patient management, requesting appropriate and timely investigations and skilful physical examinations. The quality of teaching and learning is of course impacted by high volumes of workload [4]. The focus in this article is on how a deviation from the traditional ward round structure might benefit the learning opportunities for junior doctors. 

We will cover:

  • The common issues encountered during ward rounds
  • 7 suggestions on how to structure your ward round

Trainees might experience ward rounds as service orientated with little time for teaching. However, they are important in developing skills in patient management, requesting appropriate and timely investigations and physical examinations. The quality of teaching and learning is of course impacted by high volumes of workload [4]. 

The Faculty of Medical Leadership and Management (FMLM) conducted a survey in 2017, consisting of 400 respondents which highlighted that 71% of junior doctors had experienced situations which required them to possess leadership and management skills within their working day [3]. This demonstrates the prevalence of these skills and the importance of their applicability within the daily work of a junior doctor. Their ongoing development and daily practice is essential. Trainee doctors might feel their job mainly is about service provision and may feel undervalued and unsupported. However, their job on the ward is important as their input has a large impact on the patient’s day to day management. There are many learning opportunities, which can be highlighted by changing the structure of how ward rounds are carried out. 

Ward rounds are often undervalued, considering that they represent the patient and medical team interface it is the opportunity for us to excel in our management plans in order to move the patient’s care forward. However ordinary ward rounds might be regarded, they involve highly complex decision making and require the utilisation of extremely skilful communication skills. Nonetheless, there are certain issues that are frequently experienced which impact the efficiency of the ward rounds with the potential to influence patient safety. 

Common issues encountered during ward rounds

Medical team

  • Interruptions by the bleep/pager influencing the clinical examinations and decision making.
  • Registrars being asked to leave the ward round if they are on -call to focus on other acute medical/ surgical duties.
  • Consultants running late due to delays in clinic or in theatres and thereby starting the ward rounds late in the afternoon which will impact the time that is left for junior doctors to carry out post round jobs.
  • Charge nurse and nurse at bedside not present to inform the medical team of issues that occurred overnight.
  • Patients on outlier wards will usually be seen last on the ward round. 

Patient notes

  • Illegible handwriting in patient notes, loose documents in the patient’s folder in need of filing.
  • Not sufficient number of computers, which at times require re-booting several times. This is time consuming and uses valuable time where patients could have been seen by the medical team. 
  • Patient information being presented on different software, such as; blood results, radiology investigations, ECHO’s and clinic letter notes. It can be a slow process to collate all the necessary information during the ward round. 
  • Different medical team members often require access to patient notes at the same time. This can be challenging due to a lack of electronic records.
  • No access to GPs records with important information such as co-morbidities and medication list, junior doctors are usually asked to chase this up.
  • The full medical team may not be present during the ward round leading to repeat conversations.
  • Finding out if a test has been requested, by calling the laboratory.

A ward round that is structured and well conducted will result in a reduction in delirium and falls, reduce the incidents of DVTs/PEs, have fewer hospital acquired infections, prevention of pressure sores, fewer readmissions and have more timely discharges [5]. 

Suggestions on how to structure your ward round 

1 – Shared mental model from all team members; doctors, nurses, pharmacists, physiotherapists, occupational therapists, dietitians, social care workers, patients and relatives. Gain their understanding of the patient’s medical problems and planned actions [5].

2 – Doctors from any grade/seniority can present the history of presenting complaint, medical history, medications, completed investigations, differential diagnoses and NEWS. The tasks should be varied. 

3 – Before the ward round takes place, discuss how it is going to be conducted and what the expected outcome is. 

4 – Before seeing the patients, go through:

  • Number of days on the ward, reason for admission
  • Past medical history including list of medications on admission
  • Working diagnoses and management plans during this admission
  • List of current medical issues
  • Blood results
  • Radiology investigations
  • Outstanding investigations, reviews by other specialties
  • Opinion from dietitians, therapists, social care workers

5 – Allow the junior doctor to lead the ward round, carry out a debrief at the end with structured feedback. This will not only present a great learning opportunity and boost in confidence, but also helps with motivation and job satisfaction by feeling like a valued member of the team as opposed to only scribing on the rounds. 

6 – During the ward round have a checklist where the following points are reviewed and discussed:

  • NEWS
  • Analgesia
  • Number of days on antibiotics with the indication
  • Diet and food diary with bowel function
  • Pressure areas and mobilisation plan from physio- and occupational therapists
  • VTE prophylaxis
  • Estimated time of discharge
  • Engaging the patient in the working diagnoses and decision making 

7 – At the end of the ward round, discuss the plan for each patient and divide up the workload and tasks [2].

Medicine is Brilliant, and one way to keep it this way is to make sure the next generation are equipped to lead.”

Professor Jane Dacre PRCP, Former President of the Royal College of Physicians

By getting involved in leadership trainees can improve the way they feel about their working environment [3]. It is proven that effective clinical leadership results in better patient outcomes. However, leadership development for junior doctors are not as developed as other areas in their training. As a junior doctor you will spend most of your time on the ward, communicating with the allied healthcare professionals and function as liaison between the MDT, consultants and relatives. Junior doctors therefore have a crucial role in detecting issues due to the time spent on the wards. By helping junior doctors develop this essential skillset, it will facilitate their efficiency as well as innovating solutions to common issues.

We are aware of the lack of time in prioritising clinical workload, job rotations and exams. Giving junior doctors the opportunity to develop their management and leadership skills will provide them with the tools to feel confident about their meaningful contributions.

References

  1. Perversi P et al (2018). Exploring reasoning mechanisms in ward rounds: a critical realist multiple case study. BMC Services Research https://doi.org/10.1186/s12913-018-3446-6
  2. http://www.acutemedicine.org.uk/wp-content/uploads/2014/10/5.2-Developing-Leadership-on-Ward-Rounds.pdf  accessed on 01.04.21
  3. Hynes G et al (2017). The state of medical leadership and management training for junior doctors FMLM 2017 junior doctor survey. Faculty of Medical Leadership and Management. 
  4. Laskaratos, F. M. et al (2015). The educational value of ward rounds for junior trainees. Medical education online, 20, 27559. https://doi.org/10.3402/meo.v20.27559
  5. Caldwell G (2009). The Importance of Ward Rounds. Western Sussex Hospitals NHS Foundation Trust. 
  6. https://fabnhsstuff.net/storage/The-Importance-of-Ward-Rounds-plus-appendices.pdf accessed 01.04.21