"The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds

Experiences and Needs of Core Participants in Surgical Ward Rounds: Qualitative Exploratory Study

Background

Surgical ward rounds (SWRs) are typically led by doctors, with limited involvement from key participants, including patients, family members, and bedside nurses. Despite the potential benefits of a more collaborative and person-centered approach, efforts to engage these stakeholders remain rare.

Objective

This qualitative exploratory study aims to examine the experiences and needs of doctors, nurses, patients, and their relatives during SWRs as part of a participatory design process.

Methods

Data were collected through ethnographic field studies, focus groups with the health care providers, patients, and relatives, and dyadic interviews conducted as part of home visits to patients and their partners after discharge. Field notes and interview data were analyzed using systematic text condensation.

Results

Lack of organization, traditional roles, and cultural norms compromised the quality, efficiency, and user experience of SWRs in multiple ways. SWRs were routine-driven, treatment-focused, and received lower priority than surgical tasks. Unpredictability resulted in unprepared participants and limited access for nurses, patients, and relatives to partake.

Conclusions

The study identified a gap between the organizational and cultural frameworks governing the SWRs and the experiences and needs of key participants. Digital technologies were perceived as a potential solution to address some of these challenges.

Proof of Concept for a Digital Framework to Support a Shared Agenda at Surgical Ward Rounds: Participatory Design Study

BACKGROUND

Surgical ward rounds (SWRs) are often unstructured and deprioritized compared to traditional surgical tasks, leading to limited interdisciplinary collaboration, unprepared patients, and low family attendance.

OBJECTIVE

This study aimed to co-design and develop a digital framework to facilitate a shared agenda for SWRs, ensuring all core participants can attend and participate effectively.

METHODS

Participatory Design (PD) methodologies were employed, utilizing user-engaging activities within an iterative process. A multidisciplinary team, including patients, relatives, healthcare providers, technology designers, and researchers, collaborated in workshops and testing to translate user needs into prototypes of technologies consisting of the digital framework.

RESULTS

A logistics system was developed for nurses to pre-book the SWRs in designated time slots, enabling them to prepare relevant data and partake in the dialogue with patients. Additionally, a mobile health application (mHealth app) displayed the schedule for patients and relatives, helping them to participate and prepare questions in advance. Multiple iterations ensured that the digital framework met user needs and was feasible for clinical practice.

CONCLUSIONS

Our findings underscore the importance of collaboration between users and technology designers in developing digital health technologies. Engaging the users helped identify technical and organizational constraints that needed to be addressed to integrate the digital framework into clinical settings.

Lost in transcription - how accurately are we documenting the surgical ward round?

BACKGROUND

Ward rounds are crucial to providing high-quality patient care in hospitals. Ward round quality is strongly linked to patient outcomes, yet ward round best practice is severely underrepresented in the literature. Accurate and thorough ward round documentation is essential to improving communication and patient outcomes.

METHODS

A prospective observational cohort study was performed by reviewing 135 audio-visual recordings of surgical ward rounds over 2 years at two hospitals. Recordings were transcribed, and an external reviewer stratified discussion points as Major, Minor, or Not Significant. Discussion was compared to the ward round note to assess the accuracy of documentation based on bedside discussion. The primary endpoint was the accuracy of Major discussion in the patient case notes. Secondary objectives involved investigating variables that may have impacted accuracy (e.g., patient age, sex, length of stay in hospital, and individual clinicians).

RESULTS

Nearly one third (32.4%) of important (Major) spoken information regarding plans and patient care in the ward round was omitted from the patients' written medical record. Further, 11% of patient case notes contained significant errors. Patient age (P = 0.04), the day of the week on which the ward round occurred (P = 0.05) and who the scribing intern was (P ≤ 0.001) were found to impact documentation accuracy. There was a large variation in interns documenting ability (35.5%-88.9% accuracy).

CONCLUSIONS

This study highlighted that a significant portion of important discussion conducted during the ward round is not documented in the case note. These results suggest that system-wide change is needed to improve patient safety and outcomes.

Optimizing ward rounds: systematic review and meta-analysis of interventions to enhance patient safety

BACKGROUND

Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds.

METHODS

This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42023394325). MEDLINE, Embase, Emcare, and PsycInfo were searched for studies with interventions aiming to improve ward round processes or patient outcomes in hospital settings. Studies were excluded if there was no baseline comparator or they were not in the ward round setting. Interventions were coded as checklist interventions (that is electronic or paper-based pro formas, templates, and checklists), structure interventions (that is defined rules or protocol to guide or standardize conduct), or other interventions. Outcomes were assessed via meta-analyses using the I2 statistic, Cochran's Q P value, and random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the Newcastle-Ottawa scale for non-randomized studies.

RESULTS

This review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. Checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay.

CONCLUSION

This is the first systematic review with meta-analyses synthesizing the evidence of all ward round interventions targeted at improving patient and process outcomes. Results from this review should be used to inform guidelines for the 'ideal ward round'.

Interventions to Improve Patient Care on Surgical Ward Rounds: A Systematic Review

BACKGROUND

Ward rounds are an essential component of surgical and perioperative care. However, the relative effectiveness of different interventions to improve the quality of surgical ward rounds remains uncertain. The aim of this systematic review was to evaluate the efficacy of various ward round interventions among surgical patients.

METHODS

A systematic literature search of the MEDLINE (OVID), EMBASE (OVID), Scopus, Cumulative Index of Nursing and Allied Health (CINAHL), and PsycInfo databases was performed on 7 October 2022 in accordance with PRISMA guidelines. All studies investigating surgical ward round quality improvement strategies with measurable outcomes were included. Data were analysed via narrative synthesis based on commonly reported themes.

RESULTS

A total of 28 studies were included. Most were cohort studies (n = 25), followed by randomised controlled trials (n = 3). Checklists/proformas were utilised most commonly (n = 22), followed by technological (n = 3), personnel (n = 2), and well-being (n = 1) quality improvement strategies. The majority of checklist interventions (n = 21, 95%) showed significant improvements in documentation compliance, staff understanding, or patient satisfaction. Other less frequently reported ward round interventions demonstrated improvements in communication, patient safety, and reductions in patient stress levels.

CONCLUSIONS

Use of checklists, technology, personnel, and well-being improvement strategies have been associated with improvements in ward round documentation, communication, as well as staff and patient satisfaction. Future studies should investigate the ease of implementation and long-term durability of these interventions, in addition to their impact on clinically relevant outcomes such as patient morbidity and mortality.

Evaluation of the feasibility of a video-transmitted surgical ward round: a proof of concept study

BACKGROUND

Surgical ward rounds are key element to point-of-care interprofessional postoperative treatment and technical and communicational aspects are relevant for the patient's safety and satisfaction. Due to COVID-19 restrictions, the training opportunity of experiencing a face-to-face surgical ward round was massively hampered and thus, we developed a digital concept. This study aims to investigate the feasibility of video-transmitted ward rounds integrating surgical and communicational aspects with live streaming from wards. Further, medical students were asked for their satisfaction and their subjective learning success.

METHODS

The proof-of-concept study consisted of self-reported subjective evaluation of competences in ward round skills. Qualitative feedback was collected to gain deeper insight and students' empathy was rated by using the student version of the Jefferson Empathy Scale (JES).

RESULTS

One hundred three medical students participated. The students were satisfied with the video-transmitted ward round (M = 3.54; SD = 1.22). In the subjective evaluation students' ward round competencies rose significantly (p < .001, Mpre = 3.00, SD = 0.77; Mpost = 3.76, SD = 0.75). The surgeon was rated as empathic (M = 119.05; SD = 10.09). In the qualitative feedback they named helpful aspects like including an expert for communication. However, they preferred the face-to-face setting in comparison to the digital concept.

CONCLUSIONS

It was feasible to implement a video-transmitted ward round within a pandemic. The format worked technically, was well-accepted and also led to a subjective rise in the students' competencies. Video-transmitted ward rounds may be integrated to support the medical education, though, they cannot replace the face-to-face setting.

Improving Thoracic Surgery Ward Round Quality and Enhancing Patient Safety in a Referral Centre

Introduction Ward rounds are vital clinical processes that facilitate an opportunity for daily review and management of thoracic surgery inpatients. The aim of this study was to compare thoracic surgery ward round documentation against locally agreed standards and design a template to improve the detail and uniformity of this process to enhance patient care. Materials and methods Data for this audit was collected retrospectively and prospectively. Data was collected during three auditing periods and managed on Microsoft Excel. Descriptive statistics were used for its analysis. Chi-square and Fisher's Exact tests were used to test for differences in reporting rates. Results and discussion Initially, a total of 199 ward round notes were reviewed. Imaging results (19%) and discharge planning (23%) were not reported. eCARE (electronic Clinical Assessment for Round Evaluation) was developed to ensure that all aspects of patient evaluation recommended by the guidelines were included. Reporting rates significantly improved after such changes. We analysed the effect of the new ward round note on discharge planning (23.3 vs 41%, p<0.001), complication rates (32.6 vs 21.9%, p=0.03), post-surgical length of stay (LOS) (7.0 vs 5.0, p<0.001). Conclusion Over a year, we audited the Thoracic Surgery Department's ward round documentation against locally agreed standards in line with national recommendations. Several important items were not regularly reported. Using closed-ended questions improved reporting rates, and patient care was optimised. Further research should explore the impact of this new documentation method on patient care and postoperative outcomes in our Trust as well as other cardiothoracic centres.

[Measuring individual competencies and team performance in clinical learning settings of interprofessional collaborative practice: Empirical development of the Interprofessional Ward Round Individual and Team Assessment Tool (IP-VITA)]

BACKGROUND

Interprofessional training wards (IPTW) can contribute to the development of interprofessional competencies. In order to evaluate the acquisition of competencies, instruments are needed that record both team performance and individual competencies in the clinical teaching setting in third-party assessment. This paper describes the Interprofessional Ward Round Individual and Team Assessment-Tool, IP-VITA ("Interprofessionelle Visiten Individual und Team Assessment Tool") and its development.

METHOD

Based on the empirical exploration of the three observation instruments "Teamwork Assessment Scale" (TAS), "McMaster-Ottawa Scale" and "Individual Teamwork Observation and Feedback Tool" (iTOFT) in at least four rounds each at the HIPSTA (with n=8 students and trainees each), a preliminary version of the IP-VITA was created. This preliminary version was then refined in subsequent empirical steps: a consensual validation in the research team was followed by a "member check" with the clinical colleagues of the HIPSTA, the input from external experts and an empirical test in an alternative setting.

RESULTS

The IP-VITA is an empirically developed multimodal instrument to assess the interprofessional competencies of trainees and students as well as their team performance in clinical settings with patient interaction. It comprises three parts. In part A, structural data, the persons involved and the essential patient characteristics are recorded. Part B consists of 12 items and a free-text field for recording behaviour at the individual level. Part C also consists of 12 items and evaluates behaviour at team level.

DISCUSSION

The IP-VITA instrument was developed specifically for the context of evaluating interprofessional ward rounds in a clinical educational setting. The instrument takes into account the ambiguous position of the assessment of interprofessional collaboration between individual competence and team performance. Beyond the HIPSTA, it can be used as a formative assessment instrument, and it may also be useful for summative assessments.

Introducing a structured daily multidisciplinary board round to safely enhance surgical ward patient flow in the bed shortage era: a quality improvement research report

Hospital bed shortage is a worldwide concern. Their unavailability has caused elective surgery cancellations at our hospital peaking in spring 2016 at over 50%. This is often due to difficult patient step-down from intensive care (ICU) and high-dependency units (HDU). In our general/digestive surgery service admitting approximately 1000 patients yearly, ward rounds were run on a consultant firm basis.We report quality improvement (ISRCTN13976096) after we introduced a structured daily multidisciplinary board round framework (SAFER Surgery R2G) adapted from the 'SAFER patient flow bundle' and the 'Red to Green days' approaches to enhance flow. We compare 2016-2017, when our framework was applied for 12 months.We used a Plan-Do-Study-Act (PDSA) methodology. Our intervention consisted in (1) systematically communicating the key care plan after the afternoon ward rounds to the nurse in charge; (2) 30' 10:00 hours Monday-to-Friday multidisciplinary board rounds, attended daily by the senior team and weekly by hospital and site managers, revising the key care plan to aim at safe, early discharges, assessing the appropriateness of each inpatient day and tackling any cause of delay. We measured patient flow by average length of stay (LOS), ICU/HDU step-downs and operation cancellations count, monitoring safety through early 30-day readmissions. Compliance was assessed by board round attendance and staff satisfaction rate surveys.After 12 months of intervention (PDSA-1-2, N=1032), compared with baseline (PDSA-0, N=954) average LOS significantly decreased from 7.2 (8.9) to 6.3 (7.4) days (p=0.003); ICU/HDU bed step-down flow increased by 9.3% from 345 to 375 (p=0.197), surgery cancellations dropped from 38 to 15 (p=0.100). 30-day readmissions increased from 0.9% (N=9) to 1.3% (N=14)(p=0.390). Average cross-specialty attendance was 80%. Satisfaction rates were >75%, regarding enhanced teamwork and faster decisions.The SAFER Surgery R2G framework has increased patient flow in the context of an enhanced multidisciplinary approach, requiring senior staff commitment to remain sustainable.

The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service

BACKGROUND

The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds.

METHODS

The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus.

RESULTS

Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend.

CONCLUSION

The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.

Descriptive study of parents' perceptions of paediatric ward rounds

OBJECTIVES

To explore parents' perceptions of ward rounds in two different ward settings (medical and surgical unit) in a tertiary paediatric hospital in Australia and to understand key factors influencing them.

DESIGN

A descriptive study was conducted based on 100 semistructured interviews across two different inpatient units: medical (n=50) and surgical (n=50). Quantitative data, obtained from closed-ended responses, were analysed using descriptive statistics. Qualitative data, obtained from open-ended responses, were analysed using inductive content analysis, facilitating a more in-depth understanding of parents' perceptions of ward rounds and their lived experience.

RESULTS

Parents in both medical and surgical units reported high levels of satisfaction with ward rounds, with a median parental satisfaction rating of 4 out of a possible 5 (comparative in both settings). Two major themes were identified influencing parental perceptions of ward rounds: team-family dynamics and managing uncertainties inherent to ward rounds.

CONCLUSION

This study demonstrates that parents highly value ward rounds, primarily for the opportunity they offer to collaborate with the clinical team and to ask questions. Parental satisfaction was high in both medical and surgical units, despite notable differences in ward round structure and function. Our study highlights key areas where small changes could empower parents and enhance their overall hospital experience.

General Surgery Resident Autonomy: Truth and Myth

Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.

Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study

BACKGROUND

The effect of team dynamics on infection management and antimicrobial stewardship (AMS) behaviours is not well understood. Using innovative visual mapping, alongside traditional qualitative methods, we studied how surgical team dynamics and communication patterns influence infection-related decision making.

MATERIALS/METHODS

Between May and November 2019, data were gathered through direct observations of ward rounds and face-to-face interviews with ward round participants in three high infection risk surgical specialties at a tertiary hospital in South Africa. Sociograms, a visual mapping method, mapped content and flow of communication and the social links between participants. Data were analysed using a grounded theory approach.

RESULTS

Data were gathered from 70 hours of ward round observations, including 1024 individual patient discussions, 60 sociograms and face-to-face interviews with 61 healthcare professionals. AMS and infection-related discussions on ward rounds vary across specialties and are affected by the content and structure of the clinical update provided, consultant leadership styles and competing priorities at the bedside. Registrars and consultants dominate the discussions, limiting the input of other team members with recognised roles in AMS and infection management. Team hierarchies also manifest where staff position themselves, and this influences their contribution to active participation in patient care. Leadership styles affect ward-round dynamics, determining whether nurses and patients are actively engaged in discussions on infection management and antibiotic therapy and whether actions are assigned to identified persons.

CONCLUSIONS

The surgical bedside ward round remains a medium of communication between registrars and consultants, with little interaction with the patient or other healthcare professionals. A team-focused and inclusive approach could result in more effective decision making about infection management and AMS.

Public Perception of General Surgery Resident Autonomy and Supervision

BACKGROUND

Despite patients being important stakeholders in surgical training, little is known about the public's perception of trainee participation in surgical care. This study evaluates the public's perception of surgical resident autonomy and supervision.

STUDY DESIGN

An anonymous electronic survey was sent to adult panelists older than 18 years in the US using SurveyGizmo. The design of the survey used Dillman's Tailored Design Method to optimize response rate. Participants completed surveys including demographic characteristics and perceptions toward general surgery resident autonomy. Univariable and multivariable analyses were used as appropriate.

RESULTS

Survey response rate was 93% (2,005 of 2,148). Demographic characteristics including age, gender, race or ethnicity, and highest level of education were nationally representative. Most respondents (87%) had health insurance. On multivariable logistic regression analysis, factors associated with participants who would never allow a resident to perform any portion of the operation include: female gender (odds ratio [OR] 1.58; 95% CI, 1.28 to 1.95), no health insurance (OR 1.38; 95% CI, 1.03 to 1.84), Black race (OR 1.82; 95% CI, 1.38 to 2.41), and Hispanic ethnicity (OR 1.49; 95% CI, 1.03 to 2.15). Participants who were younger than 50 years (OR 1.57; 95% CI, 1.24 to 1.98), male (OR 1.90; 95% CI, 1.56 to 2.32), of Black race (OR 1.45; 95% CI, 0.10 to 1.91), Hispanic ethnicity (OR 1.49; 95% CI, 1.05 to 2.11), working in healthcare (OR 2.18; 95% CI, 1.67 to 2.86), or insured (OR 1.46; 95% CI, 1.07 to 1.99) were more likely to believe that resident involvement increases complications.

CONCLUSIONS

Among survey participants broadly representing the US population, resident participation in operations is not universally accepted. Public perception of surgical resident autonomy and supervision is important, as GME continues to evolve to address readiness for independent practice.

Impact of the COVID-19 pandemic on Otolaryngology trainee education

BACKGROUND

The COVID-19 pandemic has reduced clinical volume with a negative impact on trainee education.

METHODS

Survey study of Otolaryngology trainees in North America, during the COVID-19 pandemic in April 2020.

RESULTS

Of 216 respondents who accessed the survey, 175 (83%) completed the survey. Respondents reported a universal decrease in clinical activities (98.3%). Among participants who felt their program utilized technology well, there were significantly decreased concerns to receiving adequate educational knowledge (29.6% vs 65.2%, P = .003). However, 68% of trainees still expressed concern in ability to receive adequate surgical training. In addition, 54.7% of senior trainees felt that the pandemic had a negative impact on their ability to secure a job or fellowship after training.

CONCLUSIONS

Trainees universally felt a negative impact due to the COVID-19 pandemic. Use of technology was able to alleviate some concerns in gaining adequate educational knowledge, but decreased surgical training remained the most prevalent concern.

Predictors for Early Physical Recovery for General and Orthopedic Patients after Major Surgery: Structural Equational Model Analyses

BACKGROUND

Attention to factors that may affect patients' ability to experience enhanced recovery after surgery is essential in planning for postoperative care.

AIMS

To create models of predefined pre,- peri-, and postoperative variables in order to analyze their impact on patients' physical recovery on postoperative days 1 and 2 after major orthopedic and general surgery.

DESIGN

An exploratory design with repeated measures was used, including 479 patients who had undergone orthopedic (289) or general surgery (190) at three hospitals.

METHODS

Pain, nausea, and level of physical ability were measured preoperatively and on postoperative days 1 and 2 by using the Numerical Rating Scale and items from the Postoperative Recovery Profile. Structural equation modeling was used to explore the impact of the predefined variables on patients' physical recovery.

RESULTS

The orthopedic group contained significantly more women and significantly more patients with pain and opioid use. Although the models showed good fit, "traditional" preoperative (pain, nausea, physical abilities, chronic pain, opioid use) and perioperative variables (anesthesia, length of surgery) constituted few (orthopedic) or no (general surgery) predictive properties for physical recovery. Postoperative average pain intensity, average nausea intensity, and physical ability explained physical recovery on day 1, and physical recovery on day 1 predicted physical recovery on day 2.

CONCLUSIONS

"Traditional" predictors had little effect on patients' postoperative physical recovery, while associations with common postoperative symptoms were shown. Further research is needed to explore additional variables affecting early physical recovery and to understand how soon patients are physically ready to return home.