Can Checklists Solve Our Ward Round Woes? A Systematic Review

Implementation of a Checklist for Surgical Inpatient Rounds: An Observational Cohort Study

BACKGROUND

The surgical ward round is the linchpin of inpatient care. Despite this, it is often pressured by external forces such as theatre times, on-call demands, or outpatient clinics. Checklists have been successful in saving lives, particularly in the operating room. Some of this work has translated to the surgical ward round, but no studies have examined the direct impact on patient communication. As a result, this study aimed to determine how a structured checklist impacted documentation and discussion in the surgical ward round.

METHODOLOGY

A pre-observational and post- observational cohort intervention study was conducted to examine the impact of a 17-item checklist on the surgical ward round. Ward rounds were filmed to evaluate clinical documentation and discussion.

RESULTS

One hundred thirty-five patient encounters were recorded and transcribed over 24 months: 65 pre-intervention and 70 post-intervention. There were 59 females and 76 males. The mean age was 62 (SD=15.2). There were 105 benign cases, 30 malignant cases, 32 elective patients, and 103 emergency patients. The documentation of 'medication review', 'investigations', and 'patient concerns' significantly increased following the implementation of a checklist. Documentation of 'impression' significantly decreased. Doctor-patient communication and collaborative discussion rates of important items were not impacted by the checklist.

CONCLUSIONS

This checklist did not improve discussion in the surgical ward round. However, it improved the documentation of several items on the checklist (patient's medication, investigations, and concerns). This study identifies areas where checklists can positively improve the ward round and highlights the significant areas where improvements can be made.

The medical ward round: evidence, pitfalls, and tips

Ward rounds are pivotal for patient-centered care and bedside teaching. In today's hospitals, care is provided by multidisciplinary and multiprofessional teams. To conduct an effective and efficient ward round, active patient involvement is essential, and the input from all team members must be shared and integrated into the diagnostic and therapeutic plan. The organization and structure of ward rounds, the roles and responsibilities of participants, the preparation before the round, and the communication rules must be clearly defined. Successful ward rounds require a focused, explicitly structured, patient-centered communication, and a balanced interprofessional information exchange. Bedside interprofessional ward rounds preceded by a discussion of the patient's condition and clinical course outside the room appear to optimally support comprehensive, collaborative patient-centered care, while fostering alignment within the interprofessional healthcare team. However, stringent round structure and strong leadership are needed to ensure active involvement of all interprofessional team members, and time efficiency.

Improving Job Completion in Acute Medical Units Through Role-Specific Documentation: A Quality Improvement Project

ABSTRACT

High-quality documentation is vital for efficient patient care. This study aimed to enhance documentation clarity in the acute medical unit (AMU) at our local institution and to improve job completion rates and reduce missed jobs per patient per day (JPD). From January 26 to April 10, 2024, we collected data on 606 patients and 2,298 jobs. Four collaborators documented patient plans using either Standard Documentation or a novel Role-Specific Documentation. Standard Documentation used a single "Plan" heading, while Role-Specific Documentation used specific headings for "Doctors," "Nurses," and "MDT" (Multidisciplinary Team). Data were analyzed using Student t-test (p < .05). Standard Documentation group documented 1,291 jobs for 345 patients; Role-Specific Documentation group documented 1,007 jobs for 261 patients. Role-Specific Documentation had fewer missed jobs (147 vs. 294, p = .0002) and a higher percentage of completed jobs (85.74% vs. 77.99%, p = .0003). Although total job completion showed no significant difference, Role-Specific Documentation had more completed JPD (3.47 vs. 2.94, p = .0052). The Role-Specific Documentation system improved job completion and reduced missed JPD. Despite fewer patients, the new system proved more efficient, suggesting potential for wider adoption. Future studies should explore the documentation methods' impact on clinical outcomes and operational metrics.

Standardizing Best Practices: An Initiative Utilizing Surgical Ward Round Checklists to Enhance Patient Safety and Documentation in Our Trust

Aims/Background Comprehensive ward round documentation is crucial for ensuring effective communication and patient safety. Standardized checklists have been shown to improve documentation quality in various healthcare settings. This article presents the findings of a comprehensive audit consisting of two cycles, which incorporate feedback, bring about implications, and evaluate the impact of a standardized proforma on inpatient ward round documentation for General Surgery patients in a high-volume surgical unit. Methods Initially, a staff survey was conducted to identify deficiencies in ward round documentation, highlighting the need for a standardized proforma. To establish a baseline, a retrospective review of 45 ward round entries assessed five key areas: diagnosis, disease management, objective assessments, discharge planning, and documentation logistics. Subsequently, within a month of implementing the changes, 20 ward round entries were analyzed based on the same criteria during a second cycle. Results During Cycle 1, we found that 95.6% of the notes lacked information on Venous thromboembolism (VTE) prophylaxis, while nearly 88.9% were missing data on current issues, and 46.7% did not include pain scores. Additionally, we found that bowel function and fluid balance information were absent in 62.2% and 95.6% of ward round entries, respectively. Cycle 2 showed a significant improvement in terms of documentation for most of the items. Most of the variables were documented in all the reviewed proformas and others such as VTE prophylaxis and fluid balance showed a significant improvement being documented in 95% of the proformas. Conclusion Employing a standardized ward round proforma demonstrably improved documentation completeness across all safety parameters within our surgical unit. This enhanced focus on crucial safety discussions during ward rounds is expected to further elevate patient safety outcomes.

Enhancing interprofessional ward rounds by identifying factors associated with low satisfaction and efficiency: a quantitative and qualitative national survey of Swiss healthcare professionals

AIMS OF THE STUDY

Interprofessional ward rounds are a cornerstone of patient-centred care for medical inpatients and offer opportunities to discuss and coordinate patient treatment and further management. We aimed to identify factors associated with lower satisfaction and efficiency of interprofessional ward rounds, as reported by physicians and nurses.

METHODS

An anonymous Swiss nationwide online survey of physicians and nurses was conducted in 28 Swiss internal medicine inpatient departments between 9 August and 19 October 2023. Analyses were conducted from November to December 2023. The primary outcome was physicians' and nurses' perceived lower satisfaction with ward rounds, which was assessed using visual analogue scales ranging from 0 to 10, with lower satisfaction defined as scores below the median. The main secondary outcome was perceived lower efficiency using a similar definition. Qualitative analysis was performed through inductive thematic analysis.

RESULTS

The survey had a response rate of 21.6% (547/2530). Of the 547 physicians and nurses included in the final analysis, the median satisfaction was 7 points (interquartile range [IQR] 6-8). A total of 61% of physicians (156/254) and 76% of nurses (224/293) reported lower satisfaction. Lower satisfaction was reported significantly more frequently by nurses (adjusted odds ratio [OR] 2.33, 95% confidence interval [CI] 1.58-3.43; p ≤0.001) and female team members (adjusted OR 1.95, 95% CI 1.32-2.9; p <0.01). The median perceived efficiency of ward rounds was 7 points (IQR 5-8), and the nursing profession was associated with lower perceived efficiency (adjusted OR 1.95, 95% CI 1.3-2.93; p <0.01). Adherence to in-house guidelines for ward rounds was associated with satisfaction (adjusted OR for lower satisfaction 0.25, 95% CI 0.16-0.39; p <0.001) and perceived efficiency (adjusted OR for lower efficiency 0.27, 95% CI 0.17-0.43; p <0.001). Both physicians and nurses preferred to perform ward rounds as part of an interprofessional team. The qualitative analysis of the data revealed a preference for structured interprofessional ward rounds and the active involvement of nurses.

CONCLUSIONS

This survey revealed an overall high preference for interprofessional ward rounds. In addition, we identified several factors that were associated with lower satisfaction and efficiency. Structured in-house protocols for ward rounds may increase the satisfaction and efficiency of interprofessional collaboration during ward rounds.

A Multi-Center Study on the Implementation and Challenges of Nursing Three-Level Ward Rounds in Tertiary Hospitals in Shanxi Province

Background

The "Key Points of the Core System of Medical Quality and Safety" (hereinafter referred to as the "Key Points") was promulgated by the National Health Commission of China in 2018, requiring that nursing ward rounds should be carried out with reference to the three-level ward round system; In 2020 and 2022 editions of the "Evaluation Standards for Tertiary Hospitals", which were implemented in China, required that nursing ward rounds should be carried out with reference to the "Key Points". Additionally, the Action Plan for Comprehensively Improving Medical Quality (2023-2025) also mentions the need to improve the quality of three-level ward rounds. However, there are no detailed guidelines regarding implementing "Nursing Three-level Ward Rounds".

Purpose

This study aimed to investigate the current situation of nursing three-level ward rounds in tertiary hospitals after the promulgation of the "Key Points of the Core System of Medical Quality and Safety" to provide insights and guidelines regarding relevant standards, so as to better implement of the requirements of "nursing ward rounds" in the "Evaluation Standards for Tertiary Hospitals" and "improving the quality of three-level ward rounds" in the "Action Plan".

Methods

A multi-center study was conducted in February 2024, including all tertiary public hospitals in the Shanxi Province, China. A questionnaire survey using the self-designed "Questionnaire on the Implementation of Nursing Three-level Ward Rounds" was carried out. The questionnaire included the basic information of the hospital and the implementation of the three-level (namely I, II, and III) rounds (including "five aspects": ward round personnel, object, content, frequency, and record), which is expressed by quantity and composition ratio. Next is the text analysis method. First, the "five aspects" of the hospital that filled in the questionnaire survey with "nursing three-level ward rounds have been carried out" were assessed. Second, the five aspects of each hospital were assessed for consistency with the "Nursing Three-level Ward Rounds System" (hereinafter referred to as the "System") of their respective hospitals.Third, the consistency of the "System" of the hospital with the "Key Points" was assessed. The results of the analysis of the former are expressed in terms of quantity and composition ratio; the results of the latter two were analyzed using Fisher's exact test method to compare any differences.

Results

Notably, 14 of the 67 tertiary public hospitals (20.9%) carried out nursing three-level ward rounds. There were 4-10 situations in the five aspects of I, II, and III ward rounds filled in by the hospitals. The five aspects of the I, II, III ward rounds in 14 hospitals were significantly comparable with the "System", which, in turn, was comparable with the "Key Points" (P < 0.05).

Conclusion

Not all tertiary public hospitals in the Shanxi Province have not all carried out nursing three-level ward rounds. Furthermore, the five aspects of the hospitals that carried out nursing three-level ward rounds were not entirely consistent in terms of ward round personnel, object, content, frequency, and record. The filling in of the nursing three-level ward rounds carried out by the hospitals is inconsistent with the respective "System"; the "System" of the hospital is not in line with the "Key Points".

Impact on Nursing Work

Nursing administrators should be aware of the newly issued norms and requirements in their workplace, and revise the relevant systems in accordance with the norms and requirements in a timely manner. Additionally, the revision of the system should cover the core requirements of the norms and be practicable. The system should be supervised to ensure that 100% of the implementation is in accordance with the system.

Lost in translation: Unveiling medical students' untold errors of medical history documentation

OBJECTIVE

The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting.

METHODS

In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness.

RESULTS

Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth in contrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed.

CONCLUSIONS

Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.

The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: A narrative review

Objectives

This narrative review aimed to explore the impact of checklists and error reporting systems on hospital patient safety and medical errors.

Methods

A systematic search of academic databases from 2013 to 2023 was conducted, and peer-reviewed studies meeting inclusion criteria were assessed for methodological rigor. The review highlights evidence supporting the efficacy of checklists in reducing medication errors, surgical complications, and other adverse events. Error reporting systems foster transparency, encouraging professionals to report incidents and identify systemic vulnerabilities.

Results

Checklists and error reporting systems are interconnected. Interprofessional collaboration is emphasized in checklist implementation. In this review, limitations arise due to the different methodologies used in the articles and potential publication bias. In addition, language restrictions may exclude valuable non-English research. While positive impacts are evident, success depends on organizational culture and resources.

Conclusions

This review contributes to patient safety knowledge by examining the relevant literature, emphasizing the importance of interventions, and calling for further research into their effectiveness across diverse healthcare and cultural settings. Understanding these dynamics is crucial for healthcare providers to optimize patient safety outcomes.

A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit

Background and aim Ward-round documentation is important for clinical communication and patient safety. Standardized checklists have improved ward-round documentation in surgical and medical settings. This quality improvement project aimed to introduce a standardized ward round proforma to improve documentation in a UK specialist stroke unit. Methods Ward round entries were assessed against internally agreed standardized criteria. A stroke-specific ward round proforma was designed and introduced with input from the multidisciplinary team. A repeat audit was performed, including assessment of the use of different proforma sections. Multidisciplinary team members were invited to provide feedback via an anonymous online survey. Results A total of 111 ward round entries were reviewed before the proforma was introduced. Ninety-five ward round entries were reviewed following introduction of the proforma, and 84.2% of these used the proforma for documentation. Overall documentation of standardized criteria improved from 48.7% to 62.1% with substantial improvement seen in documentation of neurological examination, presence/absence of mechanical venous thromboembolism prophylaxis, and blood test results. Multidisciplinary team feedback was positive. Conclusions The stroke-specific ward round proforma improved the quality and consistency of documentation in the unit. An updated proforma was designed using these results and multidisciplinary team feedback.