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Merriman C, Freeth D. SIN-BARRSS - Developing a mnemonic to support nurses' participation in interprofessional ward rounds in intensive care: An appreciative inquiry for quality improvement. Intensive Crit Care Nurs 2024; 81:103609. [PMID: 38155052 DOI: 10.1016/j.iccn.2023.103609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES To develop and pilot a mnemonic to increase the willingness and ability of bedside nurses to contribute to patient reviews in the daily interprofessional ward round. RESEARCH METHODOLOGY/DESIGN Appreciative inquiry quality improvement study, using ethnographic observations and appreciative inquiry discussions, augmented by quantitative data collection of basic facts. SETTING Large (44 beds) critical care unit in the United Kingdom. MAIN OUTCOME MEASURES Interprofessional development and acceptance of mnemonic; successful preparation for pilot; use and usability of mnemonic; improvements in bedside nurses' contributions to ward round discussions (frequency and focus). RESULT/FINDINGS Interprofessional development of a usable and useful mnemonic was successful, pilot implementation showed promising levels of take up and acceptance. Compared to before the quality improvement project bedside nurses were more willing and able to participate in ward round discussions, did so more often, and used the mnemonic script with insight and flexibility. CONCLUSIONS The implementation of a mnemonic supported bedside nurses' contributions to the ward round. This could provide a framework for introducing similar programmes to other intensive care units. Appreciative inquiry methodology could be replicated in other settings to aid the improvement of interprofessional ward rounds, or to address other quality improvement priorities. IMPLICATIONS FOR CLINICAL PRACTICE A mnemonic can provide a structure which supports bedside nurses' contributions in ways that make good use of bedside nurses' professional expertise and most up to date knowledge of patients' clinical state. Furthermore, a well-designed mnemonic can be used flexibly and provides an outline script that supports less experienced and less confident nurses to make well-focused and well received contributions to rapid interprofessional discussions. In turn, this can increase these nurses' confidence and capability. More experienced and confident nurses, and ward round leaders, can use the same mnemonic flexibly as an aide memoir that guards against missing information and insights that could affect the quality and safety of patient care.
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Affiliation(s)
- Clair Merriman
- London and Queen Mary University of London, Oxford Brookes University, United Kingdom.
| | - Della Freeth
- London and Queen Mary University of London, The Science Council, United Kingdom
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Bell CL, Allan JL, Ross S, Powell DJH, Johnston DW. How can we better prepare new doctors for the tasks and challenges of ward rounds?: An observational study of junior doctors' experiences. Med Teach 2021; 43:1294-1301. [PMID: 34224286 DOI: 10.1080/0142159x.2021.1940912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Ward rounds play a crucial role in the delivery of patient care in inpatient settings, but involve a complex mix of tasks, skills and challenges for junior doctors to negotiate. This study informs the development of high-quality training by identifying the activities that junior doctors perform, and those associated with stress during real-life ward rounds. MATERIALS AND METHODS All activities performed by FY1 doctors (n = 60) over 2 ward rounds were coded in real-time by a trained observer using the work observation method by activity timing (WOMBAT). Doctors' heart rate was continuously recorded and non-metabolic peaks in heart rate used as a physiological indicator of stress. RESULTS During ward rounds, FY1 doctors commonly engaged in indirect patient care, professional communication, documentation and observation. Very little time was spent on direct patient care (6%) or explicit supervision/education (0.01%). Heart rate data indicated that stress was highest during administrative tasks while interacting directly with patients while stepping out of rounds to complete personal tasks, when answering bleeps and while multi-tasking. CONCLUSIONS Training that specifically covers the activities involved, skills required, and challenges inherent in real-life ward rounds may better prepare FY doctors for this complex area of practice.
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Affiliation(s)
- Cheryl L Bell
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
| | - Julia L Allan
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
| | - Sarah Ross
- NHS Tayside/School of Medicine, University of Dundee, Dundee, United Kingdom of Great Britain and Northern Ireland
| | - Daniel J H Powell
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
- Rowett Institute, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
| | - Derek W Johnston
- Health Psychology, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
- School of Psychology, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
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März E, Wessels I, Kollar I, Fischer MR. "I just stand around and look friendly" - Comparing medical students' and physicians' ward round scripts. Med Teach 2021; 43:560-566. [PMID: 33569977 DOI: 10.1080/0142159x.2021.1877267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Even though ward rounds are important learning opportunities for medical students, unfavourable ward round scripts of students and physicians may hinder learning in such situations. We investigated medical students' and physicians' ward round scripts with respect to (a) the content focus of ward round activities, and (b) the potential of these activities for knowledge construction. METHODS We conducted standardized interviews with 50 medical students and physicians in internal medicine at different expertise stages. Activities participants labelled as typical for ward rounds were coded with respect to their content focus and their potential with regard to knowledge construction. RESULTS Regarding content focus, especially residents mainly named activities bound to patient care. Teaching- and learning-related activities were very rare, but more frequently mentioned by students and more experienced physicians. With respect to potential for knowledge construction, students regarded significantly more passive activities (= low potential for knowledge construction) as typical for ward rounds, especially when they described their own role. CONCLUSIONS Medical students should be supported in their development of conceiving ward rounds as valuable learning opportunities. Residents should be asked to take their teaching responsibility seriously, for example by demanding an active engagement of the students during ward rounds.
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Affiliation(s)
- Esther März
- Institute for Medical Education, University Hospital, LMU Munich, Munich, Germany
| | - Insa Wessels
- bologna.lab, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ingo Kollar
- Lehrstuhl für Psychologie m.b.B.d. Pädagogischen Psychologie, Universität Augsburg, Augsburg, Germany
| | - Martin R Fischer
- Institute for Medical Education, University Hospital, LMU Munich, Munich, Germany
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Proske A, Link BC, Beeres F, Nebelung S, Füchtmeier B, Knobe M. [Residency program under scrutiny (part 2)-How do residents prepare for emergency operations?]. Chirurg 2021; 92:62-69. [PMID: 33009593 DOI: 10.1007/s00104-020-01286-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postgraduate medical education in trauma and orthopedic surgery residents largely relates to learning and teaching surgery. During this crucial stage of surgical development some of the didactic challenges are caused by heterogeneous and contradictory expectations of trainees and trainers alike. So how do residents prepare for emergency surgery? To date there is neither an expert consensus nor scientific investigations in the clinical context on this topic. METHODS Between February and April 2015 questionnaires were issued to all physicians active in the field of trauma and orthopedic surgery within the Trauma Network East Bavaria (27 clinics, 255 physicians). The participants were asked to rate the importance of certain elements functioning in the preparation of two emergency operations using a Likert scale. The intensity with which residents generally realize these elements of preparation was also documented. The aim was to objectify if and to what extent the presumed normal practices diverge from clinical reality. RESULTS A total of 150 questionnaires were analyzed (return rate 59%). Discussion with the consultant (85.3%, n = 128), examination of the patient (80.0%, n = 120), surgical approach (76.0%, n = 114) and study of patient files (68.0%, n = 102) were considered to be the most important elements; however, many of the participants admitted that these elements of preparation are not sufficiently performed. CONCLUSION The personal preparation of residents for an emergency operation should be classified as extremely important; however, the requirements and reality do not seem to hold true in the clinical environment. This seems to be most likely due to structural and organizational issues.
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Affiliation(s)
- Andreas Proske
- Klinik für Orthopädie, Unfallchirurgie und Sportmedizin, Krankenhaus Barmherzige Brüder Regensburg, Prüfeningerstraße 86, 93049, Regensburg, Deutschland.
| | - Björn-Christian Link
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Luzern, Schweiz
| | - Frank Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Luzern, Schweiz
| | - Sven Nebelung
- Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Bernd Füchtmeier
- Klinik für Orthopädie, Unfallchirurgie und Sportmedizin, Krankenhaus Barmherzige Brüder Regensburg, Prüfeningerstraße 86, 93049, Regensburg, Deutschland
| | - Matthias Knobe
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Luzern, Schweiz
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Kydonaki K, Takashima M, Mitchell M. Family ward rounds in intensive care: An integrative review of the literature. Int J Nurs Stud 2020; 113:103771. [PMID: 33080477 DOI: 10.1016/j.ijnurstu.2020.103771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The involvement of family members in the ward rounds is a novel but under-researched family-centered care intervention in adult intensive care units, with limited evidence on the impact it has on patient and family-centered outcomes. OBJECTIVES This integrative review aimed to understand how family rounds are implemented in critical care and to appraise the evidence on outcomes for patients, family members, and healthcare professionals. DESIGN An integrative review methodological framework permitted the inclusion of all research designs. DATA SOURCES MEDLINE; CINAHL; PsycINFO; Cochrane Library; Web of Science Current Contents Connect; Web of Science-Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global, Embase were systematically searched. REVIEW METHODS We reviewed studies that referred to or used as an intervention the involvement of family members in daily critical care team rounds. We included primary research in adult intensive care units regardless of patients' length of stay. We excluded patients receiving end-of-life care. We considered any outcome related to the critically ill patient and/or their family member, outcomes related to the healthcare professionals, and outcomes related to clinical and/or nursing treatment. The Mixed Methods Appraisal Tool was used to appraise the quality of the studies. The review was registered in the Prospero database. RESULTS From the 541 articles initially retrieved, 15 studies met the inclusion criteria and were included in the review. Studies originated from the United States of America and Canada since 2003, and a variety of designs were used. Four before and after studies and a non-randomized experimental study explored the impact of structured family rounds on family and staff satisfaction, showing limited improvement in satisfaction. Six cross-sectional survey studies explored family members' and clinicians' perceptions and demonstrated a positive attitude towards family-centered rounds, but some concerns were raised from the nursing staff. Three qualitative studies and a mixed-methods study identified structural and cultural factors influencing healthcare professionals' and families' acceptance of family rounds. Most studies were of poor to moderate quality, with limited confidence in the outcomes reported. CONCLUSIONS Most studies reported improved family satisfaction as the main outcome. Future research should focus on longitudinal patient and family-centered outcomes, including mental health outcomes, and on qualitative data to understand the processes, barriers, and facilitators to implement family-centered rounds in intensive care units.
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Affiliation(s)
- Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, 9 Sighthill Court, EH11 4BN Edinburgh, UK.
| | - Mari Takashima
- School of Medicine, Centre for Applied Health Economics, Griffith University, Nathan campus, N16 -1.10K, QLD 4111, Australia.
| | - Marion Mitchell
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Address N48 2.14, Nathan Campus, 170 Kessels Road, Nathan, QLD 4111, Australia.
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Abstract
PURPOSE This paper aims to explore if health professionals share understanding of teamwork that supports collaborative ward rounds. DESIGN/METHODOLOGY/APPROACH A purpose-designed survey was conducted in two acute medical and two rehabilitation wards from a metropolitan teaching hospital. Medical officers, nurses and allied health professionals participated. To understand characteristics that support collaborative ward rounds, questions developed from literature and industry experience asked: what are the enablers and challenges to teamwork; and what are clinicians' experiences of positive teamwork? Descriptive and thematic analyses were applied to the dimensions of effective teamwork as a framework for deductive coding. FINDINGS Seventy-seven clinicians participated (93% response rate). Findings aligned with dimensions of teamwork framework. There was no meaningful difference between clinicians or specialty. Enablers to teamwork were: effective communication, shared understanding of patient goals, and colleague's roles. Challenges were ineffective communication, individual personalities, lack of understanding about roles and responsibilities, and organisational structure. Additional challenges included: time; uncoordinated treatment planning; and leadership. Positive teamwork was influenced by leadership and team dynamics. PRACTICAL IMPLICATIONS Ward rounds benefit from a foundation of collaborative teamwork. Different dimensions of teamwork present during ward rounds support clinicians' shared understanding of roles, expectations and communication. ORIGINALITY/VALUE Rounds such as structured rounding, aim to improve teamwork. Inverting this concept to first develop effective collaboration will support team adaptability and resilience. This enables teams to transition between the multiple rounding processes undertaken in a single ward. The emphasis becomes high-quality teamwork rather than a single rounding process.
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Affiliation(s)
- Victoria Walton
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
| | - Anne Hogden
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Julie Johnson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David Greenfield
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
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Grünewald M, Klein E, Hapfelmeier A, Wuensch A, Berberat PO, Gartmeier M. Improving physicians' surgical ward round competence through simulation-based training. Patient Educ Couns 2020; 103:971-977. [PMID: 31810763 DOI: 10.1016/j.pec.2019.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Ward rounds are an essential part of physicians' daily routine. Existing studies suggest that their practical implementation is inconsistent. Therefore, developing interventions to train ward round competence and assessing if they are effective educational tools are crucial goals for research. METHODS We analysed a simulation-based tutorial dedicated to fourth-year medical students, including casework and ward round simulation. We investigated the effectiveness of this intervention regarding ward round competence through a randomized controlled trial. Performance was assessed with the modified/validated surgical ward round assessment tool by two blinded and trained raters. Supplementary, motivation during the ward round tutorial was assessed for all students at different time points. RESULTS Analysis of the ratings show that, in contrast to the control group (pre: 66.1 vs. post: 64.8 points, p = 0.72), the ward round competence of the intervention group (pre: 62.6 vs. post: 69.6 points, p = 0.0169) improved significantly after participating in the ward round tutorial. CONCLUSION The results show that our simulation-based training is an effective way to improve competence of medical students in conducting surgical ward rounds. PRACTICE IMPLICATIONS Participation in ward round trainings is a valuable tool to prepare students for their future professional practise.
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Affiliation(s)
- Marc Grünewald
- Technical University of Munich, TUM School of Medicine, TUM Medical Education Center, Nigerstr. 3, 81675 Munich, Germany.
| | - Evelyn Klein
- Technical University of Munich, TUM School of Medicine, TUM Medical Education Center, Nigerstr. 3, 81675 Munich, Germany; Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaningerstrasse 22, 81675 Munich, Germany.
| | - Alexander Hapfelmeier
- Technical University of Munich, Institute of Medical Informatics, Statistics and Epidemiology, Ismaninger Str. 22, 81675 Munich, Germany.
| | - Alexander Wuensch
- Technical University of Munich, TUM School of Medicine, TUM Medical Education Center, Nigerstr. 3, 81675 Munich, Germany; Clinic of Psychosomatic Medicine and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstraße 5a, 79104 Freiburg, Germany.
| | - Pascal O Berberat
- Technical University of Munich, TUM School of Medicine, TUM Medical Education Center, Nigerstr. 3, 81675 Munich, Germany.
| | - Martin Gartmeier
- Technical University of Munich, TUM School of Medicine, TUM Medical Education Center, Nigerstr. 3, 81675 Munich, Germany.
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Carpenter A, Vora SM, Kestenbaum S, Thompson A, Devine M, Tenison E, Quicke E, Liang K, Deibel F. Afternoon ward rounds: bad for patients, bad for doctors? Future Healthc J 2019; 6:118-122. [PMID: 31363518 PMCID: PMC6616176 DOI: 10.7861/futurehosp.6-2-118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hospital medicine in the UK is under unprecedented pressure, with increasing demand on physicians as well as challenges in recruiting new doctors into the physicianly specialties. We sought to assess the prevalence of the afternoon ward round and its effect on those undertaking them. We sampled each hospital within our postgraduate region, surveying junior doctors working on inpatient medical wards. We surveyed roughly two-thirds of eligible doctors, -finding that 30% of juniors had some commitment, of varying frequency, to ward rounds beginning after 1.00pm. Of the -doctors involved in afternoon ward rounds, the majority felt they contributed to late finishes, delayed discharge of -patients, reduced team efficiency and reduced job -satisfaction. Just under 80% felt they were less likely to consider a career in hospital medicine as a result The afternoon ward round lives on, and we should not -underestimate its effect. Low junior doctor morale coupled with high work intensity can lead to burnout as well as -impairing the effectiveness of the clinical service. Clinical -leaders should consider leaving this practice in the past so we can cope with the challenges of the future.
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Abstract
Ward rounds are a highly important forum for collaborative medical reasoning. Despite being prevalent for over a century, they are under-researched. In particular, no clear and comprehensive statement of the purpose of ward rounds exists in the literature. This letter provides such a statement. Having the purpose of ward rounds clearly described helps to provide a foundation for evaluating the effectiveness of rounds and suggesting ways in which rounds can be improved.
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Affiliation(s)
- Paul Perversi
- Deakin University, Burwood Campus, Melbourne, Australia.
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Perversi P, Yearwood J, Bellucci E, Stranieri A, Warren J, Burstein F, Mays H, Wolff A. Exploring reasoning mechanisms in ward rounds: a critical realist multiple case study. BMC Health Serv Res 2018; 18:643. [PMID: 30119624 PMCID: PMC6098637 DOI: 10.1186/s12913-018-3446-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ward rounds are an important and ubiquitous element of hospital care with a history extending well over a century. Although originally intended as a means of educating medical trainees and junior doctors, over time they have become focused on supporting clinical practice. Surprisingly, given their ubiquity and importance, they are under-researched and inadequately understood. This study aims to contribute knowledge in human reasoning within medical teams, meeting a pressing need for research concerning the reasoning occurring in rounds. METHODS The research reported here aimed to improve the understanding of ward round reasoning by conducting a critical realist case study exploring the collaborative group reasoning mechanisms in the ward rounds of two hospitals in Victoria, Australia. The data collection involved observing rounds, interviewing medical practitioners and holding focus group meetings. RESULTS Nine group reasoning mechanisms concerning sharing, agreeing and recording information in the categories of information accumulation, sense-making and decision-making were identified, together forming a program theory of ward round reasoning. In addition, themes spanning across mechanisms were identified, further explaining ward round reasoning and suggesting avenues for future exploration. Themes included the use of various criteria, tensions involving mechanisms, time factors, medical roles and hierarchies. CONCLUSIONS This paper contributes to the literature by representing rounds in a manner that strengthens understanding of the form of the group reasoning occurring within, thus supporting theory-based evaluation strategies, redesigned practices and training enhancements.
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Affiliation(s)
- Paul Perversi
- School of Information Technology, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125 Australia
| | - John Yearwood
- School of Information Technology, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125 Australia
| | - Emilia Bellucci
- School of Business, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125 Australia
| | - Andrew Stranieri
- Centre for Informatics and Applied Optimisation, Federation University, University Drive, Mt Helen, VIC 3350 Australia
| | - Jim Warren
- Department of Computer Science, The University of Auckland, 38 Princes Street, Auckland, 1010 New Zealand
| | - Frada Burstein
- Caulfield School of Information Technology, Monash University, 900 Dandenong Road, Caulfield East, VIC 3145 Australia
| | - Heather Mays
- Caulfield School of Information Technology, Monash University, 900 Dandenong Road, Caulfield East, VIC 3145 Australia
| | - Alan Wolff
- Wimmera Health Care Group, 83 Baillie Street, Horsham, VIC 3400 Australia
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Paradis E, Leslie M, Gropper MA. Interprofessional rhetoric and operational realities: an ethnographic study of rounds in four intensive care units. Adv Health Sci Educ Theory Pract 2016; 21:735-48. [PMID: 26704051 DOI: 10.1007/s10459-015-9662-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/13/2015] [Indexed: 05/28/2023]
Abstract
Morning interprofessional rounds (MIRs) are used in critical care medicine to improve team-based care and patient outcomes. Given existing evidence of conflict between and dissatisfaction among rounds participants, this study sought to better understand how the operational realities of care delivery in the intensive care unit (ICU) impact the success of MIRs. We conducted a year-long comparative ethnographic study of interprofessional collaboration and patient and family involvement in four ICUs in tertiary academic hospitals in two American cities. The study included 576 h of observation of team interactions, 47 shadowing sessions and 40 clinician interviews. In line with best practices in ethnographic research, data collection and analysis were done iteratively using the constant comparative method. Member check was conducted regularly throughout the project. MIRs were implemented on all units with the explicit goals of improving team-based and patient-centered care. Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between MIRs' educational and care-plan-development functions all prevented teams from achieving collaboration and patient-involvement. Moreover, physicians' de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers' contributions. This study suggests that the MIRs model, as presently practiced, might not be well suited to the provision of team-based, patient-centered care. In the interest of interprofessional collaboration, of the optimization of clinicians' time, of high-quality medical education and of patient-centered care, further research on interprofessional rounds models is needed.
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Affiliation(s)
- Elise Paradis
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- The Wilson Centre, 144 College St Room 702, Toronto, ON, M5S 3M2, Canada.
| | - Myles Leslie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, 750 East Pratt Street, 15th Floor, Baltimore, MD, 21202, USA
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 500 Parnassus Ave, MUE 410, San Francisco, CA, 94143-0648, USA
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Ahmad A, Weston PJ, Ahmad M, Sharma D, Purewal T. A cost-benefit analysis of twice-daily consultant ward rounds and clinical input on investigation and pharmacy costs in a major teaching hospital in the UK. BMJ Open 2015; 5:e007367. [PMID: 25854972 PMCID: PMC4390722 DOI: 10.1136/bmjopen-2014-007367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Misuse of investigations, medications and hospital beds is costing the National Health Service (NHS) billions of pounds with little evidence that approaches centred on reducing overuse are sustainable. Our previous study demonstrated that twice-daily consultant ward rounds reduce inpatient length of stay and suggested a reduction in overuse of investigations and medications. This study aims to assess the impact of daily consultant ward rounds on the use of investigations and medications and estimate the potential cost benefit. SETTINGS The study was performed on two medical wards in a major city university teaching hospital in Liverpool, UK, receiving acute admissions from medical assessment and emergency departments. PARTICIPANTS AND INTERVENTION The total number of patients admitted, investigations performed and pharmacy costs incurred were collected for 2 years before and following a change in the working practice of consultants from twice-weekly to twice-daily consultant ward rounds on the two medical wards. OUTCOME MEASURES We performed a cost-benefit analysis to assess the net amount of money saved by reducing inappropriate investigations and pharmacy drug use following the intervention. RESULTS Despite a 70% increase in patient throughput (p<0.01) the investigations and pharmacy, costs per patient reduced by 50% over a 12-month period (p<0.01) and were sustained for the next 12 months. The reduction in investigations and medication use did not have any effect on the readmission or mortality rate (p=NS), whereas, the length of stay was almost halved (p<0.01). Daily senior clinician input resulted in a net cost saving of £336,528 per year following the intervention. CONCLUSIONS Daily consultant input has a significant impact on reducing the inappropriate use of investigations and pharmacy costs saving the NHS more than £650K on the two wards over a 2-year period.
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Affiliation(s)
- Aftab Ahmad
- Department of Diabetes/Endocrinology and General Medicine, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
| | - Philip J Weston
- Department of Diabetes/Endocrinology and General Medicine, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
| | - Mahin Ahmad
- Department of General Medicine, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
| | - Dushyant Sharma
- Department of Diabetes/Endocrinology and General Medicine, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
| | - Tejpal Purewal
- Department of Diabetes/Endocrinology and General Medicine, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
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Abstract
Models suggested for managing acute, non-elective, medical admissions include expanding geriatric services, extending the role of the acute physician and rejuvenating the role of the general physician. We investigated improving inpatient care by changing consultants' work patterns and placing a higher priority on the ward rounds. A focus group and a questionnaire were used to study the impact on several ward round parameters. All respondents reported an overall satisfaction: 93% rated the quality of care as good or excellent, 75% reported increased safe patient discharges and 68% observed improved teamwork. Length of stay reduced to 4 days from 5.3 days without an increase in readmission. The main themes showed improved quality of care, better assured patients and relatives, and better consultant job satisfaction, but also showed reduced junior doctors' independent decision-making and a slight reduction in specialty-related activity. The study concluded that placing a higher priority on ward rounds by altering consultants' work patterns has a positive impact on inpatient care.
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Affiliation(s)
- Ash Soliman
- Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Shahzad Riyaz
- Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | | | | | - Andy Mills
- Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Kapil Kapur
- Barnsley Hospital NHS Foundation Trust, Barnsley, UK
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