Interprofessional ward rounds in an adult intensive care unit: an appreciative inquiry into the central collaboration between the consultant and the bedside nurse

Done well, ward rounds (WRs) promote effective, safe care and collaboration; but WR quality varies. An improvement-focused appreciative inquiry (AI) into a large intensive care unit's WR practices identified a pivotal axis of collaboration between the most senior medical role (the consultant) and the bedside nurse (BSN). This paper examines that axis of interprofessional collaboration (IPC) to deepen understanding of its implications. Data included ethnographic observations, interviews, and co-constructed AI with groups of staff. Four key concepts emerged from cyclical interpretive analysis: "need," "presence," "ability" and "willingness." BSNs and consultants needed the interprofessional WR to enable their work; WR effectiveness was affected by whether they were both present, then able and willing to participate in IPC. BSN presence was necessary for effective and efficient IPC between these key roles. Indirect contributions, based on prior exchanges with colleagues or through written notes, reduced the joint problem-solving through discussion and negotiation that characterizes IPC to less efficient asynchronous interprofessional coordination. Factors affecting "presence," "ability" and "willingness" are discussed alongside potential mitigations and acknowledgment of asymmetric power. Appreciative examination of interprofessional WRs identified mechanisms supporting and undermining effective WR IPC and the centrality of consultants' and BSNs' collaboration.

Patients' experiences of clinical team meetings (ward rounds) at an adult in-patient eating disorders ward: mixed-method service improvement project

AIMS

Ward rounds are key to treatment-related decision-making, but are often stressful. This project aimed to explore and improve patients' experiences of the clinical team meeting (CTM; historically known as ward round) in an adult in-patient eating disorders unit. A mixed-method approach was adopted with in vivo observations, two focus groups and an interview. Six patients participated. Two former patients contributed to data analysis, co-production of service improvement initiatives and write-up.

RESULTS

The mean CTM duration was 14.3 min. Patients spoke half of the time, followed by psychiatry colleagues. 'Request' was the most discussed category. Three themes were identified: CTMs are important but impersonal, a sense of palpable anxiety was generated and staff and patients had divergent views regarding CTM goals.

CLINICAL IMPLICATIONS

The co-produced changes to CTMs were implemented and improved patient's experiences despite COVID-19 challenges. Factors beyond CTMs, including the ward's power hierarchy, culture and language, need addressing to facilitate shared decision-making.

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.

Using instant messaging applications to promote clinical teaching of medical students

BACKGROUND

The main purpose of this study was to evaluate the use of Telegram as an Instant messaging application in clinical teaching of medical students, especially clinical ward rounds.

MATERIALS AND METHODS

In this quasi-experimental study, Telegram as an Instant messaging application was employed. To do this, a Telegram group entitled as "Lavender" was created and then selected patients were divided between students and externs daily. After that, students and externs were asked to take medical histories, perform complete physical examinations, and then share their data in the Lavender group. Ultimately, to evaluate the effects of this intervention, two quantitative and qualitative approaches were used.

RESULTS

From the students' point of view the highest average was associated with "Readiness for teaching round" (3.71 ± 1.34) and the lowest average was related to "Time-saving for studying about illnesses" (2.08 ± 1.44). In addition, medical trainees mentioned that reporting patients' daily medical histories and progress notes could create a reflective process. The suggestion made by many medical trainees was to select and discuss simpler cases who have more teaching points for them, while other trainees recommended focusing on common illnesses in the Lavender group.

CONCLUSION

The use of messaging software applications such as Telegram in medical education has created a new paradigm, which could facilitate interpersonal interactions among trainees.

Using a checklist within simulation improves trainees' confidence on ward rounds

Ward rounds are integral to maintaining patient safety in everyday clinical care. Junior doctors are often expected to conduct independent rounds on graduation, but many feel ill-equipped to do so. We developed a safety checklist and simulation sessions to improve junior-led ward round practice at one district general hospital. We found that embedding a checklist within simulation is an effective way to teach ward round skills and increase confidence among undergraduate and postgraduate medical trainees.

Conducting a good ward round: How do leaders do it?

RATIONALE, AIMS AND OBJECTIVES

Ward rounds (WRs) are complex social processes. Done well, WR discussions and decisions contribute to timely, safe, effective progression of care. However, literature highlights medical dominance; marginalisation or absence of other perspectives, safety risks and suboptimal resource use. This study examined leadership behaviours and what supported good interprofessional WRs, defined as enabling interprofessional collaboration and decision making which progresses patient care in a safe and timely manner. Deepening appreciation of this art should support learning and improvements.

METHOD

Mixed-method appreciative inquiry (AI) into how WRs go well and could go well more often.

CONTEXT

daily interprofessional consultant-led WRs in a large adult critical care unit.

DATA

ethnographic and structured observations (73 h, 348 patient reviews); AI conversations and interviews (71 participants). Inductive iterative analysis shaped by Activity Theory.

PARTICIPANTS

256 qualified healthcare professionals working in the unit.

RESULTS

Leadership of good WRs supported (and minimized contradictions to): making good use of expertise and time, and effective communication. These three key activities required careful and skilled orchestration of contributions to each patient review, which was achieved through four distinct phases (a broadly predictable script), ensuring opportunity to contribute while maintaining focus and a productive pace. This expertise is largely tacit knowledge, learnt informally, which is difficult to analyse and articulate oneself, or explain to others. To make this easier, and thus support learning, we developed the metaphor of a conductor leading musicians.

CONCLUSIONS

Whilst everyone contributes to the joint effort of delivering a good WR, WR leadership is key. It ensures effective use of time and diverse expertise, and coordinates contributions rather like a conductor working with musicians. Although WR needs and approaches vary across contexts, the key leadership activities we identified are likely to transfer to other settings.

The Ward Round: Patients' Perceptions of a Patient-Centered Approach and Their Suggestions for Improved Participation

PURPOSE

To explore, through a learning activity for healthcare students, how patients perceived the ward round and its patient-centered approach.

PATIENTS AND METHODS

Patients admitted for elective orthopedic surgery were invited to participate in the study, which involved answering a survey comprising seven intersectional questions and eight free text questions. In addition, medical and nursing students did semi-structured interviews with the patients, covering the same free text questions. Twenty-three patients answered the survey, of whom fifteen also completed the interviews. The results from the interviews were explored using a thematic content analysis.

RESULTS

Forty-three percent (10/23) of the patients strongly agreed or agreed that their knowledge of patient-centered ward round was sufficient to be able to participate actively, and thirty percent (7/23) indicated they had good knowledge of the laws and regulations governing the care of patients. Most of the patients felt satisfied with how their own and their relatives' experiences were taken into account. The categories information and to be listened to were mentioned repeatedly by patients as priorities for patient-centered ward rounds. The interview analysis revealed four main categories: preparation, communication, organization, and safety as important and in need of improvement.

CONCLUSION

Less than half of the patients surveyed felt they could participate in the ward round, which indicates that there is an opportunity for improvement and development. Better information and communication about legal rights, as well as about the structure and content of the ward round, could be valuable to patients before admission. It is also important to find a way for patients' individual wishes to be more fully and easily conveyed to medical staff. Creating a more tailor-made ward round for each patient and fulfilling a patient-centered approach will likely entail a substantial organizational and mental shift.

Do ward rounds offer effective teaching and training? Obstacles to learning and what makes good teaching in a large tertiary care hospital from trainee doctor's perspective

Background: Ward rounds (WR) have been integral to the process of teaching and learning medicine and also provides a vital opportunity to communicate with the patient, their relatives, and other healthcare professionals. Yet in recent years trainees' perception of the educational value of WRs seems to have declined. Objectives: The aim of this study to assess trainees' perception of the educational value of WRs at King Abdulaziz Medical City(KAMC), Riyadh, a 1500 bed academic hospital in Saudi Arabia. Methods: A self-administered, paper-based survey was distributed to physicians in training at KAMC between October and December 2019. All residents who attended WRs were invited to participate. The questionnaire was adapted from a survey used in a previous study. The demographic section requested details of the respondent's age, gender, specialty, and seniority. The second and third sections asked about the logistics of current ward round practices. It included several questions on the structure as well as the duration and frequency of ward rounds. The fourth and fifth sections asked for participant's perception of the opportunities for, and the obstacles to, learning on ward rounds. The subsequent sections asked several questions onward round structure and the clinical teacher. Responses were requested on a 5-point Likert-type scale (strongly disagree, disagree, neutral, agree, strongly agree). The last section asked the participant for general comments and feedback Result: The study targeted 250 residents in specialties that routinely performed WRs. Only 166 residents returned the questionnaire (response rate of 66.4%). Male 89 (53.6%), medical 108 (65.1%), surgical 58 (34.9%), resident in first year 81 (48.8%). The overall average time spent on WR was 13 (± 11 SD) hours per week. The WR was perceived as a good opportunity to learn about diagnostic investigation 138 (83%) and patient management 133(80.1%), history taking114 (68.7%) physical examination 103 (62.0%), and time management skills 86 (51.8%). The majority of our trainees felt that the WR was educationally very useful to 86 (52%) and attribute to at least a third of the education they receive during their training. They also reported that about the quarter of the time spent on WRs is devoted to teaching. The good teacher described as enthusiastic to teach 137 (82.5%), provide feedback to trainees 135 (81%), do not rush 139(83.7), communicate to trainee 144 (86.7), and consultant level,101 (60.8). Trainees also identify a few factors that hinder their training such as lack of time 130 (79%), and the number of patients 129 (78.3). Conclusion: This study identifies the strengths and weaknesses of WR in our institution. Finding will help training supervisors in addressing and rectifying these shortcoming and factors hinder training.

Clinicians' perceptions of rounding processes and effectiveness of clinical communication

RATIONALE, AIMS, AND OBJECTIVES

Ward rounds present opportunities for medical officers, nurses, allied health clinicians, and patients to interact and plan patient care. A recent literature review found eight types of rounding processes. Different purposes, varying levels of representation from clinical professions, and understanding of each others' roles revealed a complex activity. A shared understanding of rounding processes facilitates positive teamwork and improves patient care. We examined how clinicians perceive the nature of rounding processes they undertake within their practice, multidisciplinary team attendance at rounds, and the effectiveness of team communication.

METHODS

We surveyed frontline professionals in two acute care and two rehabilitation wards from a metropolitan teaching hospital. There were 77 participants representing medical officers, nurses, and allied health clinicians. Participants selected the type of rounding processes undertaken on their ward from a list of six defined types, then answered questions about who participated in the rounds and their perceptions of the effectiveness of multidisciplinary communication. Survey findings were analysed using descriptive statistics and comparison.

RESULTS

Overall, professionals were inconsistent in the identification of number and types of rounds. Participants nominated processes more consistently within individual clinical disciplines than by clinical speciality. Medical officers identified rounds most consistently, while some nurses were unable to identify any rounding processes undertaken. The perceptions clinicians had of their own attendance at rounds differed from that of their colleagues. Despite variation in perceptions about rounds, professionals reported effective multidisciplinary communication patterns overall.

CONCLUSION

Rounds are a common yet complex activity. Rounds are revealed to be a taken-for-granted organizational activity with diversity in function, attendance, and participation, yet rounding processes are perceived and experienced differently between health professions. These differences impact on multidisciplinary attendance at rounds amongst peers. Making and communicating explicit round expectations and roles for clinicians supports coordinated teamwork and care planning.

Introduction and validation of a surgical ward round checklist to improve surgical ward round performance in a tertiary vascular service

BACKGROUND

Surgeons administer care in an increasingly complex clinical environment. Time constraints put strain on individual clinicians and the multidisciplinary team, increasing the risk of human errors. The World Health Organization surgical checklist has shown to mitigate this risk perioperatively. We describe the development, introduction and outcomes of a novel ward round safety checklist.

METHODS

The vascular team ward rounds at Christchurch Hospital were assessed over a 2-week period for ward round quality indicators. A ward round safety checklist was developed and then introduced. Two further assessments were conducted to evaluate for improvement in the ward round quality indicators. Ward rounds were timed with the length of each consultation recorded and staff perception assessed.

RESULTS

Significant gains across both clinical indicators and staff feedback measures were observed. Of the 21 ward round quality indicators, 20 showed statistically significant improvement, as did all subjective measures. Significant improvements included observation chart review (20% to 75% to 81%), drug chart review (10% to 54% to 78.6%) and anticoagulation/antiplatelet treatment (32% to 61% to 58.1%) (P < 0.05). Mean consultation time per patient did not increase (3 min 58 s to 3 min 48 s and 4 min 30 s) (P = 0.857 and P = 0.119).

CONCLUSION

This study provides evidence that introducing a structured ward round safety checklist improved ward round quality, without adversely affecting consultation time. The familiar checklist structure promotes its acceptance and team cohesion. Whether the improvements observed translate to improved patient outcomes and reduced adverse events reporting is the subject of ongoing study.

A Ward-Round Non-Technical Skills for Surgery (WANTSS) Taxonomy

BACKGROUND

Around half of surgical adverse events occur outside the operating room. However the majority of nontechnical skills (NTS) training programs have been developed for the intraoperative environment. Ward rounds are a crucial part of extraoperative care and to date no specific NTS training manual has been developed targeting emergency general surgical ward rounds.

AIM

To develop a NTS taxonomy for emergency general surgical ward rounds that can be used to improve surgical team members' NTS and improve outcomes.

METHODS

A literature review of existing NTS taxonomies was conducted, followed by semistructured interviews and observational data collection, to determine good and poor surgical ward-round behaviors. These behaviors were reviewed by a panel of subject matter experts and categorized into a taxonomy, using the Non-Technical Skills for Surgeons taxonomy framework as a guide.

RESULTS

The Ward-round Non-Technical Skills for Surgery taxonomy includes examples of good and poor ward-round-specific behaviors, grouped into elements and categories. The taxonomy can be used as both a training and teaching manual for the surgical team.

CONCLUSION

Ward rounds are a crucial part of extraoperative surgical care. The Ward-round Non-Technical Skills for Surgery taxonomy provides surgical teams with a manual to help them improve their ward-round NTS.

The surgical ward round checklist: improving patient safety and clinical documentation

Purpose

The daily surgical ward round (WR) is a complex process. Key aspects of patient assessment can be missed or not be documented in case notes. Safety checklists used outside of medicine help standardize performance and minimize errors. Its implementation has been beneficial in the National Health Service. A structured WR checklist standardizes key aspects of care that need to be addressed on a daily surgical WR. To improve patient safety and documentation, we implemented a surgical WR checklist for daily surgical WRs at our hospital. We describe our experience of its implementation within the general surgical department of a teaching hospital in the UK.

Methods

A retrospective review of case note entries from surgical WRs (including Urology and Vascular surgery) was conducted between April 2015 and January 2016. WR entries of 72 case notes were audited for documentation of six parameters from the surgical WR checklist. A WR checklist label with the parameters was designed for use for each WR entry. A post-checklist implementation audit of 61 case notes was performed between Jan 2016 and August 2016. To assess outcome on patient safety, adverse events relating to these six parameters reported to the local clinical governance team were reviewed pre – and post-checklist implementation.

Results

Overall documentation of the six parameters improved following implementation of the WR checklist (pre-checklist=26% vs post-checklist=79%). Documentation of assessment of fluid balance improved from 8% to 76%. Subsequent audit at 3 months post-checklist implementation maintained improvement with documentation at 72%.

Conclusion

The introduction of the surgical WR checklist has improved documentation of key aspects of patient care. The WR checklist benefits patient safety. It improves communication, documentation and ensures that key issues are not missed at patient assessment on WRs. A crucial factor for successful documentation is engagement by the senior clinicians and nursing staff on its benefits which ensures appropriate use of WR checklist labels occurs as doctors rotate through the surgical placement.

A systematic review of the costs and cost-effectiveness of clinical pharmacists on hospital ward rounds

Introduction: There is a lack of good quality economic evidence for the inclusion of pharmacists on hospital ward rounds in addition to, or as an alternative to, traditional ward-based clinical pharmacy services. There has been no systematic review of the cost or cost-effectiveness of pharmacists attending and contributing on ward rounds. Areas covered: A literature search was conducted in Medline, Embase, Cochrane, and CINAHL and reported in accordance with the PRISMA guidelines in May 2019. As well, a search using Google Scholar and a targeted hand search were undertaken. Studies that reported any estimate of the cost or cost-effectiveness were included if pharmacist participation on inpatient hospital ward rounds was the predominant focus of the intervention. The identified studies were subsequently screened by three reviewers who extracted data on their clinical and economic design. A bias assessment was completed using the ROBINS-I tool. Expert opinion: Seven studies were identified investigating a clinical pharmacist's inclusion on hospital ward rounds where there was a cost estimated. However, none were deemed to be a full economic evaluation and all were found to be open to a serious risk of bias. Future evaluations should include a comparator group and investigate the cost and cost savings of the service, alongside their clinical outcomes.

Incorporating point-of-care ultrasound into daily intensive care unit rounds: Another source of interruptions?

Point-of-care ultrasound (POCUS) is the use of bedside ultrasonography by the treating clinician, incorporating those images into direct clinical decisions. While there are a number of different techniques and training pathways in this relatively new modality, there has been little discussion around the logistics of integrating POCUS into the standard critical care "business day" of ward rounds, procedures and meetings. This article explores some of these aspects and presents data from an online survey of POCUS practitioners.

Opening the black box: An observational study of teaching and learning interactions for paediatrics trainees on consultant ward rounds

AIM

Ward rounds are complex activities in which education must be balanced against service. Limited evidence exists regarding how to optimise ward round education. In order to improve the educational experience, we aimed to understand the teaching and learning interactions on ward rounds with a particular focus on the experience of paediatric trainees.

METHODS

We conducted an initial quantitative survey as a needs assessment regarding learning and teaching in clinical settings using a structured survey of 21 trainees. This was followed by an observational study using focused ethnography of 20 consultant ward rounds in a general medical department of tertiary paediatric hospital. We used a structured observation form to document ward round characteristics and educational interactions. Data were analysed using inductive content analysis to understand key influences on teaching and learning interactions.

RESULTS

Trainees reported a discrepancy between the actual educational value of ward rounds (mean rating 2.7/5) and what they desired (mean 4.3/5). Ward round ethnography revealed examples of excellent education and practice alongside missed opportunities. Explicit education on rounds was dominated by technical content with little focus on other aspects of professionalism. Major influences on educational interactions were the ward round model - consultant-as-expert versus learner-centred - and the hidden curriculum.

CONCLUSION

There are many examples of excellence in ward round education, yet there remains substantial scope to better harness the education potential of rounds. This requires us to challenge assumptions, enable feedback and reflection and make learning explicit - while putting the learner at the centre of educational opportunities.

Prescribing and medication communication on the post-take ward round

Gaps in communication between medical officers and poor planning are associated with prescribing errors and may result in patient harm. This study describes medication communication on post-take ward rounds (PTWR). Over 6 weeks on 24 PTWR, 130 patients, prescribed 1244 medications, were observed. Of these, 811 (65%) medications were discussed, with 249 discussions (relating to 126 medications) being 'in-depth'. Of 191 planned medication-related actions, 38 (20%) were not implemented by the end of the PTWR and 21 (11%) by time of discharge from hospital. This study suggests that the level of medication communication and subsequent actions are suboptimal. Processes to improve this situation should be explored.

Educational opportunities on a ward round; utilising near-peer teaching

Near-peer teaching (NPT) has been shown to be useful in undergraduate and postgraduate medical teaching, but there is sparse knowledge of its applicability in clinical settings, such as the ward round. The current study assessed the suitability of NPT on a consultant ward round and ascertained its advantages and disadvantages as a teaching method in this setting. NPT was trialled on three consecutive consultant ward rounds on a palliative medicine inpatient unit in a cancer centre. Both learner (three junior doctors) and facilitator (one consultant) views were sought via questionnaires and interviews. Data were analysed using thematic content analysis. All participants felt that NPT gave a better educational experience compared with traditional ward rounds. Participants found NPT improved their own teaching ability, was quick and easy to use, and was tailored to the learner. More advantages were cited than disadvantages. Disadvantages were only mentioned by senior doctors and included time off the ward round and lack of teaching for the senior member of the near-peer pair. Thus, NPT could be a useful educational tool to provide differentiated learning in busy clinical settings. However, more research is needed to ensure that it can meet the learning needs of senior trainees.

Video-based on-ward supervision for final year medical students

BACKGROUND

Constructive feedback is an essential element of the educational process, helping trainees reach their maximum potential and increasing their skill level. Video-based feedback has been described as highly effective in various educational contexts. The present study aimed to evaluate the feasibility and acceptability of video-based, on-ward supervision for final year students in a clinical context with real patients.

METHODS

Nine final year medical students (three male, six female; aged 25.1 ± 0.7 years) and eight patients (five male, three female; aged 59.3 ± 16.8 years) participated in the pilot study. Final year students performed routine medical procedures at bedside on internal medicine wards at the University of Heidelberg Medical Hospital. Students were filmed and were under supervision. After performing the procedures, an oral feedback loop was established including student, patient and supervisor feedback on communicative and procedural aspects of skills performed. Finally, students watched their video, focusing on specific teachable moments mentioned by the supervisor. Written evaluations and semi-structured interviews were conducted that focused on the benefits of video-based, on-ward supervision. Interviews were analysed qualitatively, using open coding to establish recurring themes and overarching categories to describe patients' and students' impressions. Descriptive, quantitative analysis was used for questionnaire data.

RESULTS

Supervised, self-chosen skills included history taking (n = 6), physical examination (n = 1), IV cannulation (n = 1), and ECG recording (n = 1). The video-based, on-ward supervision was well accepted by patients and students. Supervisor feedback was rated as highly beneficial, with the video material providing an additional opportunity to focus on crucial aspects and to further validate the supervisor's feedback. Students felt the video material would be less beneficial without the supervisor's feedback. The setting was rated as realistic, with filming not influencing behaviour.

CONCLUSION

Video-based, on-ward supervision may be a powerful tool for improving clinical medical education. However, it should be regarded as an additional tool in combination with supervisors' oral feedback. Acceptance was high in both students and patients. Further research should address possibilities of efficiently combining and routinely establishing these forms of feedback in medical education.

iPad use at the bedside: a tool for engaging patients in care processes during ward rounds?

BACKGROUND

Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings.

AIMS

To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events.

METHODS

Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey.

RESULTS

Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief.

CONCLUSIONS

Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done.

The educational value of ward rounds for junior trainees

The ward round (WR) is a complex task and medical teachers are often faced with the challenge of finding a balance between service provision and clinical development of learners. The educational value of WRs is an under-researched area. This short communication aims to evaluate the educational role of WRs for junior trainees and provides insight into current practices. It also identifies obstacles to effective teaching/training in this setting and provides suggestions for improving the quality of WR teaching.

An interventional study on intensive care unit drug therapy assessment in a rural district hospital in India

Background:

Intensive care unit is a potential area for drug-related problems. As many of the patients treated are complex patients, clinical pharmacy intervention could find drug therapy problems.

Materials and Methods:

Drug information liaisons daily attended ward rounds with intensivists and screened the patient for drug therapy assessment using the American Society for Health-System Pharmacists clinical skills competition DTA format. This was a prospective study done for 6 months from August 2012 to January 2013. Simple statistics were used to tabulate the drug-related problems assessed.

Results:

A total of 72 patients were screened for drug therapy problems, for which 947 drug doses were prescribed in the study period. The total number of prescriptions was 148. The average number of drugs per prescription was 6.39 and the average number of drugs per patient was 13.15. A total of 243 problems were identified; on an average, 1.67 problems were present per prescription. The total number of drug interactions identified was N = 192 (78.2%); majority of them (61.4%) were of type C (not serious). So, 55.73% of them were monitored and not stopped or substituted. The second type of problem was a correlation between drug therapy and medical problem (7.4%). Appropriate drug selection and drug regimen was the third problem, and the adverse drug reactions and therapeutic duplications accounted for approximately 2% of the drug-related problems identified.

Conclusion:

Drug interactions constituted the major problem of ICUs, but not many were serious or significant. Consensus in assessment of drug-related problems and convincing intensivists with good quality evidences are required for better acceptance of interventions.

Older patients' participation in team meetings-a phenomenological study from the nurses' perspective

Although the importance of patient participation is acknowledged in today's healthcare, many challenges remain before patient participation can become an integral part of care provision. The ward round has traditionally been the forum for crucial decisions about patient care, but often with limited possibilities for patient participation. As part of the process of improving patient participation, the round in the present study has been replaced by a team meeting (TM) to which the patient has been invited. The aim of this study is to highlight nurses' experiences of older patients' participation in TMs. The research process was guided by the principles of phenomenological reflective life world research. Data were collected in a Swedish hospital, in a ward specializing in older patients. Nine nurses, who had invited and planned for a patient to participate in TMs and/or had experienced TMs in which patients participated, were interviewed. The essential meaning of patient participation in the TM, as experienced by the nurses, is that patient participation can be supported by a safe relationship in which the patient can make his or her voice heard. Participation is challenged by the patients' vulnerability and by the subordinated role assigned to the patient. The essential meaning is further described by its constituents: "the need for a guide," "patient participation challenged by structures," and "creating space for the whole human being." In conclusion, the nurse plays a core role in guiding the patient in an unfamiliar situation. The meaning of patient participation in the TM needs to be discussed by professionals so that the patient perspective is present.