Tuesday, 3 September 2013

How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

Follow me on twitter @HemadriTweets

PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.


anu susan said...

I think this is fantastic. The only downside would be is if you had 40 patients, then it could take all day. Also sometimes more junior members of the staff need to see patients themselves in order to get into the groove of decision making. It is a great boon for the SHO's who get a lot of teaching and finish all their jobs and also amazing for the patients who get sorted straight away.

M HEMADRI said...

Thanks for your comments Anu.

Like any method if it is practised it comes out smoothly. On some occasions when we have had a large number of patients (e.g. post on-call) of course it takes longer but everyone is more prepared so that the efficiency is not lost.

The consultant ward round was only twice a week, the rest of the days it was registrars making decisions (after seeking appropriate advice as needed).

You are right that from the patient's perspective this is perfect. That is what we should all be looking for.