Routine RoundsWe have a 26 bed ward, shared between 2 consultants. When one is on leave the other is responsible for all 26 cases. I count the start time, as the time in my office when I commence looking up information on new arrivals on the ward since the day before. I look up previous summaries, letters and current blood tests and imaging and if there is time the current prescription. This often takes from 08:00 to 08:40. I then arrive on the ward for the Boardround which lasts from 08:45 to 09:00 and the 5 minutes Safety Huddle. We then start seeing patients. I count the end time as the end of handover of any updates to the Nurse in Charge. I always do 2 full rounds a week and sometimes more. If the other Consultant is away and the Registrar is present, and we have enough other Juniors, we split the cases 50:50 and debrief afterwards.
I count whether we get a briefing from the nurse before we start the round, whether there is a nurse with the patient during the review (I count the briefest glimpse of the nurse as “nurse present”) and whether we can find a nurse to update after the review.
Post take roundsI now only do post take rounds on a few Saturday and Sunday mornings a year (18 rounds in 2017). I try to monitor the take from home using a virtual private network connection. I arrive in my office at 07:00 and prepare for the round at 08:00. I spend that hour, as above, in looking up summaries, letters, results, imaging etc. At 08:00 I go to the Acute Medical Unit and “hear” all the cases presented by the night team of a Registrar and 2 Senior House Officers. We then do all the bedside reviews and we are meant to finish by 09:30. Once I have seen the night admissions, the night team leave, and I review the evening admissions, pretty much solo. At about Noon, I meet with the daytime AMU Consultant and handover all the admissions. I count the end of that meeting as the end time.
The statistics from 2016 :
Routine Rounds 121
Case Reviews 1769, 466 new arrivals to the ward, 1303 reviews
Average time per case review 15 minutes 54 seconds*
Briefing at Boardround 1503 (85%)
Nurse with patient 328 (18.5%)
Report back to nurse 1478 (83.6%)
*I cannot tease out time taken for new arrival review from routine review
Post Take Rounds 18
Case Reviews 206 cases
Average time per case review 24 minutes 24 seconds
Briefing from nurse 0
Nurse with patient 8 (3.8%)
Report back to Consultant 170 (82.5%)*
*A senior nurse usually, but not always, present at Report Back
The statistics for nurse with patient during the Consultant led clinical review remain very low (18.5% on our general ward, and just 3.8% on the Acute Medical Unit). Poor communications are repeatedly cited as a reason for errors and complaints in healthcare. At the crucial review consultation, the team is simply not present.
This is our first full year working on a single general ward and The Boardround has resulted in an important improvement in briefing from the Nurse in Charge, prior to seeing the patients. It has also resulted in an improvement in “Report back to Nurse”, because we do not have to rush away to another ward to complete the round.
The time taken per general ward review has increased from 10 mins 42 seconds in 2010 to 15 minutes 54 seconds in 2016. The greatest change in this time has been the drop in number of Junior Doctors available to do the rounds. For post take rounds the time per patient in 2010 was 15 minutes 30 seconds and is now 24 minutes 24 seconds. Some of this may be because I now only do weekend post take rounds, when there are far fewer staff around. The other change since 2010 has been the fragmentation of the admitting team, and fewer Doctors physically available for the post take round.
A personal reflection
- It is interesting how much longer ward round reviews have become over the last 6 years.
- Back in 2010, it was common for me to have 2 to 4 other Doctors on Routine Rounds, whereas now it is common to have just 1.
- For post take rounds, I used to do a lot of weekday rounds, when the post take team was protected by a large cohort of day doctors coming on duty. At weekends there is no large cohort, so it is much more difficult to gather the team and hold it together during the round.
- The cohesiveness of teams is less, this means in turn it is far more difficult to know whom to trust, hence the need to check everything. You may think this is too much obsession, but I recall finding a man in acute renal failure, who had had been in hospital 3 days, had had 3 or 4 sets of renal bloods done but no evidence that anyone had looked at the results, considered the problem and taken action. The admission renal tests had not been written on the admission proforma, nor noted on the post take round, nor had any of the subsequent results … until I picked him up as a new arrival on our ward …
- The statistics for nurse with the patient during clinical review, remain depressingly low, particularly for post take rounds. Poor communication is cited as the root cause of many errors and complaints. We don’t have even poor communication at the bedside, we most often have none, and these are the most importantly acutely ill patients, and also others who may be discharged. I know of at least 2 cases whom I discharged because I believed the patient’s own report on mobility and activities of daily living, who were swiftly readmitted. A nurse acquainted with the patient would likely have spoken up and said for example “The patient cannot walk and is not continent”
Dr Gordon Caldwell FRCP [email protected]