Medication communication during ward rounds on medical wards: Power relations and spatial practices

Introducing multidisciplinary ward rounds in Malawi: a best practice implementation project

INTRODUCTION

The Royal College of Physicians (RCP) and the Royal College of Nursing (RCN) in the United Kingdom advocate the use of structured multidisciplinary team (MDT) ward rounds since they can enable safe, effective, improved care and enhanced staff satisfaction.

OBJECTIVES

This project sought to implement best practices for MDT ward rounds in a male medical ward in a hospital in Malawi.

METHODS

The project was conducted in line with the JBI Evidence Implementation Framework. A baseline audit of MDT ward rounds was conducted with six staff members. Audit criteria consisted of ten best practices, as recommended by JBI, the RCP, and the RCN. Stakeholder meetings were held to review the baseline audit results and highlight areas of non-compliance. JBI's Getting Research into Practice (GRiP) tool was used to identify barriers to compliance with best practices, and a follow-up audit was conducted to determine changes in practice.

RESULTS

The results only showed improvement for one criterion, which rose from 33% to 100% (n=6) where nurses attended the ward round.

CONCLUSIONS

This study demonstrated some challenges in evidence implementation projects and how these can, in part, be overcome. While the results only demonstrated improvement for one criterion, this paper shows how audits can be used to promote best practice, which in this case resulted in nurses being more involved in ward rounds, improvements in MDT communication, enhanced nurse inclusion in decision-making and, consequently, patient care.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A233.

Exploration of 'micro' level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory

BACKGROUND

Macro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The 'micro' level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored.

OBJECTIVE

Explore 'micro' level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory.

METHOD

A qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique).

RESULTS

Three micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation.

CONCLUSION

Clinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Decision-making about changing medications across transitions of care: Opportunities for enhanced patient and family engagement

BACKGROUND

Older patients often have complex medication regimens, which change as they move across transitions of care. Engagement of older patients and families in making medication decisions across transitions of care is important for safe and high-quality medication management.

AIMS

To explore decision-making between health professionals, older patients and families about medication changes across transitions of care, and to examine how patient and family engagement is enacted in the process of decision-making in relation to these medication changes.

METHODS

A focused ethnographic design was undertaken with semi-structured interviews, observations, and reflective focus groups or interviews. Reflexive thematic analysis was conducted on transcribed data. The study was undertaken at a public teaching acute care hospital and a public teaching community hospital in Australia.

RESULTS

In all, 182 older patients, 44 family members and 94 health professionals participated. Four themes were conceptualised from the data: different customs and routines, medication challenges, health professional interactions, and patient and family involvement. Environments had differences in their customs and routines, which increased the potential for medication delays or the substitution of unintended medications. Medication challenges included health professionals assuming that patients and families did not need information about regularly prescribed medications. Patients and families were informed about new medications after health professionals had already made decisions to prescribe these medications. Health professionals tended to work in disciplinary silos, and they had views about their role in interacting with patients and families. Patients and families were expected to take the initiative to participate in decision-making about medication changes.

CONCLUSIONS

Patient movements across transitions of care can create complex and chaotic medication management situations, which lacks transparency, especially for older patients and their families. A greater focus on pre-emptive and planned discussions about medication changes will contribute to improving patient and family involvement in medication decision-making.

SIN-BARRSS - Developing a mnemonic to support nurses' participation in interprofessional ward rounds in intensive care: An appreciative inquiry for quality improvement

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.

Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication

BACKGROUND

Communicating about medications across transitions of care is important in older patients who frequently move between health care settings. While there is increasing interest in understanding patient communication across transitions of care, little is known about older patients' involvement in formal and informal modes of communication regarding managing medications.

OBJECTIVE

The aim of this paper was to explore how older patients participated in managing their medications across transitions of care through formal and informal modes of communication.

METHODS

The study was conducted across two metropolitan hospitals: an acute hospital and a geriatric rehabilitation hospital in metropolitan Melbourne, Australia. A focused ethnographic design was used involving semi-structured interviews (n = 50), observations (203 h) and individual interviews or focus groups (n = 25). Following thematic analysis, data were analysed using Fairclough's Critical Discourse Analysis.

RESULTS

Data analysis revealed two major discursive practices, which comprised of an interplay between formal and informal communication and environmental influences on formal and informal communication. Self-created patient notes were used by older patients to initiate informal discussion with health professionals about medication decisions, which challenged traditional unequal power relations between health professionals and patients. Formal prompts on electronic medication administration records facilitated the continuous information discourse about patients' medications across transitions of care and encouraged health professionals to seek out older patients' preferences through informal bedside interactions. Environmental influences on communication comprised health professionals' physical movements across private and public spaces in the ward, their distance from older patients at the bedside and utilization of the computer systems during patient encounters.

CONCLUSION

Older patients' self-created medication notes enabled them to take on a more active role in formal and informal medication communication across transitions of care. Older patients and family members did not have continuous access to information about medication changes during their hospital stay and systems often failed to address older patients' key concerns about their medications, which hindered their active involvement in formal and informal communication.

PATIENT OR PUBLIC CONTRIBUTION

Older adults, family members and health professionals volunteered to be interviewed and observed.

Measuring with quality: the example of person-centred care

Qualitative data analysis should be embedded in routine health service measurement, management and organizational practices. The rigorous use of such analyses should become an institutional norm, comparable to the routine use of quantitative data. Our case is intended to have general relevance, but we develop it by reference to person-centred care and patient-centred outcome measures (PCOMs). The increased use of qualitative data analysis of individualized PCOMs is a crucial complementary counterweight to steps towards the standardization of PCOMs. More broadly, our argument is that health care organizations cannot make confident judgements about whether they are offering appropriate care without collecting qualitative data on what matters to individual patients. Introducing properly supported and conducted qualitative data analyses is important in its own right, and also helps underpin the validity and usefulness of quantitative measurement.

Nurses’ views of fundamental relational skills used in clinical practice: a cross-sectional pilot study

Objective

Effective communication skills are one of the core competencies of nursing curricula internationally. Nurses are generally regarded as proficient. Despite our complete trust in the profession, deficiencies and gaps exist. However, it is not clear to which extent nurses use key communication skills in practice, and whether or not confident in using these skills compounds environmental issues that occur. This study explored nurse's confidence and application of relational skills competencies in nursing practice.

Methods

A 13-item online survey was used to collect data.

Results

Being self-aware on key areas where there was more uncertainty. Nurses also lacked confidence in exploring the impact of their personal feelings and values on their interactions. Nurses were also less confident on responding appropriately to instances of unsafe or unprofessional practice and using information and communication systems and technology.

Conclusions

Given the potential impact of poor relational skills on quality client care, an increased emphasis on caring and compassion, and the ever-expanding use of communication technologies, there is a need to explore the need for reflective practice to enhance continuous professional development for nurses to enhance their relational skills.

A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward

Providing healthcare services that respect and meet patients' and caregivers' needs are essential in promoting positive care outcomes and perceptions of quality of care, thereby fulfilling a significant aspect of patient-centered care requirement. Effective communication between patients and healthcare providers is crucial for the provision of patient care and recovery. Hence, patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns, beliefs, and contextual variables. Achieving patient-centered care and communication in nurse-patient clinical interactions is complex as there are always institutional, communication, environmental, and personal/behavioural related barriers. To promote patient-centered care, healthcare professionals must identify these barriers and facitators of both patient-centered care and communication, given their interconnections in clinical interactions. A person-centered care and communication continuum (PC4 Model) is thus proposed to orient healthcare professionals to care practices, discourse contexts, and communication contents and forms that can enhance or impede the acheivement of patient-centered care in clinical practice.

Correcting medical decisions: a study in nurses' patient advocacy in (Finnish) hospital ward rounds

During daily hospital ward rounds, medical teams, led by doctors, assess the progress of an individual patient's health. It is widely reported in the research literature that nurses play a relatively passive role during these rounds, because although they may have valuable information about the patient's condition and progress, and indeed their role includes advocacy on behalf of their patients, nurses nevertheless can experience difficulties in participating during case constructions. Here we report an instance from a (gastro-surgical) ward round in a Finnish hospital, in which nurses played a key role in reversing a consultant's initial decision to discharge a patient. They did so not by directly challenging the consultant's opinion, but by employing indirect means to introduce their discrepant perspective: they provide descriptions and ask questions that draw attention to information that results in the doctor coming to a different assessment than theirs of the patient's condition, and a different decision about what should be done (the patient was not discharged from hospital). The encounter reported here is taken from a corpus of ward round discussions in a Finnish hospital. The method of our study is Conversation Analysis.

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.

The Differences in Antibiotic Decision-making Between Acute Surgical and Acute Medical Teams: An Ethnographic Study of Culture and Team Dynamics

BACKGROUND

Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties.

METHODS

An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015-May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings.

RESULTS

In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use.

CONCLUSIONS

In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.

Exploring reasoning mechanisms in ward rounds: a critical realist multiple case study

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.

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.

An exploratory study of healthcare professionals' perceptions of interprofessional communication and collaboration

Interprofessional communication and collaboration during hospitalisation is critically important to provide safe and effective care. Clinical rounds are an essential interprofessional process in which the clinical problems of patients are discussed on a daily basis. The objective of this exploratory study was to identify healthcare professionals' perspectives on the "ideal" interprofessional round for patients in a university teaching hospital. Three focus groups with medical residents, registered nurses, medical specialists, and quality improvement officers were held. We used a descriptive method of content analysis. The findings indicate that it is important for professionals to consider how team members and patients are involved in the decision-making process during the clinical round and how current social and spatial structures can affect communication and collaboration between the healthcare team and the patient. Specific aspects of communication and collaboration are identified for improving effective interprofessional communication and collaboration during rounds.

Hospital pharmacists seen through the eyes of physicians: qualitative semi-structured interviews

Background Pharmacist-physician collaboration can lead to many positive outcomes. However, collaboration between healthcare providers is complex and rarely performed optimally. Objectives To study physician-pharmacist collaboration in hospital settings, from the physician's point of view. Setting Eight regional non-teaching hospital facilities, within a local area of northwest Switzerland, supplied by an independent central pharmacy. Method Physicians were sampled using a maximal variation purposive method. Qualitative semi-structured interviews were conducted and their content was recorded. Mind maps were made with the collected data. An inductive approach was used for the analysis. Main outcome measure Physicians' main perceptions of hospital pharmacists. Results Twelve physicians and one medical student were interviewed (average interview length 37 min). Key opinions (n ≥ 7) include the following: physicians lack knowledge about hospital pharmacists' roles, competences and activities. Physicians report a lack of presence and involvement of hospital pharmacists. Although physicians value hospital pharmacists' complementary competences, they also point out a knowledge gap between them and that hospital pharmacists lack clinical competences. Some pharmaceutical activities (e.g. drug formulary management or participation in ward rounds) lead to significant drawbacks for physicians. Other pharmaceutical activities (e.g. teaching and supervision) are valued and sought for by physicians. Physicians report they take drug treatment decisions as they bear the legal responsibility. Conclusion The presence, visibility and implication of hospital pharmacists need to be improved, and physicians should be more aware of what they can offer them. Physicians' expectations and needs should be taken further into consideration and new models of interaction should be developed.

Ward rounds, participants, roles and perceptions: literature review

Purpose

– The purpose of this paper is to classify and describe the purpose of ward rounds, who attends each round and their role, and participants’ perception of each other’s role during the respective ward rounds.

Design/methodology/approach

– A literature review of face-to-face ward rounds in medical wards was conducted. Peer reviewed journals and government publications published between 2000 and 2014 were searched. Articles were classified according to the type of round described in the study. Purposes were identified using keywords in the description of why the round was carried out. Descriptions of tasks and interactions with team members defined participant roles.

Findings

– Eight round classifications were identified. The most common were the generalised ward; multidisciplinary; and consultant rounds. Multidisciplinary rounds were the most collaborative round. Medical officers were the most likely discipline to attend any round. There was limited reference to allied health clinicians and patient involvement on rounds. Perceptions attendees held of each other reiterated the need to continue to investigate teamwork.

Practical implications

– A collaborative approach to care planning can occur by ensuring clinicians and patients are aware of different ward round processes and their role in them.

Originality/value

– Analysis fulfils a gap in the literature by identifying and analysing the different ward rounds being undertaken in acute medical wards. It identifies the complexities in the long established routine hospital processes of the ward round.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Observation for assessment of clinician performance: a narrative review

BACKGROUND

Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery.

METHODS

A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines.

RESULTS

The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors.

CONCLUSIONS

Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.

Pharmacists' Interprofessional Communication About Medications in Specialty Hospital Settings

Effective communication between pharmacists, doctors, and nurses about patients' medications is particularly important in specialty hospital settings where high-risk medications are frequently used. This article describes the nature of communication about medications that occurs between pharmacists and other health professionals, including doctors and nurses, in specialty hospital settings. Semistructured interviews with, and participant observations of, pharmacists, nurses, and doctors were conducted in specialty settings of an Australian public, metropolitan teaching hospital. Twenty-one individuals working in the settings of emergency care, oncology care, intensive care, cardiothoracic care, and perioperative care were interviewed. In addition, participant observations of 56 individuals were conducted in emergency care, oncology care, intensive care, and cardiothoracic care. Detailed thematic analysis of the data was performed. Across all of the settings, pharmacy was less visible than medicine and nursing in terms of pharmacists' work performed, pharmacy documentation and resources, and pharmacists' physical visibility. Pharmacists, doctors, and nurses largely worked alongside one another rather than with each other. When collaboration occurred, the professional groups engaged in mostly reactive communication to accomplish specific medication tasks that needed completing. Interprofessional differences in attitudes toward medications and medication management communication behaviors were evident. Pharmacists need to engage in more proactive communication in order to reduce the risk of medication errors occurring.

Surgical ward round quality and impact on variable patient outcomes

OBJECTIVE

To investigate the relationship between variability in surgical ward round (WR) quality and clinical outcomes.

BACKGROUND

Evidence increasingly suggests that ward-based care plays a key role in surgical outcomes. The WR is the focal point of surgical inpatient care. Assimilating various sources of clinical information is necessary for thorough patient assessment during the WR; whether this relates to outcomes has not previously been examined.

METHODS

WRs were observed for patients on a surgical high-dependency unit in a tertiary academic surgical unit. All sources of clinical information (SCI) were considered. Thoroughness of assessment, defined as the percentage of SCI assessed by the clinician, was recorded as a marker of WR quality. Complications were recorded from patient records; preventability was based on Agency for Healthcare and Research Quality guidelines. The relationship between WR quality and incidence of preventable complications was analyzed.

RESULTS

Sixty-nine WRs were observed over 37 days for 50 patients receiving care in the high-dependency unit. Observed morbidity rate was 60% (30/50). Seventy-four percent of all complications (35/46) occurred on the high-dependency unit. There was significant variability in WR quality: clinicians assessed 9% to 91% (mean = 55% ± 17%) of SCI (analysis of variance P = 0.025). Low-quality (% SCI assessed less than the mean) WRs resulted in a greater incidence of patients experiencing preventable complications [83% (10/12) vs 39% (7/18)] (P = 0.034), odds ratio = 6.43 (95% confidence interval = 1.05-39.3). Forty-one percent of complications (19/46) could have been diagnosed earlier or possibly prevented.

CONCLUSIONS

Patient assessment during WRs is variable. Less thorough WRs result in delayed diagnoses and preventable complications, and they negatively affect outcomes. Focusing on WR quality and training may improve patient care.