Ward Rounds- A recently neglected part of inpatient care

My write up in the souvenir of KOACON 2015

More than two decades back when I did my house surgeoncy, I had tough time with the length of ward rounds. Ward rounds started at 7:45AM and it would continue beyond 12noon without a coffee break. My feet ached, mind was numb with hypoglycemia. In those moments I used to think why rounds can’t be faster and why it was taking so much of time. But later with a personal experience, that impression changed.

During my early PG days, my grandmother got admitted in the pay ward with a minor surgical problem in the busiest surgical unit. Each day I noticed that she was waiting for the time of rounds. One day, on the operation day of the unit; rounds was not taken till afternoon. My grandmother was unhappy and was wondering why no one has come so far for rounds. I tried to console her by informing her that it was the operation day. Initially she was comforted but soon she started grumbling. Soon it was a full blown tantrum and she refused lunch.

The time flew past the afternoon to evening, I did my best to comfort her without any response. I tried to contact the members of the concerned unit. They were held up in the OT. I gave up the hope of pacifying her and told her that probably there won’t be any rounds as it was already very late. She remained inconsolable. Then there was a knock on the door and the unit chief was standing outside the door. He peeped inside without even stepping in and asked “How are you grandmother? Are you better enough to go home? My grandmother was beaming and became an unrecognisably different person.

From that day I understood the psychological importance of ward rounds to the patient. But it is important for the treating team as well. It helps to establish a rapport with the patient, helps in early detection of complications and often saves one from embarrassment or even legal proceedings.

Over the years I have noticed that doctors as a community have become unaware of the importance of rounds. Rounds is often delegated to junior colleagues and many regard it as a nuisance. The patient is forgotten and more attention is given to the case sheets, investigation reports and the x-ray or MRI images. Some even think it is the best time to catch up with missed calls, emails, Facebook or Whatsapp messages.

Ward rounds is a highly complex clinical activity that needs careful attention and a systematic approach. It is essential for ensuring safe and high quality patient care. Neglect can lead to catastrophic outcome. Iatrogenic causes are an important cause of mortality and morbidity in admitted patients. Medical errors are reported to almost in half the number of patients. A properly taken rounds can minimise medical errors and improve patient care.

A recent joint statement by Royal College of Physicians and Royal College of Nursing have called for making ward rounds the cornerstone of inpatient care and have put forward suggestions for the best practices. It calls for restoration of ward rounds to its central importance in how we care for and communicate with our patients.

Objectives of ward rounds

  1. Confirming, refining or even changing the diagnosis.
  2. Assessment of response to treatment, need for investigations, review of medications.
  3. Early detection of complications such as drug reactions, compartment syndrome, venous thromboembolism, neurovascular compromise, infection etc.
  4. Communicating with the patient and relatives.
  5. To prevent harm.

Practical tips

  1. Introduce yourself and the team members.
  2. Small talk to understand the patient as a human being and to remind us not to think of the patient as a diagnosis or procedure.
  3. Go through the original presenting complaints and their response to treatment.
  4. Ask for any new symptoms or concerns.
  5. Ask about fever, sleep, bowel and bladder movements, appetite and the PAIN.
  6. Note down the vital signs.
  7. Check pain control. Ensure proper analgesia.
  8. Check all indwelling devices such as IV lines, Foley catheters, epidural line, drains etc.
  9. Focussed clinical examination.
  10. Look for complications such as bed sores, fat embolism, neurovascular injury, and thromboembolism.
  11. Check the surgical wound.
  12. Examine the injured or diseased limb.
  13. Encourage early mobilization.
  14. Check investigation results, x-rays, consultations.
  15. Review themedications- Dose, cross reactions, allergies, signs and symptoms of important side effects.
    1. Have a mental checklist of important side effects. Few examples.
      1. Linezolid- Thrombocytopenia
      2. NSAIDs- Renal failure, gastric irritation, bronchospasm, thromboembolism
      3. Aminoglycosides- Hearing loss, renal failure.
    2. InstallMedscape app in yoursmartphone. Helps you to check
      1. Dosage
      2. Cross reactions
      3. Contraindications
      4. Important side effects
  16. Communicate with the surgical team, nurses and relatives regarding the diagnosis, response to treatment, risks, concerns etc.
  17. Identify problems to be anticipated in the individual patient and brief the nurses/residents.
  18. Ensure proper filling of case sheets, orders, investigations, consultations and medication prescriptions.
  19. Ifto be discharged
    1. Inform regarding activity restrictions if any.
    2. Medications to be taken.
    3. Follow up.
    4. Problems to watch out for.

We need to rediscover the art of taking rounds. It will definitely help in improving patient care. It will help us as well by reducing medical errors, preventing complications and also by helping us to fulfil our role as the trustees of the welfare of our patients.

Further reading

  1. Ward round. The suggestions for improvement. http://www.linus-geisler.de/dp/dp22_ward.html
  2. Ward rounds: what goes around comes around. The Lancet. Vol 380 Oct. 2012 http://dx.doi.org/10.1016/S0140-6736(12)61740-1.
  3. What’s Wrong With Ward Rounds? Postgrad Med J. 2013;89(1058):733-734.
  4. Royal College of physicians joint statement. http://www.hug.uk.net/reports_pdf/WARD%20ROUNDS.pdf

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