The ward round is brokenBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4390 (Published 25 September 2017) Cite this as: BMJ 2017;358:j4390
All rapid responses
Thanks to Mr Shyan Goh for his excellent response to my article.
I feel his pain and completely agree that the solutions I have enacted work only in my specific environment.
Extrapolating these to the situation he sadly finds himself in may not be possible in totality or at all.
I certainly do not believe that simply introducing an electronic medical record is the solution to all woes.
In fact, it may bring even more problems.
However, this only highlights the need for different solutions for different areas.
It also highlights my argument that the current ways of working need to change.
I hope he manages to find new ways of working to help with the pressures and to help patients.
Competing interests: I wrote the article
Dr Morgan's astute observation that the art of the ward round has not been the focus of more formal teaching is I agree surprising, given many wards' heavy reliance on it. Perhaps the span of three hundred or so years hints that adaptation and change is needed.
Seeing patients after a ward round, I have commonly been told the experience was daunting for them or unfamiliar given the array of unknown faces, and of its disservice to good bedside manner. Other more sympathetic patients seem to put up with this known routine. If patients do not respond well (albeit anecdotally), we need to question the real reason for today's ward round and re-evaluate what could be done at and away from the patient's bedside.
As a medical student often squeezed just inside a curtain, I have often questioned the efficiency and format of the ward round. Dr Morgan's method of pre-assimilation of information is I think far more sensible, and I have also witnessed 'board rounds', where complete teams can discuss patients beforehand and lead to a more informed and streamlined subsequent ward round. However as is usually the case, one format will not work as well for everybody. Regardless, I agree that more thought into adapting the ward round to suit current needs would be a welcome thing.
Competing interests: No competing interests
I would like to share an alternate perspective of clinicians who look after 90% patients admitted in hospitals:
You are the regional director of a multi-million pound coffee business. Today like any other working day, you will visit all branches in your business, regardless of performance. You will decide if any changes are needed with each branch and what to do about it.
The method you have chosen to conduct this process is time-proven given limited resources. There is no way to access all information from your own office in a timely fashion. You have to drive from store to store throughout the morning; some are not even in your locality or province. Thankfully, as a hand-on director you already had some idea what is happening in each store from your experience the day before.
When you arrive, your well-trained entourage of assistants help filter masses of data. You cannot rely on having the local manager around since each manager concurrently run between 4 – 8 other shops; often a ragtag group of businesses not involving coffee (for example, plumbing hardware, IT consultancy, etc). The store manager is often absent, attending to other ‘more urgent’ routine and your team often have to leave a written note to ensure handover is completely documented.
You are shown financial reports going back over the past 24 hours and bundles of customer comment cards. As you assess the situation, you have frequent interruptions from customers ordering new drinks and staff asking you how to make them. You do all of this standing in the middle of the store, but not always with local shareholders in attendance since they elect not to be present. Within 10 minutes or less, you announce your practical solution after consulting with local customers.
You then move on to the next store. If you are lucky, you can find the location of all mobile coffee carts in the smoking region. By the time you get to the last store (there is no limit to the number of stores you are put in charge every day) you are tired but satisfied at the 200+ decisions made so far.
After all that, at 8.30 am on most days, you personally attend a board meeting juggling other businesses involving complex physical tasks with surgical precision in the multi-faceted businesses conglomerate. Attendance is compulsory; your personal KPI can be affected if you are just 1 minute late.
Welcome to my reality.
Dr Morgan shared an interesting perceptive of the ward round, in which he called the concept “broken” and a rapid respondent has labelled as “anarchic” practice.
I beg to differ.
I wish to highlight various aspects and privileges of critical care medicine (CCM) not shared by the majority of hospital medicine practice:
1. Each CCM team has a maximum number of patients to look after; such limit is due to actual beds located in a bunkered silo (called Intensive Care Unit - ICU) within a tertiary level (or bigger) hospital. Usually each ICU is organised so that each CCM team in the roster (often 12 hours) looks after no more than 10-12 “beds”, whether or not there is a patient on it.
2. Each bed is allocated one highly trained nurse with relevant qualifications, (usually on permanent staff roster). The usual ratio is 1 CCM nurse for each bed plus one senior nurse (“floating”) in charge.
3. Under “team based care”, each intensivist take over the care of the patient for the entire shift and hands over to the next specialist on the roster. There is no one ICU specialist that is ultimately responsible for the entire patient journey in the ICU, or indeed the entire hospital stay.
4. Correct me if I am wrong, but certain trusts proudly advertised the fact that there are ICU specialists onsite 24/7 in their facilities. Few other clinical services have the funding or staffing to do that.
5. Many ICUs have entirely computerised medical records, where as a significant proportion of clinical services in the rest of the NHS is only partial electronic, or run on almost entirely handwritten medical records.
6. All patients directly under CCM care are located within the ICU, whereas for many of the other clinical teams, their patients are distributed unevenly over many wards across the entire hospital.
7. For other clinical teams, due to paper-based documentation and the spread of patients all over the facility, it is nearly impossible for anyone to gather all the notes and charts to bring them to a single room and discuss the history, review test results in comfort with a cappuccino in hand. People like us walk to the ward, read the notes (of patients under the care of the team in that ward) at the desk, before seeing the patients.
8. CCM teams may have other duties, including dealing with ward consults, but their core duties is dealing with their 10 patients within their walls for the entire 12 hour shift. Other clinical teams have to see all the patients under their care and yet be ready to start the outpatient clinics and (for surgical teams) operating lists on time.
No doubt Dr Morgan may have a good idea, but it will take more than just implementing electronic medical records to achieve some parity of resources if he expects other clinicians have do the same outside the confines of the ICU silo.
I understand how my view of the world may become tunnel-visioned if I only look after maximum of 10-15 patients within 20 metres of my office, handing over the care to another specialist with each shift (and not get called at home), with no outpatient or theatre obligations for the majority of the shift.
Time for the NHS to build more buildings, hire more permanent staff, stop outpatient clinics and operating theatre commitment?
I would not be holding my breath waiting for parity in these resources in my reality.
Competing interests: No competing interests
Dr Morgan's excellent article is a timely reminder that 'this is how we learned to do it' is not an adequate reason to follow any strategy in healthcare. Medicine is remarkable for the juxtaposition of cutting edge research with archaic working practices.
I anticipate objections to Dr Morgan's approach based on the belief that the traditional ward round is the only way to teach the next generation of healthcare professionals. Such objection would be unfounded. Processing and filtering data, communicating, making a plan and revising it based on new information are skills that are as relevant now as ever. Learning them today can only happen through a multidisciplinary approach and an education strategy that teaches how to manage the ever-expanding influx of data attached to every patient.
Competing interests: No competing interests