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Restore the prominence of the medical ward round

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6451 (Published 31 October 2013) Cite this as: BMJ 2013;347:f6451

Rapid Response:

Re: Restore the prominence of the medical ward round

In his call to arms in defence of the medical ward round,1 Dr Cohn calls for a re-prioritisation of ward rounds in clinical practice, to improve patient care and maximise physician efficiency. Increasingly, this fundamental process of care stands in the clinical spotlight. In their recent joint statement,2 the Royal College of Physicians and the Royal College of Nursing highlighted the perceived variability in both purpose and conduct of ward rounds, calling for restoration of rounds to a position of central importance.

Ward rounds have long been the mainstay of interaction between hospital clinicians and their patients. As such, the conduct of thorough, high quality ward rounds is critical to the provision of quality inpatient care. Dr Cohn draws parallels between the medical physician’s ward round and the surgeon’s operating list, between the incomplete surgical procedure and the abbreviated medical round. To do so, however, is to succumb to the belief that a surgeon’s focus of patient care must be on his or her operating list, and the measure of a surgeon’s skill dependent and technical ability alone.

Surgical training is undergoing a paradigm change, in recognition of the need to focus more holistically on all aspects of patient care. Processes of postoperative care are under increased scrutiny, in the wake of data suggesting that variable patient outcomes result primarily from deficiencies in the management of postoperative complications, rather than failures in the operating room.3 We recently conducted an observational study of surgical ward rounds within an academic tertiary centre, recording wide variations in the quality of ward rounds and thoroughness of patient assessment.4 Crucially, this study demonstrated a significant association between poor quality rounds and the incidence of preventable postoperative complications, with a greater than sixfold increase in risk of events such as pneumonia or urinary tract infections.

In order to improve the quality of ward rounds, Dr Cohn suggests additional training (or re-training) will be required, with a specific focus on “softer” non-technical skills. Traditionally, trainees have learned the skills needed to conduct ward rounds through experience alone. Concerns about ward round quality suggest that this model of training is no longer be sufficient; the association between poor quality rounds and increased complications suggest this is no longer ethically tenable.

Simulation has increasingly established itself as an effective alternative to the traditional Halstedian model of medical education. Providing a dedicated, controlled learning environment, with realistic scenarios, and without risk to patients,5 initial studies have suggested simulation may play an effective role in the improvement of training for ward rounds, as well.6, 7 Whilst these studies have initially considered ward rounds in the context of surgery, their principles and methodology could be easily translated into the medical setting as well.

Ward rounds represent the defining care process of ward-based care, and it is clear that improvement and standardisation is necessary. The need for change in the manner in which rounds are approached must apply to all specialties if patient care is to be optimised, and the hospital experience improved.

References
1. Cohn A. Restore the prominence of the medical ward round. BMJ 2013; 347:f6451.
2. Royal College of Physicians, Royal College of Nursing. Ward rounds in medicine: principles for best practice. 2012. London, UK. Royal College of Physicians.
3. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361:1368-75.
4. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2013 [in press].
5. Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg 2013.
6. Pucher PH, Aggarwal R, Srisatkunam T, Darzi A. Validation of the Simulated Ward Environment for Assessment of Ward-Based Surgical Care. Ann Surg 2013.
7. Pucher PH, Darzi A, Aggarwal R. Development of an evidence-based curriculum for training of ward-based surgical care. Am J Surg 2013 [in press].

Competing interests: No competing interests

05 November 2013
Philip H Pucher
Clinical Research Fellow
Rajesh Aggarwal, NIHR Clinician Scientist in Surgery
Imperial College London
South Wharf Road, London, W2 1NY