Fiona Lake: Value in rounds

WARD rounds are central to care in hospitals. They are a sensible way for a team of carers to look after a group of patients methodically.

Ideally, relevant health professionals review patients and discuss problems, investigations, diagnoses, care and discharge plans as a team, and with the patient and family. The round should guide the provision of care in a safe environment based on the best evidence.

It is also a forum for education.  

What really happens is quite different. In a US observational study of general medicine ward teams, a median of 9 patients (range, 2–18) were seen in a median time of 120 minutes (range, 25–241 minutes) — about 13 minutes per patient.

There was much discussion about the patient. However, impacting on that communication were the facts that, on average, only 66% of team members were present at the beginning of each patient presentation, the majority of time was spent away from the bedside and nurses were not present. Medications charts were discussed in 69% of cases, invasive lines in 9% and prophylaxis for deep vein thrombosis in 16%. Education was not prominent.

What about in Australia? I am sure we do better and worse.

Competing demands, high turnover, sicker patients and more students and trainees are challenges. But these realities do not excuse potential compromises in safe care, because evidence shows we can do better.

What guides can we use to ensure our rounds are safe, constructive and educational?

From a communication and safety viewpoint, all members should take part in ward rounds and work together as a team. Nurses are essential, contributing knowledge from their 24-hours-a-day of interaction with the patient.

The use of checklists has been shown in surgery to contribute to safer care. Why not on ward rounds?

Examples of ward round checklists can be adapted for local need and to improve adherence to safe care and interprofessional communication. Students can be given the role to ensure all areas are covered — as long as you give them the authority to speak up on areas missed.

NSW Health is rolling out a new model for multidisciplinary ward rounds, in response to the Garling Report, which should address safety and communication, as well as outlining team members, round structure and the checklist for different clinical areas (such as psychiatry and the acute care).

As much as possible ward rounds should be done at the bedside. When patients are involved in bedside teaching, they leave hospital understanding more about their disease and are more satisfied with care.

Lack of communication is one of most frequent complaints from patients, so allow patients to listen and be part of the discussion. When done sensitively, appropriately and with clarity, most will appreciate it.

What about education? I think we should stop trying to “teach”. Rather we need to look at ways to integrate clinical care and education more closely.

Involve everyone in the case discussion, not by asking knowledge-based questions but by inviting input to thinking and analysis. Ask the resident to summarise their understanding and plan before completing the notes; get everyone to take turns being the lead in interacting with the patient.

You will always be there to intervene if the dialogue is not going well, but you get a chance to observe your students and trainees. As the provision of care is in their hands most of the time, you can gauge whether they are safe. Feedback is essential and you can model this by inviting reflection on your performance.

One resource includes two points for pausing — the first to check team understanding and the second patient understanding.

I suggest a third — reflection on the interaction and provision of feedback. Then we can feel more confident that we have communication, safety and education back into patient care.


Professor Fiona Lake is a respiratory physician and professor of medicine in the School of Medicine and Pharmacology, University of WA.