The ward round is one of the fundamental activities of medical professionals worldwide. The primary purpose of the ward round is to assess the clinical state of the inpatient and plan further management. Ward rounds often involve different leaders, junior medical staff, and nursing staff each day and high patient turnover. Medical staff of surgical units are routinely under time constraints as a result of the requirement to attend to operating lists and outpatient clinics. It is not unusual for inpatients to see completely different teams of health professionals from one day to the next.1,2 Documentation in the medical record is paramount to ensuring the flow of information from one health professional to another.
Experience from the aviation industry has indicated that the use of checklists helps to minimize human error.3 Recent studies have shown improvement in patient care when checklists are used.4,5 The surgical community has embraced check-lists in other areas of the hospital, most notably in the operating room, where the “time-out” or World Health Organization surgical safety checklist has become mandatory5 and endorsed by the Royal Australasian College of Surgeons.6 The aim of this study was to build on this idea of a structured checklist and apply it to other aspects of the day-to-day surgical routine to minimize human error and missed aspects of care.
The use of a checklist in a general surgical unit was recently studied at Logan Hospital in Australia.7 The current authors believed that a checklist could be tailored to orthopedic surgery ward rounds. Such a checklist would have the potential to drastically improve ward round documentation, especially in a major metropolitan hospital. It would ensure documentation of clear orders for allied health and nursing staff also caring for ward patients. In addition, an itemized checklist could prompt medical staff to engage nursing and allied health staff in their relevant aspects of patient care, thus improving team communication.
Materials and Methods
The ethics committee of the authors' institution approved this study. A data collection form was developed that enabled medically trained observers on the orthopedic unit to document whether the surgical staff (registrars and residents) performing the ward rounds discussed, documented, or both discussed and documented a set of predefined aspects of patient care determined by the authors (Figure 1).
The data collection form used by the observers during the ward rounds. It was a compact and easy to complete tick box sheet. The observers ticked the left box if that particular aspect of care was discussed, then ticked the right box if it was documented in the medical record. The time spent with each patient was recorded. The patient's initials and the observer's initials were also recorded, allowing the primary author (A.J.T.) to double check any irregularities. Abbreviations: Abx, antibiotics; Mgmt, management; Op, operation; Pt, patient; VTE, venous thromboembolism; WB, weight bearing.
Observations were recorded as either discussed or not discussed at the time of patient contact and documented or not documented within the medical record at the conclusion of the ward round. In addition, the presence of nursing staff, physiotherapy staff, or both and the duration of patient interaction in seconds were re-corded for each patient during the round.
To reduce bias via the Hawthorne effect,8 the orthopedic team was not made aware that the study was being conducted. In the first phase of the study (cohort A— standard care), orthopedic ward rounds were observed and data were collected for 2 weeks. There were 132 eligible patient encounters, defined as those in which orthopedics was the primary team caring for the patient, thus omitting consultations.
For cohort B, a structured checklist was introduced for use during the ward round and inserted into the medical record (Figure 2). It was printed on a sheet of paper with a colored edge for quick reference. The junior medical staff on the orthopedic unit were educated about the check-list and given 1 week to practice using it. Data were then recorded for a 2-week period. The same observers (J.D., C.M.) recorded all 4 weeks of the observation period and the same junior medical staff were involved in both cohorts. A team of 4 junior medical staff members were observed during cohort A and cohort B. By having more staff involved in the audit period, the authors believed that the effect of a particular resident's performance on the overall results of the study was removed.
The checklist used by the medical staff during orthopedic ward rounds. It was easy to examine, mainly involved ticking off the appropriate boxes, and required minimal further documentation. Abbreviations: AH, after hours; BP, blood pressure; DVT, deep venous thromboembolism; HMO, health maintenance organization; HR, heart rate; HWB, heel weight bearing; Non-op, nonoperative; NWB, non-weight bearing; O/E, on examination; Obs, observations/vital signs; Post-op, postoperative; Pre-op, preoperative; PWB, protected weight bearing; RR, respiratory rate; SaO2, arterial oxygen saturation; T, temperature; TWB, touch weight bearing; WBAT, weight bearing as tolerated.
The chi-square test was used to compare differences in proportions. Continuous data were analyzed using an independent samples t test for comparing means. All calculations were performed with SPSS version 22 software (IBM, Armonk, New York). A 2-sided P value of less than .05 was considered significant. The authors calculated that a minimum of 78 patient encounters needed to be recorded, 39 before and 39 after the introduction of the checklist (α=0.05; 1-ß=0.9).
During cohort A (standard care), a total of 132 patient encounters were observed. For cohort B, a total of 68 patient encounters were observed. Thus, a total of 200 patient encounters were observed. A nurse was present for 89.5% of the patient encounters and a physiotherapist for 84.5%.
The results for cohort A highlighted several deficiencies within the current ward round, with many key aspects of care failing to be either discussed or documented. Important issues that were rarely discussed included vital signs (11.4%), venous thromboembolism prophylaxis (9.8%), and bowel status (3.8%). The aspects that were poorly documented included fasting status (9.1%), wound or dressing plan (6.8%), and weight-bearing status (11.4%). Surgical details were documented only approximately 39% of the time (Table).
Discussion and Documentation of Key Aspects of Orthopedic Patient Care Before and After Introduction of a Structured Checklist for Ward Rounds
For cohort B, the authors observed a significant improvement in both discussion and documentation of key aspects of care. Statistically significant increases were observed regarding discussion of fasting status, vital signs, wound or dressing plan, venous thromboembolism prophylaxis plan, bowel status, and weight-bearing status. Significant improvements were also seen regarding documentation of preoperative and postoperative status, fasting status, surgical details, wound observations, wound or dressing plan, venous thromboembolism prophylaxis plan, bowel status, and weight-bearing status (Table).
There was no significant difference between the 2 cohorts regarding the time spent per patient.
The orthopedic ward round has been occurring daily for more than a century, yet anecdotally almost all orthopedic surgeons could identify deficiencies with their daily rounds. This is in agreement with previous publications.2 In orthopedic units, ward rounds are often fast, leaving little time for thorough communication with the patient and between team members. Furthermore, the art of the surgical ward round is seldom formally taught, making it difficult for new junior members of the team to adapt to the processes in place.9
The idea of a checklist to evaluate ward rounds is not new. This follows from work completed on surgical checklists to improve patient safety, now mandated by the World Health Organization and governing bodies such as the Royal Australasian College of Surgeons.5,6 The premise behind these checklists is that humans are prone to making errors or missing things, and that written, mandated check boxes force physicians to at least consider particular aspects of care.
The authors subjectively identified deficiencies in documentation during standard ward rounds. In a fashion similar to the current study, Blucher et al7 observed the general surgical ward round for 2 weeks. They then used a prompter with a separate checklist to ensure that certain tasks had been addressed. In 2016, Pitcher et al10 reported a similar study with the same 2-week audit period. Introduction of a checklist for general surgical ward rounds similar to that of the current study occurred after this period. Both of these studies showed that general surgical ward rounds have many deficiencies and that the use of a standardized checklist can aid in overcoming them. The current study is the first to apply these principles to orthopedic surgery while also using medically trained and unbiased observers to record data.
Several topics were poorly discussed or documented on a regular basis, and routine parts of surgical care were especially poorly documented. Venous thromboembolism prophylaxis, attention to bowels and regular aperients, weight-bearing status, and fasting status were commonly not discussed or documented. Although there are multiple reasons for this, the time constraints of junior staff during these rounds are the most significant.
The introduction of the checklist for ward rounds significantly improved the documentation rates for most key aspects of care (Table). Discussion rates also increased, as the checklist served to prompt discussion of these key aspects of care with the entire team and often with patients. Fifteen elements studied (either discussed or documented) were significantly improved by introduction of the checklist (P<.05), with 11 of these reaching a significance level of P<.0001. Furthermore, the checklist potentially mitigates the problem of illegible hand-writing.
Checklists have the advantage of being easily transferred to an electronic medical record. Furthermore, ticking check boxes on a touch-screen device can replace typing notes for each patient during the round. Although some studies have shown that an electronic ward round progress note can be used in the same fashion as paper notes,11 this is only after some adaptation and education of the medical and allied health team.12 For specialties such as neurology, where more time is spent with each patient, electronic records and documentation have been shown to increase time spent at the bedside by physicians because they do not need to locate a workstation to check investigation results or imaging.13 To the current authors' knowledge, this has not been studied in a surgical discipline where time constraints are much greater.
One limitation of this study was the difference in the sizes of the pre- and postintervention groups. Roughly twice the number of patient interactions occurred in cohort A because of the availability of the independent observer during cohort B. However, the number collected in each cohort surpassed the number required on the power calculation. The authors acknowledge that the normal paradigm of the surgical hierarchy is that consultants are driven to ensure their juniors are collecting relevant data on the ward round, and residents and registrars are driven to please their consultants. However, the point of this checklist is to ensure that these key details are recorded regardless of the drivers within the surgical hierarchy. As the authors' first audit period showed, this paradigm does not always result in efficient and effective documentation.
A structured checklist led to vast improvement in the clarity and completeness of orthopedic ward round documentation without an extra investment of time. It also improved communication with the allied health, nursing, and other medical teams caring for the same patients. This checklist may also lead to significant improvements in patient care through the increased consideration and discussion of key aspects of patient care on orthopedic ward rounds.
- Creamer GL, Dahl A, Perumal D, Tan G, Koea JB. Anatomy of the ward round: the time spent in different activities. ANZ J Surg. 2010; 80(12):930–932. doi:10.1111/j.1445-2197.2010.05522.x [CrossRef]
- O'Hare JA. Anatomy of the ward round. Eur J Intern Med. 2008; 19(5):309–313. doi:10.1016/j.ejim.2007.09.016 [CrossRef]
- Dye RV. Human Performance Considerations in the Use and Design of Aircraft Checklists. Washington, DC: US Department of Transportation, Federal Aviation Administration, Assistant Administrator for System Safety, Office of Safety Services, Safety Analysis Division;1995.
- Alijanipour P, Heller S, Parvizi J. Prevention of periprosthetic joint infection: what are the effective strategies?J Knee Surg. 2014; 27(4):251–258. doi:10.1055/s-0034-1376332 [CrossRef]
- World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. http://www.who.int/patientsafety/safesurgery/ss_checklist/en/. Accessed July 11, 2015.
- Royal Australasian College of Surgeons. Surgical safety checklist (Australia and New Zealand). https://www.surgeons.org/media/12661/LST_2009_Surgical_Safety_Check_List_(Australia_and_New_Zealand).pdf. Accessed July 11, 2015.
- Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J Surg. 2014; 84(10):745–747. doi:10.1111/ans.12496 [CrossRef]
- McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. The Hawthorne effect: a randomised, controlled trial. BMC Med Res Methodol. 2007; 7:30. doi:10.1186/1471-2288-7-30 [CrossRef]
- Mansell A, Uttley J, Player P, Nolan O, Jackson S. Is the post-take ward round standardised?Clin Teach. 2012; 9(5):334–337. doi:10.1111/j.1743-498X.2012.00566.x [CrossRef]
- Pitcher M, Lin JT, Thompson G, Tayaran A, Chan S. Implementation and evaluation of a checklist to improve patient care on surgical ward rounds. ANZ J Surg. 2016; 86(5):356–360. doi:10.1111/ans.13151 [CrossRef]
- Morrison C, Fitzpatrick G, Blackwell A. Multi-disciplinary collaboration during ward rounds: embodied aspects of electronic medical record usage. Int J Med Inform. 2011; 80(8):e96–e111. doi:10.1016/j.ijmedinf.2011.01.007 [CrossRef]
- Morrison C, Jones M, Blackwell A, Vuylsteke A. Electronic patient record use during ward rounds: a qualitative study of interaction between medical staff. Crit Care. 2008; 12(6):R148. doi:10.1186/cc7134 [CrossRef]
- Fleischmann R, Duhm J, Hupperts H, Brandt SA. Tablet computers with mobile electronic medical records enhance clinical routine and promote bedside time: a controlled prospective crossover study. J Neurol. 2015; 262(3):532–540. doi:10.1007/s00415-014-7581-7 [CrossRef]
Discussion and Documentation of Key Aspects of Orthopedic Patient Care Before and After Introduction of a Structured Checklist for Ward Rounds
|Aspect of Care||No.a||Pd|
|Time spent per patient, average, s||93.2||77.8||.067e|
|Preoperative and postoperative discussed||68 (51.5)||44 (64.7)||.075|
|Preoperative and postoperative documented||56 (42.4)||52 (76.5)||<.0001f|
|Fasting status discussed||24 (18.2)||23 (33.8)||.013f|
|Fasting status documented||12 (9.1)||48 (70.6)||<.0001f|
|Surgical details discussed||52 (39.4)||23 (33.8)||.441|
|Surgical details documented||51 (38.6)||58 (85.3)||<.0001f|
|Vital signs discussed||15 (11.4)||22 (32.4)||<.0001f|
|Vital signs documented||110 (83.3)||61 (89.7)||.225|
|Physical examination performed||80 (60.6)||40 (58.8)||.807|
|Physical examination documented||41 (31.1)||34 (50)||.009f|
|Wound observations discussed||44 (33.3)||23 (33.8)||.945|
|Wound observations documented||37 (28)||41 (60.3)||<.0001f|
|Wound or dressing plan discussed||22 (16.7)||23 (51.5)||.006f|
|Wound or dressing plan documented||9 (6.8)||63 (92.6)||<.0001f|
|Venous thromboembolism prophylaxis plan discussed||13 (9.8)||31 (45.6)||<.0001f|
|Venous thromboembolism prophylaxis plan documented||9 (6.8)||63 (92.6)||<.0001f|
|Bowels and aperients discussed||5 (3.8)||35 (51.5)||<.0001f|
|Bowels and aperients documented||54 (40.9)||62 (91.2)||<.0001f|
|Weight-bearing status discussed||25 (18.9)||24 (35.3)||.011f|
|Weight-bearing status documented||15 (11.4)||57 (83.8)||<.0001f|
|Ongoing management plan discussed with patient or among orthopedic team||121 (91.7)||57 (83.8)||.093|
|Ongoing management plan documented||124 (93.9)||67 (98.5)||.138|