Dr Gordon CaldwellMembers
Content ArticleOn a ward round in 2005 I was about to send home a man who had been successfully treated for pneumonia with intravenous antibiotics. He asked me what was wrong with his left arm. When I looked he had an obvious infection around the intravenous cannula with signs of the infection spreading up the vein. He had been treated with intravenous antibiotics which had been changed to oral 3 days earlier. At that point the cannula should have been removed. It turned out that the infection was caused by MRSA and he required a further 2 weeks of intravenous antibiotics to eradicate the infection. I promised the patient that I would do everything I could to make sure that no one else suffered in the same avoidable way that he had. This led me to think about the process of clinical review on ward rounds. I wondered if we could develop a list of check points that we could routinely go through to protect patients from avoidable harm. During this period, I started to supervise a junior doctor on the team on a ward round and afterwards she said it had been an excellent experience but she did not know if “I had done everything?” This made me think that no one had considered what “Doing everything” was on a ward round. I asked my team to come back 2 days later to discuss what “Doing Everything” was and by the end of that week we had designed our first checklist for ward rounds. The first checklist was a one-sided piece of A4 paper with, as I recall, a table with 15 columns for 15 patients and about 25 rows of points that we thought were essential during a case review. These ranged from items such as organising the notes, filing the results, reading the notes, discussing the case, through to aspects such as does the patient have an intravenous cannula or urinary catheter? Some of the rows were marked in yellow and applied to all patients and others were white, such as the capillary blood glucose which only applied to patients with diabetes. I asked a medical student on our team to watch us working and to tick off the boxes if the appropriate action or an active decision had been considered. I asked that before we moved on to the next patient that the observer highlight any omissions so that these could be corrected. Once the ward round was completed, I kept the checklist forms as well as noting the duration of the ward round. In the early weeks we were surprised to find how much we missed out on ward round reviews. We thought we were very good at hydration and nutrition, spotting cannulas and catheters and making do not attempt cardiopulmonary resuscitation (DNACPR) decisions, but we were not. I found that we were creating a process for clinical review of the patient and a checklist to ensure completion. There were problems. Sometimes the person doing the checking did not call out on omitted items. I can recall one occasion when we had put onto the checklist “Did the consultant read today’s clinical note?” I had forgotten this was now on the checklist until about the fifth patient. I asked the medical student why he had not called me out on this and he said that he was going to tell me at the end of the round! If any team is going to use the checklist process they have to create an atmosphere within the team where it is expected that omissions or errors will be called out. Our work was published in Clinical Medicine. We heard that a whole surgical unit in Melbourne, Australia, picked up on our ward round checklist concept. They similarly found that senior doctors frequently made omissions during ward round processes. They built the checklist into a daily review template. Initially they found that the junior doctors did not complete the checklist. Eventually they found that if the registrars in the team at induction told the junior doctors “This is the way we work here” then they completed the checklist. The checklist then remained in the patient’s notes as evidence of a complete review. For a long time I wanted to find a way to incorporate the checklist into the daily clinical review notes rather than have a separate checklist for the cohort of patients. In 2015 we managed to achieve this by combining the checklist into the daily review template. At Worthing Hospital, Dr Richard Venn and his IT colleagues had pioneered electronic vital signs and nursing assessments. Tim Short[, one of the IT development team, came on one of my ward rounds and saw an opportunity to create a ward round patient review template. One side of this listed the patient’s demographics, clinical problems, vital signs and common blood test results. On the other side was our checklist. I did not want to force teams to use the checklist so this was optional as they created the ward round documentation. We called this process Ward Round Report (WRR). WRR could be run on the desktop computer, laptop, tablet or even smart phone. After the ward round, the sheets could be printed out and filed into the paper notes. With WRR there was plenty of space on side two for adding comments. For example, by this stage there was a question “Did you make any changes in the prescription today? Y/N?” This was the first time in my career that I was regularly making short notes about the reasons for changes in medications – for example, “Ramipril stopped today because systolic blood pressure only 80 mmHg”. What I have learned from this is that there is a process to patient review and being organised and consistent in following this process makes the ward round more effective, efficient and improves patient safety. By being consistent in the process we have released time which can be used for further conversation with the patient or for thinking through complicated cases or for teaching. I have also learned that “safety is no accident”. I like this phrase because of its double meaning that safety is no avoidable harm or accident to the patient and also that safety does not arrive accidentally. Patient safety should be an active process of checking for avoidable errors. With WRR errors still occur but are much less frequent. One point on my ward round form that seems idiosyncratic is asking for something memorable about the patient, such as what is or was their work, or what are their current interests and enjoyments. This creates some personal connection with the patient and certainly helps me to remember all of the patient’s clinical problems. I believe that this personal connection also engenders more commitment to patient safety. If clinical staff take away only one idea from my process, I recommend that it is this: seeking something memorable about each patient. Reference 1. Herring R, Desai T, Caldwell G. Quality and safety at the point of care: how long should a ward round take? Clin Med 2011; DOI: https://doi.org/10.7861/clinmedicine.11-1-20.
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Dr Gordon Caldwell posted an article in Clinical leadership
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