iWRAHP: improving the ward round and handover process

Introduction

Ward rounds were originally intended to educate medical trainees, providing opportunity to examine clinical signs and review symptoms. Over time, they have evolved to focus on supporting clinical practice. The ward round is now a multiprofessional, multifactorial process with healthcare professionals striving to provide high-quality patient-centred care in a reliable, reproducible and timely manner.¹ Unfortunately, the effectiveness and efficiency of the ward round has not kept up with the increasing demand on physician time and the rising number of inpatients with more complex medical and social issues.

The aim of improving the Ward Round And Handover Process (iWRAHP) is to deliver safer, faster, better levels of care to urology patients on the ward, aiming to improve patient flow and experience. Through reformatting the ward round process, the focus will be to categorise patients and prioritise the ward round based on their clinical state:

• Acutely unwell.

• Suitable for discharge.

• Stable.

The daily ward rounds will also introduce the concept of ‘real-time working’ of tasks, also known as ‘rounding-in-flow’.²

Method

All healthcare workers involved with patient care on the ward were invited to simulated ward round sessions that ran over the course of 6 weeks. These low-fidelity, multiprofessional, in situ ward round simulation sessions involved two scenarios based around inpatient care. Delegates interacted with a patient actor and were provided with patient notes, observations and drug charts. Delegates were asked to review the patient as they would on a ward round (figure 1). Following each scenario, the debrief among the group focused on the communication, team work, information sharing and human factors that impacted on decision making and implications on patient flow and experience.

Figure 1.

Ward bay for in situ simulation exercise. Delegates provided with patient notes, bedside observations and drug chart on the table. Simulated patient actor placed onto bed. Timed, observed exercise with delegates and patient actor being involved in the debrief at the bedside.

Following this period of in situ ward round simulation, implementation of the proposed changes to working practice were rolled out and included:

• Ward nurse in charge to attend and brief on ward patients at morning handover.

• Categorising ward patients based on their clinical status.

• Prioritise patients seen on ward round with ‘real-time working’.

• Afternoon ward team huddle to update on patient care.

Results

Participants were asked to complete an 11-question feedback form based on a Likert-Scale rating from 0 to 5 (strongly disagree=0 to strongly agree=5). The feedback received following the in situ ward round simulation was overwhelmingly positive. The novel experience of interacting and learning together across interprofessional boundaries was well received. Figure 2 highlights the results with participants feeling more confident in their role and understanding the role of other professionals in the team as well as increased confidence in participating in ward rounds.

Figure 2.

In situ ward round simulation feedback questionnaire Likert-Scale results.

Data collected from the hospital trust informatics department for the first 5 weeks of implementation of iWRAHP, with a comparative analysis of the same time period from the previous year showed that during iWRAHP, there were 30 fewer urology inpatient ward admissions (110 elective and acute inpatient episodes vs 140 for the same period the previous year), 50 more acute urological inpatient acute admissions onto the surgical assessment unit and a 50% increase in the number of discharges before midday and a 21% increase in the number of discharges before 18:00. A reduction in the length of inpatient stay on the ward was seen from 3 to 2 days. There was a 12% reduction in the average urology inpatient bed hour occupancy rate.

Discussion

Although doctors, nurses and allied health professionals on the ward work together on a daily basis, a period of joint training and education prior to initiation was necessary for the project to increase its chances of successful implementation, given its multidisciplinary nature.

The in situ simulation exercises provided an opportunity for members of staff to learn together in a clinical environment, away from their daily job role. It promoted conversation and discussion between healthcare professionals involved in the inpatient care journey. The process of working together and debriefing helped to break down barriers and overcome silo working.³ The debrief allowed for reflection on action to understand better how and why decisions relating to patient care are made and the potential impact of these decisions on patient flow and experience.⁴

The results highlight the increasing demand on the urology service with increased acute admissions during the iWRAHP period. There was, however, no increase in bed capacity to match the demand, thus reinforcing the importance on improving and streamlining patient flow to help towards improving patient experience by placing patients onto the ideal ward to meet their care needs.⁵

At the outset of the project, there was concern that changing the format of the ward round and introducing real-time working would result in more work for the junior doctor workforce. Calderon et al ² found that implementation of ‘rounding-in-flow’ or real-time working actually resulted in more discharge summaries complete by 09:00 and resulted in minimal changes to intern work hours. iWRAHP itself challenged established behaviours and models of working, and the project involved a change in culture and working practice. We feel that the initial in situ simulation exercise helped towards the successful implementation of those working practices.

A limitation to the iWRAHP project is its potential reproducibility into other wards. For it to be successful, it required a strong departmental and ward buy-in, team work ethic and a focus on delivering improved patient flow and timely discharges with each patient interaction. The ward was required to be well staffed with a full complement of junior doctor workforce for real-time working to be effective.

As the project itself is multifaceted, it is felt that selected components may well prove useful for other wards and specialisms, and there is potential for the changes to be moulded to fit the individual ward and department based on patient profile and staffing levels.

Conclusion

Through reformatting ward rounds and encouraging ‘real-time working’, we have shown that there is significant potential to improve rates of discharge, reduce length of stay and subsequently free up inpatient beds to reduce the number of outlier patients on other wards, thus improving the patient experience.