Perfecting the Ward Round
What makes an efficient ward round? And what does the fresh-faced doctor, straight from medical school, have anything to do with it? It won't be long until it's your first day on the job, when your senior team members look to you to guide them on the morning's round of inpatients. That's right, they're looking to you to help them make the best decisions for their patients, and as efficiently as possible. So with this in mind, how are you going to own that morning ward round? Well, preparation is key. This means turning up a little bit early and having a good routine. Or a "pre-flight check", if you will...
1. Where is everybody?
As part of your pre-flight check, confirm the location of all your patients - your team will look to you to guide them around the hospital. Nobody likes walking around in circles and revisiting wards they have already been. So check to see if any patients have been moved. Clinical decision units or medical/surgical assessment units typically move their patients to other wards soon after admission. Another point of confusion is ITU - frequently I have walked there only to find the patient was transferred to the surgical unit from where we just came, 10 minutes' walk back down the corridor! For surgical teams, don't forget to see if there are any post-operative patients that have been admitted. Day case admissions are often missed on morning ward rounds - you may think they would have all gone home on the day of surgery, but every so often one will need admitting overnight for one reason or another. Whilst your seniors should let you know, this doesn't always happen. 2. Check results
"What's the CRP? And albumin?" It can be a little embarrassing to repeatedly not know the answers to questions that are so pertinent to a patient's care. So be prepared. But whatever happens, never make up an answer. It is always better to say "I don't know but I will find out" than to make something up. What more commonly happens on a ward round, however, is when you have a result in your mind, but a small part of you can't be sure that it doesn't actually belong to another patient. So you might say a number with hesitancy or uncertainty. Admit uncertainty, don't blag it! But ultimately, the best thing is to be certain, and the only way you can be certain is if it's in black and white on a piece of paper. Moral of the story? Write it down! Either by hand on your inpatient list, or have a separate folder or sheet of paper where you keep a summary of all your patients' bloods results. Make sure you also know what the previous blood results were, because a trend is sometimes more important than just the latest result. When it comes to imaging results, print the reports for all scans performed the previous day. They will need to be immediately at hand. Log on to the imaging viewing sofware, e.g. PACS (if you're in a country where you have such a privilege) so that it is readily accessible for you and your team to view any images yourselves.
3. Know your patients
You really need to know your patients. Keep a brief up-to-date summary on your inpatient list. Key points to note include:
when was the patient admitted;
who is the consultant (if you look after more than one consultant's patients);
if the patient had surgery - what and when was it?
a brief history of the current admission
past medical history
If you're not sure, read through the notes and ask! Knowing your patients also means knowing what happened the night or weekend before. Emergencies crop up, clinical situations change and evolve - read the notes and speak with the night or weekend team. It is really useful to be able to provide a succinct verbal summary to your seniors during the ward round for every patient when the admission history is unclear or when significant events have happened out of hours.
4. Lead the round The junior doctor on my team knows that actually he is the one leading the round, not me! When I arrive, he (James) has printed the list, given me a copy, the notes are all in one place, and we begin. James makes sure we go on our "safari" between wards in a logical order, meaning that we don't have to go back on ourselves and waste precious time. If I ask for a result, I can see it for myself in black and white. If James doesn't know, he says so, and that makes me feel like I can really trust him.
At the beginning of this article I asked how are you going to own the ward round - because that's what it is about - ownership. It leads to real job satisfaction - feeling like you can deliver great care because you know the patients well, feeling trusted by your team, contributing to your team's efficiency and this can really improve morale.
If you have any more tips for how to make for a great/efficient ward round, why not write them in the comments below?