Ward rounds – are they safe and effective for patients and doctors?

Dr Tarun Solanki is a Consultant Physician and Geriatrician at Taunton and Somerset NHS Foundation Trust.

Geriatricians are, in many hospitals, now responsible for looking after more than 50% of medical in-patients and are frequently required to look after outliers on non-medical wards. A recent article in the BMJ suggests that doctors’ way of working would not be accepted by businesses making decisions with far less impact and suggests that the old concept of the ward round is broken and needs to change[i].

Since we, as geriatricians are providing a substantial element of acute inpatient care, should we not be at the forefront of improving the ward round so that it is not only effective and safe for patients but also to ensure geriatricians do not suffer from undue work pressures and risk burn-out? At a time when there are increasing pressures to improve not only patient care but also communication with patients and relatives is it necessary to review the time allotted to geriatricians to safely and effectively manage acutely unwell frail older patients under their care?

Acute geriatrics has evolved significantly over the past decade.  As a consequence of pathways to enable supported discharge from an acute admissions unit or from the emergency department, the patient who requires inpatient care is generally very unwell with multiple co-morbidities and often has significant complex social care issues.  These patients require comprehensive geriatric assessment and careful consideration of their treatment options.

Alongside the complexity of patients, there has also been a huge rise in the types of activities geriatricians are required to perform during the ward round such as  resuscitation decisions, end of life planning, DOLS, etc. to name but a few. In many hospitals all of these tasks frequently fall on consultants due to lack of trainees, rota gaps or differing work schedules.  These activities require time to perform sensitively and sympathetically.

Professor David Oliver recently stated “one of the biggest stressors in work for me and my colleagues, junior and senior, is the relentless demand for information – not from patients themselves but from their relatives”[ii].  A significant majority of clinicians of all specialities and grades will agree with Professor Oliver’s statement, however, for those of us who are dealing with a predominantly inpatient workload this will create greater stress.

The past decade has seen a significant decline in the number of hospital beds and a concomitant rise in medical admissions. This creates huge pressures on clinicians, especially geriatricians, to be involved early in the assessment of many of these patients and in early discharge planning. Early discharge also results in added administrative work for consultants who will need to communicate results of outstanding investigations to GPs, patients and care homes. As a consequence I frequently feel my ward rounds are akin to being on treadmill which is constantly being cranked up with no respite in sight.

Geriatricians have little or no control over the number of patients admitted to their base ward and particularly after a weekend may arrive on the ward to find 10 or more new admissions and probably a number of outliers. Increasingly we are working predominantly on the ward with an outpatient clinic perhaps once a fortnight. It is also clear that outpatient work is reasonably well protected with a pre-determined number of patients seen per session. Many of our organ speciality physicians tend to rotate between being on the wards and doing speciality outpatient work. The majority state that their stint on the wards is hard work and they look forward to going back to their outpatient work.  Geriatricians, unfortunately, do not have this luxury and are responsible for inpatients all year round with occasional respite for some in the outpatient setting.

The RCP document Consultant Physicians Working with Patients[iii] published in 2013 recommends 1 PA for a 20-30 patient ward round.  This equates to between 12 minutes (for 20 patients) and 8 min (for 30 patients) per patient. There is no distinction between a patient who is new to the consultant and one who is known to the consultant.  The same document recommends 45-60 min per patient in the out-patient setting for complex elderly care patients which equates to 4-5 new patients per PA in clinic.  While the time for seeing a complex need older person in clinic appears to be wholly appropriate, the time allocated to ward patients in the current environment of variable/ scant junior doctor support, rota gaps, insufficient nurse staffing to attend ward rounds etc. seems very punitive. In addition the RCP recommendation does not take into account the need for a daily board round which can take between 30 minutes and an hour depending on the number of patients on a given ward.

A poll of geriatricians in the South West of England suggests that they are coming under increasing pressure to review and discharge patients as soon as possible and that the time required to safely assess and plan patient care is insufficient. They have little or no control over the workload on wards compared to the planned and agreed output in the clinic setting.  Most felt that the RCP guidance for ward rounds is insufficient and that a new patient on the ward requires 30-40 minutes of consultant time and a follow-up around 10-15 minutes.

Caldwell et al [iv] reported in 2011 that when attention is paid to quality and safety at the point of care, it took 10 minutes per patient for routine ward round and 14 minutes for a post take patient.  Their study did not take into account any communications with relatives and the other aspects of care we are now routinely required to participate in.  In a follow-up report in 2016, Dr Caldwell reported that the time for a routine round had increased to almost 16 minutes per patient and that for a post take round to 24.5 minutes[v] per patient. Again, this update appears to account only for the medical component of the ward round and not all the additional tasks we are increasingly required to perform.

As geriatrics is the largest speciality providing acute inpatient care, it is important that we as geriatricians lead on redefining and developing safer working on wards not only to enable better, safer, and informed care for patients and relatives but also ensuring we do not suffer from burnout. Is it not now evident that clinicians responsible for the medical management of frail older acutely ill patients have the time to deliver their services safely and competently? If we do not address this issue we are in danger of failing these patients who require our expertise, and we risk increasing burnout which may ultimately result in fewer trainees choosing geriatrics – endangering the very future of the speciality.

[i] The ward round is broken. Morgan M, BMJ 2017;358:j4390

[ii] David Oliver: How much information should patients families’ expect on acute wards?  BMJ 2017;359:j4295

[iii] Consultant Physicians working with patients – Geriatric Medicine  RCP 2013 :118-125

[iv] Qualitiy and safety at the point of care: how long should a ward round take? Clin Medicine 2011; vol 11(1):20-22.

[v] Caldwell G : Ward rounds routine and post take. https://fabnhsstuff.net/2017/01/08/ward-rounds-routine-post-take-analysis/

2 thoughts on “Ward rounds – are they safe and effective for patients and doctors?

  1. I totally agree. Our Job Plans are also being scrutinised in increasing detail. We have been trying to challenge the DCC PA time allocated to review new patients on our Acute Older Person Assessment Unit for some time now. The current time allocated is unrealistic and can lead to errors or suboptimal care. Isn’t it about time that the BGS & RCP relooked at the national guidance to help support Acute Geriatricians?

    • BGS is addressing this. Ongoing involvement and input Nationally and ongoing discussions at BGS England Council (ask your regional BGS representative for updates).

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