How to run a good ward round

How to run a good ward round

What is a ward round?

When you are in hospital, the doctors and nurses will visit you most days on a ‘ward round (WR)’. This usually occurs in the morning. Each patient is usually reviewed in about 10 minutes, longer if required.

So. How to run a good ward round?

Who is present on a ward round?

• Doctors. The senior usually leads. They may be a consultant (boss), registrar (middle grade) or junior doctor
• Nurses
• Physicians associates (PAs) or Advanced care practitioners (ACPs). May lead
• Allied health professionals – e.g. physiotherapists, occupational therapists, dietitians
• Pharmacists
• Students (often).

Typical ward round, with senior doctor nearest the patient

Purpose of a ward round

Doctors and nurses, with the patients, should:

1. Monitor the patient’s progress – since last WR
2. Clarify diagnoses and current problems
3. Document management plan – which includes:
   • Setting actions and the discharge plan
   • Reviewing clinical safety checks (observations) and drug card
4. Educate – and involve students.

What makes a good one?

It depends whether you are thinking about it from the patient’s perspective or the staff. And what about the students? This page is written from the perspective of the patient, not just doctors, nurses and students. You need to think about all three. It also assumes that students are present and would benefit from involvement and teaching.

Running a good ward round is a difficult skill, especially as all three need to gain benefit, especially the patient.

Before the ward round

Make it clear who is leading, usually the most senior doctor. But it may be a PA or ACP. Before the WR, the leader should identify themselves, who everyone is, and assign roles (e.g. X checks bloods on computer, Y checks observations). Make sure they know they need to have information ready before you see a patient (e.g. U+E if they have CKD).

The leader should add an expectation of learning for students. Students should mainly listen and learn, but can ask questions at correct time, usually towards the end of the patient assessment.

Determine the order. This is very important. Before you go to Bed 1 (or 30) ask to start with the ‘quick then the sick’:

• The quick – to discharge before lunch and free up the bed, and thereby encourage hospital flow. Aim for 2 off ward and in discharge lounge by 12pm
• The sick – as they deserve your best (freshest) brain.

3Ps – preparation, preparation, preparation”

Junior should give the first patient’s drug card to leader. Start.

1. Introduction – start well

Patient – needs to know who you all are, and who is leading. Write their name down
Staff – leader introduces him/herself clearly, saying “these are doctors and nurses in the team”. Senior should stand or sit nearest patient and lead questions
Student – make sure the leader knows you are, and your level of seniority (best done pre-WR)

2. Confirm current diagnoses

Patient – should listen to what doctors say are current diagnoses. Write that down
Staff – leader states current diagnoses
Student – ‘put the tape in your head’ re those diagnoses. Do you know about them? If not, jot down you need to read up on them, and ask about them later if appropriate

3. Ask patient current problems

Patient – it is important to explain all your problems carefully, especially new ones
Staff – leader says “How are you feeling today?”
Student – start thinking about what those problems mean, e.g. if they say “I have ankle swelling”, what are its causes?

4. Check safety measures, including review of observations and drug card

Patient – ask any questions about drugs that have been stopped or started
Staff – leader makes sure team have written down abnormal observations, and has checked the drug card themselves. Make changes. Check:

• Allergies filled out?
• VTE done?
• Antibiotics reviewed? Do they still need to be IV?

Student – do you know all the drugs on the drug card, which group they are from and what they are for? If not, write them down to read about later. Have you got a clinical pharmacology book? No? Buy one!

5.  Review patients’ progress against previous plan

Patient – ask doctors the results of new tests
Staff – ask to see most up-to-date information, especially ‘big tests’ (e.g. biopsies and scans)
Student – ask yourself what does that result mean, and how you would have responded to it, and/or explained it to the patient

6. Summarise the revised plan, with key actions

Patient – listen to new plan. Write it down
Staff – leader “Ok, so this is the plan .. ” This must include a discharge plan. Juniors should ask senior for one if not given
Student – ask yourself, what would your plan have been?

7. Review documentation of WR and plan, assigning key actions

Patient – start to think about any questions you have, especially regarding the discharge plan. If you feel well ask “when can I go home?”
Staff – leader makes sure the WR and plan have been correctly documented, and it is clear who is carrying out which action
Student – this is a good time to ask questions. Make them focussed, e.g. “why did you stop that drug?”, not “please tell me about DKA”

8. Goodbye – End well

Patient – thank the doctors and nurses. Ask what is the discharge plan if not yet stated. Write down the name of the leader of the WR and ask how you can contact them if needed
Staff – ask the patient if they have any questions
Student – thank anyone that has taught you. Assess how you have contributed to the WR. Offer to come back later and help the junior doctors with jobs. Make them coffee, bring cake.

How long should a ward last?

That is a hard one. It depends on the number, types of patient, and proportion of new patients. Allow 3 hours maximum. 2-2.5 hours is better. It’s hard to concentrate over 3 hours.

Start early, no later than 8.30 am. Allow 10 mins for each patient. Don’t rush it but have it done by 11.30am so the patients can have lunch. Surgical WRs tend to be much shorter, partly as there are fewer patients, and often have one problem.

Top Tips

• Progress actions during ward round when possible. There will be less work later and things will be fresh in your mind
• All staff need a mechanism of recording their actions (e.g. paper or cyber diary)
• Remember it may be just 10 mins of your day, but those 10 mins may be the biggest moment of the patient’s day
• ‘Teach and learn’. Don’t assume the WR is about you and what you have learnt. Who have you taught?
• Return to see deteriorating patients, or those that you think didn’t understand the decisions on the WR.

Summary

We have described What makes a good ward round. We hope it has helped staff, students and patients.