The value of consultant-led ward rounds for patient safety

Recent studies show that regular consultant-led ward rounds can enhance patient safety and improve outcomes

In 2008, the Special Commission of Inquiry into Acute Care Services in New South Wales public hospitals, which focused on patient safety and quality of care, led to the recommendation, in the Garling report, that “Daily multi-disciplinary ward rounds should be introduced at which accurate and complete notes are taken which are approved by the supervising doctor within a specified time frame”.1 Subsequently, the NSW Department of Health published a document aimed at helping hospitals and clinical units implement the recommendations in the Garling report.2 Despite the recommendations and this response, it is widely asserted that the frequency of, breadth of staff participation in and significance of ward rounds for patient management have diminished in many public teaching hospitals in NSW over the past few years. However, we have been unable to find evidence supporting this contention. Paradoxically, there is broad agreement on the educational value of rounds in disseminating information and in professional mentorship at both the undergraduate and postgraduate levels.

Following publication of the Garling report, the question of whether there was adequate evidence that its proposals would achieve the desired outcomes in quality of care, patient safety and avoiding “bed block” was raised.3 To answer this question, we searched PubMed for recent objective studies on the topic, using search terms including but not limited to: ward rounds, patient care, patient treatment, patient management, patient safety, patient outcomes, treatment planning, medications, length of stay, hospital costs and bed block, and also searched the references in articles that we identified.

We did not find specific evidence of declining importance of ward rounds. On the contrary, the literature abounds with statements such as, “The importance of the post-take ward round to both patient safety and medical education cannot be overemphasised”.4 Further, many studies show that ward rounds, accompanied by research to improve their effectiveness, remain an integral part of patient care in other Australian jurisdictions and elsewhere. For example, the Royal College of Physicians (RCP) and Royal College of Nursing (RCN) in the United Kingdom have jointly published an overview of principles for best practice in medical ward rounds.5

Despite the importance accorded to ward rounds in the Garling report, the RCP/RCN review and other recent publications, we found very few studies that provide objective evidence of ward rounds being a mechanism that guarantees or improves patient safety. One such study, which introduced twice-daily consultant-led rounds in a UK hospital’s medical wards in an attempt to reduce length of stay, yielded dramatic results.6 The mean number of discharges per month increased from 68.6 to 116.1, the mean length of stay declined from 10.4 to 5.3 days, and the bed occupancy rate fell from 95.3% to 87.5% without any change in re-admission or mortality rates. Further, these improvements were sustained over a 12-month period.

In a similar study, consultant-led gastroenterology ward rounds at the Royal Bolton Hospital were conducted twice a week before 2010. Subsequently, once-daily clinical rounds were scheduled from 09:15 to 11:45, Monday to Friday, and were followed each day by a patient-centred multidisciplinary team meeting involving input from all relevant health care professionals, with the predicted date of discharge for each patient reviewed daily.7 A comparison of the 12-month periods before and after the change showed a marked decline in length of stay (from 11.5 days to 8.9 days) and a concomitant increase in number of admitted patients (from 827 to 1072). The number of inpatient deaths declined from 88 (11% of admissions) in 2009 to 62 (6%) in 2010 and the 30-day mortality fell from 121 (15%) to 87 (8%); both these differences were statistically significant. The proportion of patients being transferred to another ward fell from 20% to 8.5%. It was also noted that the resulting continuity of care improved communication among staff and with patients and their relatives.

In 2011, twice-daily consultant-led ward rounds were introduced in the acute admissions unit (AAU) at the Stirling Royal Infirmary and subsequently at the Forth Valley Royal Hospital as one component in a program of interventions aimed at early identification and rescue of patients with a deteriorating condition.8 Compared with a baseline period, the program resulted in a 71% reduction in the rate of cardiac arrests, a 73% reduction in 2222 calls to summon the cardiac arrest team and a relative reduction of 24% in the 30-day mortality for patients admitted to the AAU.

Since the 2009 landmark study on surgical safety checklists,9 there have been several reports on checklists aimed at ensuring systematic, safe and complete patient review during ward rounds. Although most covered the introductory phase only, two were carried through to an objective assessment that showed improved patient safety after the introductory phase.10,11

Although few in number, these studies demonstrate the value of ward rounds for patient care, patient safety and length of hospital stay. Ward rounds were once regarded as essential for good patient care and a necessary part of teaching and training in NSW public hospitals. They were usually conducted at the bedside at a regular time and led by a senior consultant. Emphasis was placed on orderly consideration of clinical data pertinent to the patient’s progress. The team usually included nursing staff, junior doctors and medical students. This was an era when there was considerably less constraint on medical resources, staffing and conditions of appointment. Many conditions have changed since then, leading to factors that could act directly against the recommendations of the Garling report.

Despite the dearth of literature providing a contemporary evidence base, we believe that medicine’s long and profitable experience with ward rounds justifies their retention in modern hospitals. In our opinion, they should be conducted daily, and led by senior medical staff capable of making informed decisions in the patients’ best interests; they should involve nurses and other relevant health professionals; and they should be adequately funded.