Elsevier

Journal of Critical Care

Volume 45, June 2018, Pages 110-113
Journal of Critical Care

Communication
Influence of ward round order on critically ill patient outcomes

https://doi.org/10.1016/j.jcrc.2018.02.003Get rights and content

Highlights

  • The concept of ‘decision fatigue’ is becoming more apparent in medicine.

  • The effect of the order in which critically ill patients are reviewed on a ward round is unclear.

  • This is the first paper looking into outcome measures and ward round order in critically ill patients.

Abstract

Purpose

To examine the effect of order in which patients are seen on an Intensive Care Unit (ICU) ward round on ICU length of stay (LOS), mortality and duration of mechanical ventilation.

Materials and methods

Retrospective observational study in a tertiary metropolitan ICU over a 12 month period. All patients who occupied the first and last three bed spaces of the ICU ward round, without having moved bed spaces during admission, were included. Separate analyses were performed for the absolute first and last patients.

Results

681 patients were included. There was no difference in the primary outcome, ICU LOS [median (IQR) 50 (23−102) hours for the first three patients seen vs. 51 (25–110) hours for the last three patients, p = 0.594]. No differences were found in any secondary outcomes (hospital LOS, ICU mortality or duration of mechanical ventilation).

Conclusions

The order in which patients were seen on an ICU ward did not affect ICU LOS nor related outcomes.

Introduction

Bedside clinical ward rounds form an integral part of patient care and medical education worldwide. The ward round must balance sometimes competing priorities, between delivering high-quality individual patient care, overall service provision, and teaching opportunities for junior clinicians. Patients admitted to the Intensive Care Unit (ICU) are among the most complex in the hospital, with high nursing needs, requirement for complicated medical decision making, and liaison with multiple inpatient units. Effective care for these patients must be delivered in a timely and specific manner, with a focus on clear communication among the multidisciplinary team [1]. Recent consensus statements on the importance of ward round care, such as the 2012 joint statement from the Royal College of Physicians and the Royal College of Nurses in the United Kingdom [2] emphasise that a well functioning ward round can improve patient safety, shared understanding, collaborative learning, and efficient use of resources. Despite this, variability may exist in the efficiency and quality of medical ward rounds due to factors such as intermittent interruptions and communication between healthcare professionals.

More recently, the concept of “decision fatigue” has arisen in many fields, including medicine [3]. The cognitive demand of making multiple decisions over the course of a day may result in decreased ability to recognise and resist inappropriate decision making. This phenomenon has been observed in primary care clinicians, in which unnecessary antibiotics are more likely to be prescribed at the end of a clinic session [4]. Similar to other industries, such decision fatigue is likely to result in the perceived “safer option” being pursued- judges, for example, have been shown to be less likely to grant parole as court sessions progress [5]. There is a paucity of literature, however, examining the effect of decision fatigue on ward round conduct, with no data to inform whether outcomes differ depending upon the order in which patients are reviewed during the ward round.

The aim of this study was to assess the impact of ward round order on patient outcomes. Primary outcome was length of stay (LOS) in ICU. Secondary outcomes were the duration of hospital LOS, duration of mechanical ventilation, ICU and hospital mortality.

Section snippets

Materials and methods

We performed a retrospective, single centre observational cohort study within the Royal Melbourne Hospital (RMH) ICU, a tertiary metropolitan intensive care unit. Data was collected from a twelve-month period (1st January 2014 to 31st December 2014) utilising prospectively gathered data from the RMH ICU AORTIC database which reports to the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD), and the RMH inpatient manager system (iPM). Approval was obtained from

Results

A total of 2094 patients admitted during the study period were screened for inclusion. After exclusions 681 patients continued to final analysis (Fig. 1). Data was complete for all patients. A total of 315 patients were seen as the first three patients on the ward round, and 366 patients seen as the last three patients, with the two groups similar in terms of baseline characteristics (Table 1). Median (IQR) age was 60.7 (42.7–73.2) years in patients seen first vs. 57.3 (40.4–74.7) years in

Discussion

In this retrospective, single centre observational cohort study, we did not show a difference in outcomes including length of stay, mortality or duration of mechanical ventilation between those patients who were seen last on the ward round compared with those seen first. To our knowledge this is the first study in any medical discipline to examine outcome measures depending upon order in which patients are seen on a ward round. The results from this study imply that intensive care clinicians

Conclusions

In this single centre retrospective observational cohort study, we did not find an association between ward round order and ICU or hospital LOS, mechanical ventilation, or ICU mortality. Further studies are required to establish whether these findings are generalisable to other inpatient ward round settings.

References (11)

  • D. Karalapillai et al.

    Improving communication of the daily care plan in a teaching hospital intensive care unit

    Crit Care Resusc

    (2013 Jun)
  • P. Provonost et al.

    Improving communication in the ICU using daily goals

    J Crit Care

    (2003)
  • Royal College of Physicians and Royal College of Nursing

    Ward rounds in medicine: Principles for best practice

    (2012)
  • K.D. Vohs et al.

    Making choices impairs subsequent self-control: a limited-resource account of decision making, self-regulation, and active initiative

    J Pers Soc Psychol

    (2008)
  • J.A. Linder et al.

    Time of day and the decision to prescribe antibiotics

    JAMA Intern Med

    (2014 Dec)
There are more references available in the full text version of this article.

Cited by (0)

View full text