Ameya primary hospita

MDT ROUNDS PROTOCOL

Prepared by: (CG & QU)

SEP 2016 EC
Table of Contents
Abbreviations..............................................................................................................................................II
Background..................................................................................................................................................1
Introduction.................................................................................................................................................1
Definition.....................................................................................................................................................2
Grand rounds:..........................................................................................................................................2
Daily Rounds:...........................................................................................................................................2
Multidisciplinary Team (MDT) rounds (Patient rounds):.........................................................................2
Nursing rounds:.......................................................................................................................................3
4. Purpose of rounds................................................................................................................................3
5. Team Roles..........................................................................................................................................4
Fig 1: Example of team roles on a multidisciplinary ward round................................................................5
Effective Teaching rounds/Bedside.............................................................................................................6
Do’s and don’ts during Teaching Rounds.................................................................................................6
Structuring the Ward/Teaching round.....................................................................................................7
7.1. Preparation...................................................................................................................................7
7.3. Documentation or recording........................................................................................................7
7.5. Information Tools......................................................................................................................10
References.................................................................................................................................................11

I
Abbreviations
 EMOPD: emergency OPD
 IPD: inpatient department
 MDT: multidisciplinary team
 OPD: outpatient department
 MEWS Modified Early Warning Score
 AHPs Allied Health Professionals
 HCAIs Health Care Associated infections
 DVT Deep vein Thrombosis
 LOS Length of stay

II
Background

Ward round is a complex clinical process during which the clinical care of hospital inpatients is
reviewed. This process includes:
Establishing, refining or changing the clinical diagnoses
Reviewing the patient’s progress against the anticipated trajectory on the basis of history,
examination, MEWS (Modified Early Warning Score) and other observations, and results
of investigations
Making decisions about future investigations and options for treatment, including DNAR
(do not attempt resuscitation) and any ceilings of care
Formulating arrangements for discharge
Communicating all of the above with the multidisciplinary team, patient, relatives and
careers
Active safety checking to mitigate against avoidable harm
Training and development of healthcare professionals.

Introduction

This clinical rounds protocol should be known and adhered to by all healthcare professionals,
supportive staff, students/interns/residents, patients, and families etc.

Communication among care providers is a major part of information flow in health care, and
effectiveness of communication is the cornerstone of patient safety. Consensus on the critical
role of communication in patient safety is evidenced by the fact that one of the 2006 national
patient safety goals of the Joint Commission on Accreditation of Healthcare Organizations is
“to improve the effectiveness of communication among care providers.”

Communication failure among health care providers is one of the most frequently cited causes of
preventable harm to patients. For example, a retrospective review of 16,000 in-hospital deaths
found that communication errors contributed to adverse outcomes almost twice as frequently as
inadequate clinical skill. Communication among care providers occurs in various forms,
including multidisciplinary rounds (MDR).

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Definition
Grand rounds:

It is methodology of medical education and patient care in the inpatient settings, consisting of
presenting the medical problems and treatment of a particular patient to an audience consisting of
doctors, residents, medical students, nurses, laboratory professionals, pharmacists, dieticians and
others. It was first conceived by doctors as a way for junior colleagues to round on patients.
The patient was traditionally present for the round and would answer questions; grand rounds
have evolved with most sessions rarely having a patient present and being more like lectures. An
actor portrays the patient in some instances. Originally a patient-centered experience aimed at
increasing clinicians’ knowledge for treating unique cases.
Today, Grand Round is more commonly used to educate students, showcase faculty role models,
and promote collegiality in clinical settings. Grand rounds help doctors and other healthcare
professionals keep up to date in important evolving areas which may be outside of their core
practice. Attending grand rounds is also an important supplement to medical school and on-the-
job resident training.
Grand rounds tend to present the bigger picture, including experience with patients over many
years, and the newest research and treatments in an area.

Daily Rounds:

It is daily visit by the attending physician and team to all patients on the ward. Rounding with an
attending physician is an important part of medical on-the-job training and education, but its
primary focus is immediate care for the patients on the ward.
Grand rounds tend to be open to the entire medical professional community, whereas daily
rounds are specific to individual attending physicians and their teams.

Multidisciplinary Team (MDT) rounds (Patient rounds):

MDT rounds are mechanisms through which care providers from different specialties meet to
communicate, coordinate patient care, make joint decisions, and manage responsibilities.

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Nursing rounds:

Nursing rounds are chart rounds, walking rounds, teaching rounds, or grand rounds that are held
specifically for nurses and that focus on nursing care.

Nursing round is a procedure in nursing education and in nursing care practice in which one or
more visits to a hospital patient are scheduled by two or more nurses to coordinate care,
troubleshoot, respond to patient needs, and share insights.

Nursing/ midwife staffs should conduct all types of rounds:

1. Shift round: when one shift goes out and another shift comes in, there should be a shift
round to hand over patients and their treatment status.
2. Individual round/1hr&3hr: One hourly /three hourly nursing rounds conducted by each
individual nurse to care for his/her patients.
3. Group nursing rounds: nursing/midwifery staff all together makes group rounds twice a
day or every 4 hrs in wards, OPD, EMOPD etc.

4. Purpose of rounds

Ward rounds are critical to developing rapport and building trust with patients, while discharging
a duty of care. Ward rounds also enable all individuals involved to express a shared aspiration to
make the patient the centre of attention, empowered in his or her own care.
Patient rounds involve various disciplines coming together to discuss the patient’s condition and
coordinate care. The attending physician usually leads or facilitates rounds. A resident, nurse,
laboratory technologist, pharmacist, and a team of allied healthcare professionals are also often
in attendance, such as a respiratory therapist, nutritionist, and social worker. Nursing, physician
assistant and medical students may also take part in rounds.

Usually the patient’s case is presented to the group by either the resident or the nurse. The results
of medical procedures, such as x-rays, CT scans and electrocardiograms may be discussed. Lab
work, such as blood and urine tests, will also be reviewed. The plan of care including prioritizing
treatment and establishing goals will be evaluated by the round team.

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In some facilities, a patient’s family members have the opportunity to attend rounds related to the
care of their loved one. This is especially true in pediatric and psychiatric wards. The purpose is
to have families involved in decision making and give them a chance to ask questions regarding
care.

5. Team Roles
The multidisciplinary team (MDT) includes doctors, nurses, allied health professionals (AHPs)
and pharmacists. Other members may be co-opted into the ward round as appropriate to the
patient group. All members of the team should have the opportunity to actively interact. Figure 1
outlines the possible roles for each team member.
Multidisciplinary rounds are given different names based on their purpose (e.g., discharge
rounds, daily rounds), based on the clinical unit in which they take place (e.g. medical rounds,
surgical rounds), based on location (sit-down rounds versus bedside rounds), and based on their
time frame (e.g., morning rounds, afternoon rounds, post-admission rounds). Multidisciplinary
rounds are more critical to the safety and efficiency of care, where it was shown to reduce
mortality rates.

Therefore, MDT rounds should be conducted departmentally twice daily forcritical

patients.

There are four outcome measures of multidisciplinary rounds. These are:

 Clinical outcomes: include LOS, mortality rate, ventilator days, incidence of HCAIs,
readmissions, resuscitation status, status of patient education and prevention of DVT.
 Efficiency measures: include patient volume, discharge rates, hospitalization rates, cost
savings and change in prescribing costs.
 Care provider satisfaction: satisfaction with rounds and rounds being constructive use
of time for care providers.
 Patient and family satisfaction: relationship between the policy of parents leaving the
unit during rounds and breaches in patient confidentiality, ., patients' feelings during and
after Multidisciplinary rounds, suggestions to improve Multidisciplinary rounds and
Patients' perceptions of medical care received (e.g., having adequate explanation of
problems, tests, and drugs, physician-patient relations)

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Doctor Nurse Pharmacist Patient and carers
 Leads the round  Provides update: Provide
& AHPs updates:
and introduces  vital signs  Pharmacist:
the team to the  pain control  current concerns
 reviews
patient  nutrition and  discussions with
patient’s
 Provides an hydration other health
medications
update of recent  elimination (urine professionals
 checks VTE
history, clinical and bowels)  information
prescription
examination and  mobility from carers /
 drug chart
review of patient  confusion or family
review
 Reviews drug delirium  arrangements
 AHPs:
chart  Quality and for discharge
 update of care
 Provides update: safety checks: provided
 current problems  urinary catheter  discharge and
 responses to  review of iv lines follow-up
treatment  VTE prophylaxis arrangements
 test results  pressure ulcers
 Medication  & category
 information from  Falls
patient and/or  infection control
family andnurses

Summary by doctor
Summarizes team inputs into a plan for the day and sets daily goals
Discharge planning:
 anticipated discharge needs
 place of discharge (e.g. home, rehabilitation)
 discharge date and time
 follow-up arrangements
Provides patient with information relating to plan of care and checks patient
understanding

Fig 1: Example of team roles on a multidisciplinary ward round

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Effective Teaching rounds/Bedside

Patient rounds are also used as an educational tool. They help keep everyone on the same page
when it comes to the treatment plan. Whether you are a medical, nursing or physician assistant
student, there are things you can do in order to get the most out of the experience.

Read about the patients you will be rounding on. If time permits, read patients’ histories and
review recent labs and other test results. Check patient monitoring sheets, such as the vital signs
record. Be sure to do enough research in order to at least have a basic understanding of a
patient’s diagnosis and his or her current condition.

Arrive early to avoid interrupting rounds once they have started. Additionally, be prepared to
answer questions related to your area of expertise. For instance, if you are a nursing student, you
may be asked questions related to the patient’s response to medication or the patient’s level of
consciousness.

Do’s and don’ts during Teaching Rounds

Regardless of your position, there are a few do’s and don’ts when it comes to attending patient
rounds.
1. Do pay attention: Even if you think no one will ask you any questions and you are just
observing, be attentive. You never know when you will be called on to answer a question.
2. Do silence your cell phone: Having your cell phone go off in the middle of rounds is a
distraction and can get you noticed for the wrong things and disturbances.
3. Call the patient by his/her name and introduce yourself and your team, describe what
you are going to do or talk about; give them opportunity to ask any concerns
4. Always respect the patient and ask for consents or permission before you discuss their
condition with students/families, and before you touch their body, undress their body,
examine them etc.
5. Don’t talk among yourselves: Avoid unnecessary side talks. Talking to other students or
staff when a case is being presented is distracting to others.
6. Don’t overstep your role: While it is acceptable to ask a question, always chiming in
and speaking up may be a little too much particularly if you are a student.

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 7. Strictly practice WHO 5 moments of hand hygiene [before touching a patient, before
clean/aseptic procedure, after body fluid exposure risk, after touching a patient, after
touching a patient surrounding] for your and patient safety.

Structuring the Ward/Teaching round

7.1. Preparation
Before the ward round, a period of preparation is required. Nurses should familiarize themselves
with patients’ cases and be aware of issues that need to be raised on the round.

7.2. Activities
 Pre-rounds activities: gathering and assembling information to prepare for rounds,
including pre-discussion with the patient.
 During rounds activities: communicating and exchanging information, building shared
situation awareness about patients and the state of the unit, and making decisions
collaboratively.
 Post-rounds activities: coordinating and executing care plans based on the decisions
made during rounds.

7.3. Documentation or recording

All findings and recommendations, including consultant’s recommendation on teaching/ward

rounds and bedside teaching should be recorded. Reviews and decisions need to be properly
recorded, not only for medico-legal reasons, but also to ensure continuity of care and to promote
effective communication.

7.4. Scheduling, Time spent and Student Distribution

Appropriate timing, time spent on bedside or ward round and defined number of students to
patient ratio for ward rounds are crucial in ensuring that clashes do not occur with other
scheduled activities such as drug rounds, mealtimes or visiting hours and teaching round/
bedsides with ward round and for maximum patient benefits. Therefore, at each ward student to
patient ratio should not exceed 1:2 – 4. Time spent on a patient for bedside and teaching round
should be around 1hour and 30 minutes respectively. This is shown in table 1 below. When the
Hospital accepts students from different Universities, same group of round staff should not be
assigned for teaching rounds at the same time.
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 Table 1: Timing of ward round and teaching rounds in G/TS/Shawo General Hospital
Round & Mon Tues Wed Thu Fri Sat & Sun
Timing
MDT 2:30DLT 2:30DLT 2:30DLT 2:30DLT 2:30DLT 2:30DLT,
Round & & & & & 2:30NLT
8:30 NLT 8:30NLT 8:30NLT 8:30NLT 8:30NLT
Teaching 2:30-6:30 2:30-6:30 2:30-6:30
Round DLT DLT DLT

Bedside 2:30-3:30 2:30-3:30

Teaching DLT DLT

8.5 Outcomes of Multidisciplinary rounds

Clinical Outcomes
Table 4: Reported Outcome Measures for Evaluation of the Impact of Multidisciplinary rounds
(MDR)
Clinical outcomes
Mortality rate
Length of stay
Ventilator days
Incidence of nosocomial infections
Resuscitation status
Procedure complications
Readmissions
Prevention of deep vein thrombosis
Decubiti ulcers
Achievement of clinical performance targets of albumin, hemoglobin, calcium-phosphate product, dose,
and vascular access type (fistula)
Primary and secondary fistulae patency
Duration of fistula patency following an operation
Status of patient education before discharge
Timing of discharge
Patient and family satisfaction
Patients' perceptions of medical care received (e.g., having adequate explanation of problems, tests, and
drugs, physician-patient relations)
Overall patient satisfaction with Multidisciplinary rounds (e.g., patients' feelings during and after
Multidisciplinary rounds, suggestions to improve Multidisciplinary rounds)

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Experiences of families regarding attending Multidisciplinary rounds
Maintenance of patient confidentiality
Relationship between the policy of parents leaving the unit during rounds and breaches in patient
confidentiality
Efficiency measures
Patient volume
Discharge rates
Hospitalization rates
Cost savings
Change in prescribing costs
Care provider satisfaction
Satisfaction with rounds
Rounds being constructive use of time for care providers

7.5. Information Tools

These represent a wide range of tools or formats to support information, communication, and
decision needs. These include all patient notes, results, monitoring devices, request cards and
order sheets should be made available to the team at a central point, e.g. a bedside trolley.

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References
1. Royal College of Physicians, Royal College of Nursing. Ward rounds in medicine: principles
for best practice. London: RCP, 2012.
2. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the
intensive care unit. Crit Care Med. 1995; 23:294–300. [PubMed]
3. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The
Quality in Australian Health Care study. Med J Aust. 1995; 163:458–71. [PubMed]

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