Checklists to structure internal medicine ward rounds reduce omissions and improve adherence to standards of care: a pre-post intervention study

DOI: https://doi.org/https://doi.org/10.57187/5058

Introduction

In internal medicine hospital divisions, ward rounds are a core component of daily clinical practice, during which the clinical progress of patients is assessed and decisions regarding the next stages of care are taken [1–4]. Although ward rounds are not conducted uniformly across hospitals, the model referred to as “interprofessional bedside rounding” is becoming increasingly common [5]. Such rounds are described as being “triadic,” as the healthcare providers, typically a physician and a nurse, interact with patients at their bedside [1–3].

Conducting effective ward rounds is complex and requires a large set of skills and competencies, including teamwork, interprofessional clinical reasoning, communication, organisational skills, and professionalism [6]. Junior physicians and nurses may lack some of these skills and competencies due to a lack of training during their studies [7–9]. This lack of training is likely a consequence of the absence of standardisation in how ward rounds are conducted [2,7–10].

The inability to conduct effective ward rounds may lead to errors of omission [10, 11], which result from actions that are not taken [12] due to organisational difficulties or a lack of time [13]. Such errors can negatively impact patient safety [14, 15]. Moreover, ineffective ward rounds may negatively impact healthcare team communication and collaboration, as well as patients’ understanding of care goals [1, 16–18].

Checklists are a type of cognitive aid that helps promote adherence to best practices and avoid errors of omission [19]. Evidence also shows that checklists improve clinical outcomes, including reducing rates of catheter-associated infections, reducing the duration of mechanical ventilation, and reducing rates of ventilator-associated pneumonia [20]. Furthermore, they increase satisfaction among healthcare providers by fostering team communication, teamwork, and patient-centred care [21–24]. Nevertheless, most studies have been conducted in intensive care unit settings. Little is known about the effectiveness of checklists in internal medicine hospital divisions, where the proportion of elderly and multimorbid patients is higher [24–26].

Aim of the study

This study tested the following hypotheses: (1) the implementation of a checklist to structure ward rounds in an internal medicine hospital division reduces the omission of key clinical items; and (2) the reduction of omissions improves adherence to standard-of-care protocols, namely the reduction of venous and urinary catheters in place without a recognised indication.

Methods

Local context and aim

This study was conducted in the internal medicine division of Lausanne University Hospital, a tertiary teaching hospital in Western Switzerland. The division has 170 beds distributed across seven units and provides care for 6,200 patients per year. A typical unit has 24 beds and is supervised by an attending physician, a chief resident, and a head nurse. Each unit is run by three residents, four nurses, and four nursing assistants.

In our division, bedside ward rounds are conducted daily by a resident-nurse pair. ward rounds run between 10:00 and 11:30 am. Both the resident and the nurse have dedicated time beforehand to prepare [27].

Therefore, although the daily conduct of ward rounds was structured, the content of the ward rounds was not. This resulted in substantial heterogeneity in how ward rounds were performed within the same hospital division, prompting the need to define and structure their content. We aimed to achieve this using a checklist and designed a quality improvement study following the SQUIRE guidelines [28].

Intervention

Development of a checklist

The content of the checklist was initially drafted after a literature review of published models [2, 22, 23, 29–36]. Its items were then adapted to local needs through an iterative process by an interprofessional team of nurses and physicians. The checklist was pilot tested in two different units for about 12 months to gather feedback from the teams. Based on this feedback, it was refined and approved by a local committee consisting of attending physicians, chief residents, and head nurses. The final version included 19 key items, covering the aspects of ward rounds to be addressed during each patient encounter, divided into four sections (briefing; current and new problems [2 items]; “do not forget” items [12 items]; patient time [5 items]). The checklist is presented in figure 1.

Figure 1 Internal medicine checklist (front and back). The checklist is translated into English from the original version in French.

Development of recommendations for best practice

To ensure that clinicians correctly addressed the key checklist items, a document describing the intended standard of care was prepared. A best practice recommendation was included for each item of the “do not forget” section. The recommendations for best practice were based on local guidelines (e.g. indications for and surveillance of venous catheters [37]), national guidelines (e.g. indications for urinary catheters [38]), or international guidelines (e.g. thromboprophylaxis [39]), depending on availability. The checklist and best practice recommendations were printed and distributed in pocket-card format (see figure 1); they were also made available as electronic resources on the hospital intranet.

Implementation strategy

Because residents rotate every six months in our division, we focused on training senior physicians and nurses, who do not rotate and are responsible for supervising their younger colleagues. These clinical supervisors underwent a compulsory interprofessional, 3-hour session in which the rationale for the project, the checklist, and their role and responsibilities as trainers and prompters were explained. A short video illustrating how the new structured ward round should be conducted was presented and discussed (video available upon request).

These trained senior staff members were expected to be the “champions” of the new ward round structure and to prompt its use via role modelling (systematically using the checklist during each ward round). In addition, trained staff provided regular reminders during morning meetings. Residents and nurses underwent separate 1-hour information and training sessions, also using the video.

Study of the intervention

Study design

A prospective pre- and post-intervention design was used to assess the impact of the intervention as a whole, including the checklist itself and all the elements supporting its use (e.g. training, video demonstration, prompting, and reminders). The different study phases are presented in the Appendix.

Measures

Outcomes

The primary outcome was the number of key clinical items addressed during ward rounds before and after the checklist was implemented. The key clinical items are described in the Appendix (table S1).

Secondary outcomes were (a) the number of venous or urinary catheters present in hospitalised patients (i.e. the proportion of hospitalised patients with a venous or urinary catheter), (b) the number of venous or urinary catheters that complied with institutional and national guidelines in terms of indications [37,38], (c) the proportion of patients mobilised at two specific times of the day, (d) ward round duration, (e) ward round location (bedside vs hallway), and (f) patients’ and nurses’ perceived level of understanding of care goals, assessed using a visual analogue scale (0 to 100).

Data collection

An observation plan was designed for rounds, which were conducted by a resident and a nurse (see Appendix, figure S1). No senior physician or head nurse was present during these rounds. Observations were equally distributed across all units in the division. However, the two units where the project was piloted were excluded from the pre-implementation observations. The resident-nurse pair to be observed was informed on the same day. They were blinded to the exact type of data being collected to reduce the Hawthorne effect. Each acute inpatient seen by a resident-nurse pair during the ward round counted as a patient encounter.

Observers and observers’ training

Observers were final-year medical students with several months of clinical experience who first responded to the job offer emailed to all final-year students. They were trained by the research team and performed calibration test observations as part of the training. After the test observations, observers could ask clarifying questions on how to interpret and score specific observed behaviours. This process allowed the clarification and calibration of the scoring between observers.

Observation periods

The observation of ward rounds before implementation lasted six days (27, 30, and 31 January and 1, 2, and 3 February 2023); the observation after implementation also lasted six days (18 to 21 April and 24 and 25 April 2023). A short time frame of three months was selected to avoid potential confounding factors such as physicians’ rotations, seasonal differences in patients’ diseases, and other quality improvement initiatives.

Data collection tool

Data were collected using two paper sheets with two data collection methods: an observation sheet and an audit sheet (available in the Appendix). The observation sheet collected dichotomous data on the discussion of each of the 19 items on the checklist (Yes/No), as well as data on ward round location and duration. These data were collected through direct observation. ward round location was determined by the observer, based on where most of the ward round took place. ward round duration was based on the start and end times of the ward round recorded by the observer.

The audit sheet was used to collect data on venous and urinary catheters (type and indication). First, the observers were tasked with documenting whether a urinary or venous catheter was in place by checking each patient visited. Second, the observers asked the nurse or resident in charge about the indication for the urinary or venous catheter, without discussing adequacy. Finally, based on the nurse’s or resident’s answer, the observer selected an option from a list of indications (see audit sheet). The audit sheet also collected data on patients’ and nurses’ understanding of care goals, which was assessed by questioning the nurses and the patients, typically immediately after the rounds. Rather than answering orally, nurses and patients rated their understanding on a visual analogue scale (VAS; in millimetres, from 0 to 100, with 100 representing full understanding and 0 representing no understanding at all).

Data were initially collected on paper and then transcribed into a computerised database by the observers. The first author performed quality control of the transcription process by verifying consistency between the paper forms and the computerised database.

Because sufficient mobilisation of hospitalised patients is a common concern, we sought to measure whether discussing this item during ward round would lead to a concrete impact on the rate of patient mobilisation. Therefore, a pragmatic approach was used to measure patient mobilisation. This approach was based on the behavioural mapping method, which involves patient observation at set intervals [40]. We selected two times of day during which patients in our division were the most likely to be mobilised: between 11:50 am and 12:35 pm (for lunch) and between 4:00 pm and 4:50 pm. These specific times were based on a previous study on patient mobilisation conducted in our division [41]. The members of the research team performed the mobilisation audit by visiting patients’ rooms in the different units of the division, during both periods of the day, one week before and one week after implementation. The best value per patient and per day was considered (walking > sitting > in bed).

Data analysis

Sample size calculations and statistical analysis

A pilot study prior to the intervention found that, on average, 8 out of 19 checklist items were discussed during each ward round. Sample size calculations were therefore based on an expected increase in discussion from 8 to 11 out of 19 checklist items after the intervention, with a power of 80%, an alpha level of 5%, and a one-sided test. Thus, 240 observations were required (120 before and 120 after implementation). Considering a participation rate of two-thirds (to account for patients who were unavailable for the ward round), the number of required observations was increased to 360.

Descriptive statistics are presented as absolute numbers and percentages for categorical variables and as medians [interquartile range] for continuous variables. Pre- and post-intervention comparisons for primary and secondary outcomes were initially conducted using the chi-square or Fisher’s exact test for categorical variables and the Kruskal-Wallis test for continuous variables. As continuous variables showed asymmetric distributions as assessed by Q-Q plots, only nonparametric statistics were applied. If an observation had missing information for one variable, it was excluded from the analyses of that specific variable but retained in the analyses of the other variables. No replacement of missing values, such as imputation or carry-forward methods, was performed. A two-sided p-value < 0.05 was considered statistically significant. All statistical analyses were conducted using Stata v.18.0 (Stata Corp, College Station, TX, USA).

Ethics

This study focused on quality improvement and thus did not fall within the Swiss human research laws according to the local ethics committee (CER-VD Req-2023-00794), which waived the need to approve the study protocol. Written consent was obtained from all physicians and nurses concerning the use of personal demographic data. All data were anonymised and managed in agreement with national laws on the protection of personal data.

This study is reported according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 [28].

Results

The healthcare teams working in the internal medicine division did not change during the pre- and post-intervention phases. All residents and nurses consented to participate in the scheduled observations. Physicians’ and nurses’ demographic data are provided in table 1. In total, 368 nurse-physician-patient encounters were observed (172 before, 196 after).

Primary outcome

After the ward round checklist implementation, the median number of key clinical items discussed during ward round significantly increased from 11 [IQR 8.5–13] to 16 [IQR 14–18] (p <0.001).

Figure 2 provides the proportion of ward rounds during which the key clinical items were discussed, with a before-and-after comparison. Before the intervention, most key clinical items were discussed in at most half of the ward rounds. After the intervention, all items were discussed more often (ranging from 60% to 99% of ward rounds) (figure 2). For example, the discussion of VTE prophylaxis increased from 19% of ward round before the intervention to 63% after the intervention (p <0.001), skin issues and risk of bedsores increased from 31% before the intervention to 75% after the intervention (p <0.001) and sleep quality from 35% before to 82% after (p <0.001).

Figure 2 Proportion of items of the checklist discussed before and after. VTE: venous thrombo-embolic; VC: venous catheters; UC: urinary catheters.

Secondary outcomes

Table 2 shows the results of the secondary outcomes. The proportion of patients with a venous catheter in place decreased from 71% before the intervention to 64% after the intervention (p = 0.136). More importantly, the proportion of patients with a venous catheter in place without a proper indication decreased from 16% before the intervention to 2% after the intervention (p <0.01).

Furthermore, the proportion of patients with a urinary catheter in place decreased from 9% before the intervention to 4% after the intervention (p = 0.044). The proportion of urinary catheters in place without a proper indication also decreased (9%, n = 2 before the intervention vs 0%, n = 0 after the intervention), but the number of cases was very small.

Active mobilisation was assessed for 838 patients (411 before the intervention and 427 after the intervention). Before the intervention, 47.9% (n = 197) of patients were bedridden (no evidence of them having been moved out of their beds at two distinct times during the day), 36.0% (n = 148) were out of bed but sitting in a chair, and only 12.4% (n = 51) were walking. Our intervention did not increase the number of patients mobilised during the day (table 2).

After the intervention, the proportion of ward rounds performed at patients’ bedsides increased from 45% to 60% (p = 0.022), while rounding time increased from a mean of 92 minutes (SD 24.0; 95% IC [88.6-95.9]) to 98 minutes (SD 24.8; 95% CI [94.6-101.7]) (p = 0.02).

Before the implementation of the checklist, both patients and nurses reported a high level of perceived understanding of the care goals, which increased even further in the post-implementation phase (patients: 85/100 [IQR 50-100] before implementation vs 90/100 [IQR 70-100] after implementation, p = 0.04; nurses: 90.5/100 [IQR 80-100] before implementation vs 100/100 [IQR 85-100] after implementation, p = 0.08). Before implementation, a high proportion of nurses fully understood the care goals (scores of 100/100), which also increased after implementation (47% before implementation vs 59% after implementation, p = 0.02) (table 2).

Discussion

Our study shows that the implementation of a checklist to structure ward rounds in an internal medicine division led to (a) a significant increase in the number of key clinical items discussed, thereby reducing omissions; (b) better adherence to standard-of-care protocols regarding the use of venous and urinary catheters; (c) more frequent performance of ward rounds at patients’ bedsides; and (d) a better understanding of care goals by both patients and nurses.

To our knowledge, this study is one of the first to use a checklist to structure ward rounds in internal medicine [42] and to show the benefits that can arise from the use of such tools in this setting. We followed an in-depth, literature-based process to develop our checklist and customise it to meet the needs of internal medicine. Therefore, we think that our checklist may be applied to any internal medicine division using “triadic” bedside rounds [17]. Furthermore, a checklist such as ours would be beneficial as an educational tool to guide and train less experienced medical and nursing staff and students on how to best perform ward rounds.

While a checklist’s content is essential to a successful implementation, a comprehensive approach to the implementation strategy is needed to ensure adoption and ongoing use of the tool [10]. Checklists provide structure to guide healthcare teams and help prevent key items from being overlooked. However, they should not be seen as constraints on clinicians’ autonomy, reasoning, or decision-making. Flexibility should be allowed, as long as nothing essential is omitted [10].

To reduce resistance to its use, we designed the tool to avoid adding any administrative burden by not requiring a written format. To make it easily accessible, the checklist was printed as a personal pocket card for all team members, which was also laminated and visibly attached to all laptops used during rounds.

Strategies for successful implementation also include adequate preparation, pilot periods [43, 44], video training [45], team training [18, 22, 43–50], use of prompting [22, 32, 46, 51–53], and repeated assessment through continuous improvement (plan-do-study-act) [11, 43].

A pivotal component of our implementation strategy was the use of prompting during rounds by identified “champions“. Finally, throughout the implementation process, we relied on an interprofessional coordination group to follow up on each step and troubleshoot where necessary.

In terms of the primary outcome, our pre-intervention data underscore the high risk of omissions regarding the discussion of key clinical items during ward rounds conducted without the structure provided by a checklist. We found that, at most, only 12 out of 19 items in our checklist were discussed in half of ward rounds (figure 2). Our post-intervention data showed a significant increase in the number of key clinical items discussed. This can also be considered a measure of adherence to the checklist, an element often overlooked in studies examining the clinical benefits of checklists [24].

Regarding the secondary outcomes, we assessed the effects of our intervention on adherence to selected standard-of-care protocols. We found a statistically significant decrease in the number of venous catheters in place without an adequate indication and in the number of urinary catheters in place.

In terms of secondary outcomes, we also assessed whether our checklist could lead to more frequent mobilisation of patients. While the intervention encouraged the discussion of whether a patient had been appropriately mobilised (51.2% before the intervention vs. 85.1% after), actual rates of patient mobilisation did not change (over half of the patients were found in bed or sitting). This suggests that simply discussing the need to mobilise patients is not enough and that comprehensive programs targeting this specific issue are needed [54–56].

The implementation of our checklist increased the proportion of ward rounds performed at patients’ bedsides (+31%). Bedside rounding allowed patients to have more frequent access to the full rounding process and, more importantly, to the discussion between the physician–nurse pair, allowing them to be more directly involved in their care.

Our study also showed that following the introduction of our checklist, patients had a better understanding of care goals. This may be related to two factors. First, the checklist includes dedicated time with patients specifically addressing care goals and verifying patient understanding. Second, the increased proportion of ward rounds being conducted at patients’ bedsides could have played a role by giving patients access to the discussion between the physician and the nurse [16].

In parallel with better patient understanding, we also found that nurses’ understanding of care goals improved. It has been suggested that checklist use enhances interprofessional discussions during ward rounds [16, 30], leading to better communication within the team and improving nurses’ understanding of care goals.

One of the major concerns regarding the introduction of a new ward round structure was the risk of increasing ward round duration. However, previous studies have shown either a reduction in ward round duration or no significant change [57,58]. Our study showed a small increase of 6 minutes in ward round duration after checklist implementation. However, we believe this was offset by a reduced need for clarification and further discussion of management plans later in the day.

We identified some limitations in our study. First, we cannot exclude the possibility that the Hawthorne effect influenced our results [59]. This risk was partially addressed by “blinding” the observed residents and nurses regarding the nature of the data being collected. Second, we did not gather data on the concrete use of the checklist by the residents and nurses during the post-intervention phase, nor did we gather feedback on the checklist itself in terms of utility or desirability. Rather, we focused on a proxy for the checklist’s use by the staff while counting the number of checklist items being discussed. While we do not have data pertaining to our checklist’s utility and desirability, we support the idea of adapting the checklist to the local staff’s needs, as we did during our checklist’s development and pilot phase. Third, the indications for urinary or venous catheters were directly assessed by the observers. However, the adequacy of the catheters’ indications could have been assessed with more independence by external judges. Fourth, we used a pragmatic approach to gather data on patient mobilisation, but we lacked a validation process for our approach, which means that these results should be interpreted with caution. Fifth, our monocentric study was not powered to demonstrate effects on clinical outcomes and morbidity related to omissions. The complications that can be prevented by following standard-of-care protocols are potentially serious, but rare. Therefore, to demonstrate the impact of checklist-based interventions on relatively rare complications, multicentre studies with large numbers of participants conducted over prolonged periods of time are needed.

Finally, we collected the data before the checklist’s implementation and shortly after (i.e. the following month). Therefore, we cannot draw conclusions on long-term effects. Nevertheless, we chose this timeframe to prevent the before-and-after differences from being influenced by interventions other than the checklist implementation.

Conclusion

Our study demonstrates that the implementation of a checklist to structure bedside ward rounds in an internal medicine hospital division is an effective way to increase the discussion of key clinical items, as well as to improve adherence to standard-of-care protocols regarding venous and urinary catheters.

While it remains a challenge to demonstrate the impact of ward round checklists on clinical outcomes, current data support their use, as checklists can reduce omissions and improve communication with patients and among healthcare professionals.

Data availability statement

The study protocol and all collected data are available upon reasonable request from the corresponding author.

Acknowledgments

Use of AI: The authors made limited use of ChatGPT-4 to reformulate sentences in the discussion and take full responsibility for the final content.

Authors’ contributions: SGC contributed substantially to the design of the project, to the acquisition of the data, and to their analysis and interpretation. She drafted the manuscript. She gave her final approval of the version to be published. She agreed to be accountable for all aspects of the work. DG contributed substantially to the design of the project, to the acquisition of the data, and to their analysis and interpretation. He drafted the manuscript. As the corresponding author, he gave his final approval of the version to be published. He agreed to be accountable for all aspects of the work. VA contributed substantially to the acquisition of the data, and to their analysis and interpretation. She reviewed the manuscript critically for important intellectual content. She gave her final approval of the version to be published. She agreed to be accountable for all aspects of the work. PMV contributed substantially to the analysis of the data and their interpretation. He reviewed the manuscript critically for important intellectual content. He gave his final approval of the version to be published. He agreed to be accountable for all aspects of the work. AHC contributed substantially to the design of the project and to the acquisition of the data. She reviewed the manuscript critically for important intellectual content. She gave her final approval of the version to be published. She agreed to be accountable for all aspects of the work. VR contributed substantially to the design of the project and to the acquisition of the data. She reviewed the manuscript critically for important intellectual content. She gave her final approval of the version to be published. She agreed to be accountable for all aspects of the work. PV contributed substantially to the design of the project. He reviewed the manuscript critically for important intellectual content. He gave his final approval of the version to be published. He agreed to be accountable for all aspects of the work. MM contributed substantially to the design of the project, to the acquisition of the data, to their analysis and interpretation. He reviewed the manuscript critically for important intellectual content. He gave his final approval of the version to be published. He agreed to be accountable for all aspects of the work.

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Appendix

The appendix is available in the pdf version of the article at https://doi.org/10.57187/5058.