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

Summary

BACKGROUND: Conducting ward rounds is a complex task requiring physicians and nurses to make use of a large set of competencies. The inability to conduct effective rounds can lead to errors of omission. Based on evidence gathered primarily in intensive care settings, checklists may improve the structure of ward rounds, interprofessional communication, and clinical outcomes.

OBJECTIVE: To test the hypothesis that the implementation of a checklist to structure internal medicine ward rounds reduces the omission of key clinical items.

DESIGN: This quality improvement study was designed as a prospective, monocentric, pre-post intervention study.

PARTICIPANTS: Physicians and nurses conducting ward rounds in an internal medicine division of a 1500-bed university hospital.

INTERVENTION: The implementation of a checklist with 19 key clinical items, defined as such because they are critical for patient care and must be discussed in every round for acute patients admitted to general internal medicine wards. An omission was defined as occurring when an item was not discussed. The 19 items included the patient’s main diagnostics, new diagnostics or problems, orientation, sleep, pain, nutrition, bowel habits, mobility, thrombo-embolic prophylaxis, skin and risk of bedsores, the presence and local status of IV catheters, the presence of a urinary catheter, medication review, targeted patient history and clinical examination, daily and hospital goals, discharge plan, and patient understanding.

MAIN MEASURES: The primary outcome was the number of key clinical items discussed during ward rounds before and after the checklist implementation. Secondary outcomes included (a) the proportion of patients with venous or urinary catheters, (b) catheter use in accordance with guideline-based indications, (c) the proportion of patients mobilised at two predefined times, (d) ward round duration, (e) ward round location (bedside vs hallway), and (f) patients’ and nurses’ understanding of care goals, rated on a 0–100 visual scale.

RESULTS: The study period lasted six days before implementation, from 27 January to 3 February 2023, and six days after, from 18 to 25 April 2023. Rounds conducted by a resident and a nurse were assessed using an observation plan, which ensured an equal distribution of observations across all units in the division. In total, 56 residents and 83 nurses participated in 368 patient encounters (172 pre-intervention and 196 post-intervention).The median number of key clinical items discussed per round increased from 11 [IQR 8.5–13] to 16 [IQR 14–18] (p <0.01) after the intervention. The proportion of patients with urinary catheters decreased (9% vs 4%; p = 0.04), as did the proportion with venous catheters in place without adequate indication (16% vs 2%; p <0.01). Patient mobilisation did not improve: before the intervention, 48% of patients were found in bed, 36% were sitting in their chairs, and 12% were walking, compared with 50%, 35%, and 11% after the intervention, respectively. The understanding of care goals increased for patients (score of 85/100 [IQR 50–100] pre-intervention vs 90/100 [IQR 70–100] post-intervention; p = 0.04) and, to a lesser extent, for nurses (90.5/100 [IQR 80–100] pre-intervention vs 100/100 [IQR 85–100] post-intervention (p = 0.08).

LIMITATIONS: This was a monocentric study involving one specific type of ward round.

CONCLUSIONS: The implementation of a checklist to structure internal medicine ward rounds reduced the omission of key clinical items and improved adherence to standard-of-care protocols, both of which are considered important mediators of clinical outcomes.