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Year : 2023  |  Volume : 28  |  Issue : 1  |  Page : 54-58

Quality improvement in pediatric surgical ward rounds after implementation of checklist

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission29-Jul-2021
Date of Decision20-Oct-2022
Date of Acceptance27-Oct-2022
Date of Web Publication10-Jan-2023

Correspondence Address:
Kirtikumar J Rathod
Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_169_21

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Introduction: Using checklists has been common in high-risk industries such as aviation, space, and maritime sectors. It is routinely being used in health care also. Daily ward rounds play an essential role in patient care. Missing key details in rounds are common. Sometimes, these medical errors can lead to adverse events or mismanagement of patients. A checklist was introduced for daily ward rounds in our newly established institution. This study aims to assess the improvement in the documentation.
Materials and Methods: A checklist for ward rounds was introduced in September 2018. During the study period, between July 2017 and January 2020, 30 random case records for each of the two groups were taken. Group A (without checklist) and Group B (checklist) were compared to see the documentation of patient identification, diagnosis, operative status, fresh complaints, vitals, examination findings, charting treatment, catheters/drains/intravenous access, and urinary status/bowel movements.
Results: Sixty case records were included in the study. Comparison of documentation between Group A and Group B showed a significant difference in patient identification (50% vs. 100%), diagnosis (47% vs. 100%), operative status (33% vs. 100%), fresh complaints (76% vs. 100%), vitals (63% vs. 100%), examination findings (43% vs. 100%), charting treatment (73% vs. 100%), catheters/drains/intravenous access (10% vs. 86%), and urinary status/bowel movements (30% vs. 100%).
Conclusion: Using checklists for daily ward rounds improves documentation. It reduces the gap in communication and potential errors in patient management.

Keywords: Checklist, quality improvement, ward rounds

How to cite this article:
Jayakumar T K, Sikchi R, Rathod KJ, Sinha A. Quality improvement in pediatric surgical ward rounds after implementation of checklist. J Indian Assoc Pediatr Surg 2023;28:54-8

How to cite this URL:
Jayakumar T K, Sikchi R, Rathod KJ, Sinha A. Quality improvement in pediatric surgical ward rounds after implementation of checklist. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Feb 8];28:54-8. Available from: https://www.jiaps.com/text.asp?2023/28/1/54/367384

   Introduction Top

Using checklists has been a common practice in several fields including health care. One can draw inspiration from the aviation industry, and how checklists have revolutionized the safety of aviation.[1] Strict usage of checklists and stringent adherence to it has made aviation safer than road transport. This has been true for other high-risk fields such as space industries, maritime industries, and also health care. The surgical field is no less, and the risks are higher considering human lives are at stake. It is necessary to maintain a strict protocol in serving medical care to these patients. This is especially true in teaching hospitals, where residents in multiple numbers attend to the same patients every other day. This can potentially lead to loss of information.

Daily ward round is an important aspect of patient's care during his/her course in the hospital. A round, in general, should include the right identification of the patient, diagnosis, complaints of the patient, details of vitals monitoring, examination of the specific system, assessment of the nutritional intake (fluids/solids) and output (urine and bowel movements), and charting of the treatment for that day. In a surgical ward, the round should be meticulous, including further more details of intravenous access, drains, catheters, preoperative preparation of patients, surgical site examination, dressings, instructions related to preoperative and postoperative care, and updates of latest investigations.

A standard patient file included a case sheet (which contained the patient's complaints, history, examination, and diagnoses), an investigations' chart, nurse's records (containing daily treatment and documentation of vitals and event notes), and a daily ward rounds sheet (filled by the doctor).

We hypothesize that with the help of a checklist, it is easier to accomplish a complete ward round. With a different person taking daily rounds on each day and changing consultants every day, there was dissatisfaction over the lack of proper handover of information, frequent incidents which involved missing documentation of the key events of patients' clinical course, failure to document the status of key aspects (such as epidural analgesia), missing drugs in treatment charts, and many other errors during our ward rounds presentation. This discrepancy is prevalent in many places and has been proven in several audits.[2] Hence, a ward-round checklist was designed and introduced in September 2018, in our pediatric surgery ward. The aim of this study is to analyze the effect in documentation practice in daily ward rounds by comparing the records, before and after the implementation of the daily ward round checklist.

   Materials and Methods Top

The daily ward rounds checklist [Figure 1] was introduced in September 2018. Daily rounds are taken by the on-duty resident. It was made mandatory to document details as mentioned in the checklist.
Figure 1: Daily ward rounds checklist used in our pediatric surgery ward

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This is a retrospective cohort study that included a random daily rounds sheet from the patients' records between July 2017 and January 2020, in the in-patient department. These records were divided into two groups. Group A consisted of records before the checklist implementation and Group B after the implementation of the checklist. Thirty random case records (rounds sheet) of the patients who have undergone operations or any other interventional procedures were included in each arm of the study.

In each daily rounds sheet, the observed variables included patient identification, diagnosis, operative status, fresh complaints, clinical examination, treatment charts, the status of intravenous access, catheters and drains, urinary status/bowel movements, and documentation of change in management after the ward rounds. Each variable was represented in the form of numbers and percentages.

All data were entered in Microsoft Excel and analyzed using SPSS version 23 (IBM®, SPSS®, 2019). Fischer's exact test was done to compare the proportions in each group. P < 0.05 is considered statistically significant.

   Results Top

A total of 60 case records were included in this study. Each group consisted of 30 random single daily ward round sheets from the case records. The documentation of variables was represented as proportions in each group. The results comparing variables in Group A and Group B are shown in [Table 1] and [Figure 2].
Table 1: Comparison of documentation between Group A and Group B

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Figure 2: Graphical representation comparing group A and group B

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Patient identification was documented in 50% of the daily rounds in Group A, compared to 100% in Group B (P < 0.0001), while the diagnosis was mentioned in only 47% of Group A (vs. 100% in Group B; P < 0.0001).

The operative status (whether the patient is a preoperative or postoperative case) was mentioned in only 33% of the rounds in Group A. This was 100% in Group B (P < 0.0001).

In Group A, 76% of the rounds mentioned fresh complaints, whereas 100% of them were documented in Group B (P = 0.0046).

Documentation of vitals and examination findings were incompletely documented in Group A when compared to Group B (63% vs. 100%; P = 0.0003, and 43% vs. 100%; P < 0.0001).

Treatment charts were updated daily in 73% of rounds in Group A, while 100% of Group B had documentation (P = 0.0024).

The documentation of drains/catheters/intravenous access was mentioned in only a meager 10% of the rounds in Group A. Despite having the checklist, only 86% had such documentation in Group B (P < 0.0001).

Only 30% of the rounds mentioned urinary status/bowel movements in Group A, while it was 100% in Group B (P < 0.0001).

After the rounds were presented to the attending consultant, the instructions regarding the change in management were updated in 46% of the rounds in Group A, while 93% mentioned it in Group B (P = 0.0001).

   Discussion Top

The idea of using checklists has been around for more than 70 years. The concepts of checklists have been translated from one field to the other. However, it has become popular in recent times in the medical field. WHO similarly designed a surgical safety checklist to improve the patients' safety.[3] The need for similar applications in the ward setting has been recognized previously and implemented.[4] The application of checklists has been shown to reduce morbidity and mortality in medical and surgical care. Patients' safety is as essential in the inpatient department as in the operation theatre. Standardized checklists implementation has been shown to improve the documentation in the wards.[5]

Before implementing checklists for daily ward rounds, in Group A, only 50% and 47% of patients had their identification and diagnosis mentioned in their daily rounds. Not mentioning these details can lead to accidental loss/misplacement of the records, thus causing loss of information.

Documentation of the surgical status of the patients should be done compulsorily in daily rounds. This is especially important for patients who require preoperative preparation, for example, bowel preparation, surgical field preparation by clearing body hair, preoperative antibiotics, fluids, etc. With only 33% of patients' records in Group A documenting surgical status, this often led to missing documentation of special preoperative instructions. This could potentially lead to delay or cancellation of surgery. This communication gap is one of the factors leading to compromise in patient safety.[6] For operated patients, documentation of the postoperative day has implications in terms of postoperative management, for example, (i) to allow oral feeds on a postoperative day 2 for patients who undergo laparotomies and (ii) to remove the surgical site dressing of a hypospadias patient on a postoperative day 5. This helps in the prompt management of these patients.

Although the patient's vitals were documented in the nursing charts, mentioning the same in the daily records helps quickly access the patient's condition. Only 63% of patients' records in Group A had vitals in their daily rounds. To go through multiple pages and find the vitals in nurses' charts often led to delays during the presentation of rounds. After implementing the checklist, documenting vitals in the daily rounds sheet was made mandatory. In Group B, 100% of the daily rounds mentioned the vitals.

Compared to Group A, Group B had better documentation about patients' fresh complaints (76% vs. 100%), examination findings (43% vs. 100%), and an updated treatment chart (73% vs. 100%). There were never any incidences of compromise of patient care. All patients were attended to, examined, and treatment was updated promptly. However, documentation of these details is necessary not only because of transferring the information to colleagues who take over the duties but also for medicolegal purposes.[7] Documentation of these details implies that patients' needs were immediately attended to and sorted. They also prevent medical errors related to failure to treatment documentation.

Surgical patients often have multiple intravenous accesses, abdominal/chest/wound drains, and urinary catheters. Ignoring the intravenous access device, for example, the central venous catheter (CVC), can lead to the soiling of the dressing and CVC-related sepsis.[8],[9] Checking these minute details can lead to the prevention of complications. The same applies to drains and catheters, which require proper positioning, dressing change (if soiled), catheter-related care to prevent accidental removal, and catheter-associated urinary tract infections.[10] Documentation of these details was poor in Group A (10%), compared to Group B (86%). Fourteen percentage of patients' records in Group B missed documentation despite a checklist, proving that drains/catheters can be easily overlooked.

Failing to document the bowel movements/urination status of a patient can lead to communication gaps, and an attending doctor can order unnecessary interventions, for example, prescription of laxatives, enemas, or urinary catheterization. These unnecessary measures can be avoided if these details are documented in the patients' daily records.

Once the resident completes the daily rounds, they are presented to the attending consultant. Usually, this routine follows some special instructions or advice on management from the consultant. The documentation of these details is essential, as they have several implications. For example, (i) a change of antibiotics, but failure to document the same led to the continuation of the same antibiotics by the nurse and (ii) a reduction in the dose intensity of chemotherapy. Sometimes, these instructions were not documented. The errors were timely noticed during the next rounds, and the corrections were made. These instances of failure to documentation and, thus, failure to execute an order can lead to potential errors in patient management or adverse events. The institute of medicine defined this failure to complete a planned action as a medical error. Failure of proper documentation is one of the causes of medical errors. It was extensively described by Edwards and Moczygemba.[11]

Some consider that using checklists might increase documentation time and compromise the time spent for patient interaction. Findings from a pilot study done by Soong et al. proved the contrary, demonstrating that checklists improved ward round performance without affecting the patient interaction time.[12] Similar checklists designed for nurses have proven to improve bedside attending by nurses and overall improvement in patient care.[13] A systematic review and meta-analysis of randomized control studies by the National Institute for Health and Care Excellence showed evidence for improved adherence to patient care, benefits by reducing the length of hospital stay, morbidity and mortality in intensive care units, enhanced patient satisfaction, and health staff satisfaction.[14]

The implementation of checklists for daily ward rounds has streamlined patient care in our facility. It standardized the daily ward rounds documentation and reduced the inter-observer variations. Despite having a checklist, documentation was not 100% in some areas in Group A (documentation related to drains/catheters and changes in management after rounds). This reminds us why strict adherence to a checklist is necessary. Quality improvement is a work in progress, and always, there is room for further improvement.

   Conclusion Top

Using a checklist for daily ward rounds significantly improves documentation. It reduces the communication gap and prevents potential errors in patient management. Thus, it enhances the quality of patient care.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Degani A, Wiener EL. Cockpit checklists: Concepts, design, and use. Hum Factors J Hum Factors Ergon Soc 1993;35:345-59.  Back to cited text no. 1
Mansell A, Uttley J, Player P, Nolan O, Jackson S. Is the post-take ward round standardised? Clin Teach 2012;9:334-7.  Back to cited text no. 2
Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, et al. Perspectives in quality: Designing the WHO surgical safety checklist. Int J Qual Health Care 2010;22:365-70.  Back to cited text no. 3
Amin Y, Grewcock D, Andrews S, Halligan A. Why patients need leaders: Introducing a ward safety checklist. J R Soc Med 2012;105:377-83.  Back to cited text no. 4
Hale G, McNab D. Developing a ward round checklist to improve patient safety. BMJ Qual Improv Rep 2015;4(1).  Back to cited text no. 5
Kim FJ, da Silva RD, Gustafson D, Nogueira L, Harlin T, Paul DL. Current issues in patient safety in surgery: A review. Patient Saf Surg 2015;9:26.  Back to cited text no. 6
Thomas J. Medical records and issues in negligence. Indian J Urol 2009;25:384-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
CE: Pediatric Catheter-related Bloodstream Infections. Available from://www.nursingcenter.com/journalarticle?Article_ID=594170&Journal_ID=230572&Issue_ID=594133. [Last accessed on 2020 May 13].  Back to cited text no. 8
Guidelines for the Prevention of Intravascular Catheter-Related Infections. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm. [Last accessed on 2020 May 13].  Back to cited text no. 9
CAUTI Guidelines | Guidelines Library | Infection Control | CDC. Published June 18, 2019. Available from: https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html. [Last accessed on 2021 Nov 10].  Back to cited text no. 10
Edwards M, Moczygemba J. Reducing medical errors through better documentation. Health Care Manag (Frederick) 2004;23:329-33.  Back to cited text no. 11
Soong JBV, Smith D, LeBall K, Levy JB. Improving ward round processes: A pilot medical checklist improves performance. International Forum on Quality and Safety in Healthcare. Paris: NHS; 2012.  Back to cited text no. 12
Shaughnessy L, Jackson J. Introduction of a new Ward round approach in a cardiothoracic critical care unit. Nurs Crit Care 2015;20:210-8.  Back to cited text no. 13
Chapter 28 Structured Ward Rounds; 2018. Available from: https://www.nice.org.uk/guidance/ng94/evidence/28.structured-ward-rounds-pdf-172397464641. [Last accessed on 2021 Nov 10].  Back to cited text no. 14


  [Figure 1], [Figure 2]

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