Ward Round Participation

Ward Round Participation

Content

•       Importance of ward rounds

•       Different types of  ward rounds

•       Significance of ward rounds

Objective

After completion of this lecture, student will be able to:

•       Describe the importance of ward rounds

•       Explain different ward rounds

•       Describe the significance of ward rounds

Definition

                A ward round is a visit made by a medical practitioner, alone or with a team of health professionals and medical students to hospital in-patients at their bedside to review and follow-up the progress in their health

Introduction

•       Usually at least one ward round is conducted every day to review the progress of each patient outcome

•       Pharmacist’s participation in medical ward rounds in the United States and United Kingdom dates back to the 1970s

•       Participation of pharmacists in ward rounds in various practice settings helps to promote rational drug use

•       Decreases adverse drug events, improve patient care, and reduce length of hospital stay and health care cost 

•       Enables pharmacist to contribute prospectively to patient care through the provision of drug information and promotion of rational use of drugs

Goals

•       The goals of clinical pharmacist’s participation in ward rounds are to

•       Gain an improved understanding of patient’s clinical status and progress, current planned investigations and therapeutic goals

Provide relevant information on various aspects of drug therapy such as

•       Pharmacology

•       Pharmacokinetics

•       Drug availability

•       Costs

•       Drug interaction

•       Adverse drug reactions

Optimize therapeutic management by influencing

•       Drug therapy selection

•       Drug administration

•       Monitoring and follow-up

•       Investigate unusual drug orders or doses

•       Assimilate additional information about the patient co-morbidities, medication compliance or alternative medicine use that might be relevant to their management

•       Detect, manage and prevent adverse drug reaction and drug interactions

•        Participate in the in-patients discharge planning

Classification of ward rounds

Classified based on purpose of the round and composition of the healthcare team:

•       Pre-rounds

•       Registrar / resident rounds

•       Professor / chief rounds

•       Teaching rounds

Pre-rounds

•       Usually by interns or medical postgraduate students in teaching hospital

•       Only few management decisions are made during these rounds

•       Trainee clinical pharmacist may join the interns or PGs in their pre-rounds and complete the patient medication and clinical review at this time

Registrar/resident rounds

•       In teaching hospitals, the registrars and the residents individually or as a team conduct ward rounds

•       At least once a day at a fixed time usually in the morning 

•       Useful rounds for clinical pharmacist of all levels of experience to join

Professor / chief rounds

•       In teaching hospitals, the chief of a unit or the professor in a specialty conducts rounds together with other healthcare professionals

•       Conducted for all patients under their care on a daily basis

•       More challenging for clinical pharmacist in terms of their clinical knowledge

Teaching rounds

•       In teaching hospitals, academic medical staff conducts bedside clinical teaching rounds for residents, medical PG students, interns and medical UG students

•        It is usually extensive rounds and is conducted only a few times a week

•       It provides an opportunity for clinical pharmacist to improve their clinical knowledge

Pre-ward round preparation

•       Pharmacists need to prepare well before participating in ward rounds

•       Accurate and up-to-date information on the patient’s

              -health status

              -disease management and

              -past medical history 

•       Essential for effective participation in clinical decision making

•       Review of the medication chart and the case record should be completed prior to the ward round

•       Pre-ward round preparation gives an overview of the drug and disease related issues that may arise during a ward round

•       Identify and prioritize the drug related problems

•       Prepare remedial action for the identified drug related problems

•       Maintenance of individual patient profiles, which summarize information relevant to the patient’s drug therapy

Practical tips for ward round participation

•       Complete the pre-ward round preparation well ahead of the commencement of the round

•       Prioritize the ward round (in case of more) to those rounds in which you can contribute more

•       In hospitals with a formulary, ensure that all prescriptions are in accordance with the hospital formulary

•       Carry appropriate references while working in the ward [BNF, CIMS, Drug review]

•       If potential DRPs identified, prepare to suggest alternatives to resort the problem

•       If many DRPs are identified, prioritize them and discuss the most important DRPs 

•       Avoid entering into discussions concerning diagnosis

Intervention during ward round

•       A pharmacy intervention is defined as, any action by pharmacist that directly results in a change in patient’s management or therapy 

•       Intervention by pharmacist to assist prescribing can take several forms

•       Active - [use of guidelines, particularly backed up by personal visits to influence prescribing] 

•       Passive - [drug information services]

•       Reactive - [monitoring prescriptions and seeking amendment of those that are unclear, inadequate or inappropriate]

•       The major drug related queries that may arise during ward rounds relate to:

1. Dose and frequency                      2. Choice of medication

3. Adverse effects                              4. Drug interactions

5. Formulation                                    6. Duration of therapy

•       Actions and uses/pharmacology

•       Drug availability/supply

•       Identification of patient’s medications on admission

•       Legal and administrative issues

•       Miscellaneous such as storage conditions

Communication during ward rounds

•       Clinical pharmacist must work closely with other health care professionals to meet the health care needs

•       Effective communication skills and clinical knowledge are pre-requisites for effective participation in ward rounds

•       Good inter-professional relationships are a key of success

•       Try to resolve differences in opinion in a direct manner but in a way that conveys respect for others

•       Learning of regional language helps the pharmacist to follow the conversation between the clinicians and the patients

•       It also helps you to interact effectively with the patients

•       Be cautious while discussing drug-related issues on the ward round in the presence of patients

•       Avoid bluffing or guessing, but rather undertake to retrieve the relevant information and then communicate the same to the prescriber

•        Not to challenge a medical practitioner’s integrity

Ward round follow-up

Clinical pharmacist often encounters issues during a ward round that require some follow-up. It includes:

•       Responding to enquiries

•       Communicating information

•       Completing documentation

•       Making necessary alterations

•       Discussion with the patients

Responding to enquiries

•       All unanswered queries, raised during ward rounds should be recorded and followed up at the earliest convenience

•       Responses may be given over the telephone, by e-mail, in print or in person, as appropriate

Communicating information:

·         In some instances the clinical pharmacist may need to communicate changes in drug therapy made during ward rounds to relevant  health care professional

Completing documentation:

·         Recommendations or interventions made by the pharmacist during a ward round may need to be documented appropriately

Making necessary alterations:

·         The pharmacist may need to make alterations to the patient’s care plan to meet the requirements resulting from changes in patient management

Discussion with the patients:

•       If appropriate the pharmacist should discuss drug therapy issues with the patients

•        Example: The reason for alteration in therapy, drug administration or self-monitoring techniques and cautions regarding likely adverse effects

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