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- "The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds
- ‘The longest way round is the shortest way home’ – James Joyce’s Leitrim origins
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A review on shift patterns and staffing levels is required at an organizational and local level to facilitate multidisciplinary ward rounds. Surgeon’s work schedules must have flexibility to accommodate post-take ward rounds where ample time is spent per patient. Consultant surgeon’s job plans require reconfiguration to focus adequate time on conducting quality SWRs. Currently available forecasting software tools are capable of predicting the number of emergency attendees, admissions, discharges and the time spent per operative procedure in OR, based on which information hospital managers can create weekly schedules. This information should also be used provide matching allocated clinical hours dedicated for SWRs.
I didn’t care how many detours, left turns and double backs I took as long as I got there. Whenever we go anywhere together, he always has a quicker way to get there.
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In terms of stepping up to the OR and step down back to the ward, their ward care is complex requiring judicious monitoring of a number of invasive adjuncts such as airways, drains, catheters, pumps, stomas, arterial lines, peripheral and central venous lines. Enhanced recovery programmes for major elective surgery have created a framework for multidisciplinary pre-operative and post-operative care which have ultimately shown proven benefits in terms of decreasing hospital stay and lowering complication rates . However, the lack of similar recovery programmes in emergency surgery can be supplanted by structured and standardized SWRs, which direct a multidisciplinary effort in targeting the various aspects involved in the recovery of a surgical patient.
Current barriers to multidisciplinary WRs are that they are inadequately prioritized by all HCPs, variable work shift patterns, lack of concerted efforts, frequent change in lead consultant, specialty, wards and poor handovers to name a few . While the characters in the stories are not based on real people, they are representative of the people who are an integral part of Shoreditch life, the neighbourhood I live in, which is full of people with different WorkLife experiences. Shoreditch is a special place, and I believe what makes it so is the incredible diversity of life paths that cross here, spanning the whole globe and many walks of life. This story is part of a series of stories that share insights into the characters in my book WorkLife Book Club Volume One Shoreditch. Stories that share insights that aren’t shared in the book to the main characters, the support characters and the behind the scenes characters.
"The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds
Joyce moved from job to job, selling off assets, taking out mortgages, moving house. Through all this May Murray-Joyce’s health began a long spiral of decline. Another son George died in 1902 and this was a huge blow to her as was James’ rejection of his Catholic religion. In 1859 Mary “May” Murray, the future mother of James Joyce was born. May was an accomplished pianist, no doubt influenced by her talented Aunts.
It’s the boring stretches of road where nothing appears to be happening that hold the most valuable lessons. When I was first learning about photography, I was more like Dave. I wanted to know the quickest way to get to the other side.
‘The longest way round is the shortest way home’ – James Joyce’s Leitrim origins
SWRs possess unique traits differentiating it from other medical specialty ward rounds. Firstly, consultant surgeons have to divide their weekly clinical commitments between in-patient ward care , out-patient clinics, operative theatres and administrative duties. Secondly, surgical patients differ from medical patients in that they usually transition from a surgical ward to an OR with an option of ICU before returning to the surgical ward.
Ward rounds, a keystone of hospital surgical practice, have recently been under the spotlight. Poor-quality ward rounds can lead to a greater number of adverse events, thereby cascading to an increased financial strain on our already burdened healthcare systems. Faced with mounting pressures from both outside and inside health organizations, concerted efforts are required to restore it back into prominence where it can no longer take a backseat to the other duties of a surgeon.
In order to improve handover and transfer of information, current communication technologies must be updated. Increasingly, pagers have been used in parallel with mobile devices as a means for interprofessional communication between healthcare teams. Mobile applications, particularly Whatsapp, are now widely popular and cost-effective communication tools amongst HCPs.
Ward rounds should be standardized and prioritized to improve patient care. In the age of constantly changing fashions and almost a century since publication, it is remarkable that Ulysses still occupies such an exalted position in literature. My favourite story about the often cantankerous Joyce is the one in where he is confronted by a former British Officer shortly after the end of the Great War. It was the era of men recounting what military campaigns they had fought in and how they had helped shape history. Not been a part of the ‘action’ was frowned upon in much the same way as a draft dodger is in an American election campaign today. The seasoned British officer seeking to embarrass the Dublin exile in front of a gathering asked, ‘and what did you do during the War, Mr. Joyce?
Concerns raised were that clinicians in favour of establishing private practices were neglecting poorer patients. In this code, the principle of daily ward rounds was established and, furthermore, mandated that a minimum of 2 h per day be spent in the examination of the hospital patients . Ward round continues to be an integral aspect of hospital-based practice constituting a dynamic platform for members of a multidisciplinary team to integrate information from various resources and collectively make patient-centred decisions. Most importantly, it serves as a coherent communication channel, bedside from healthcare professionals to patients updating them of their daily progress.
At this time the family had moved to 7 Clanbrassil St. It was on this very street that John Stanislaus Joyce, a charming, failed medical student, amateur tenor and incompetent business man met and fell in love with 20 year old May Murray. Joyce had moved to Dublin from Fermoy in Cork where his family were modest landlords and business people and firmly part of the rising Catholic middle classes. More people start reading Ulysses than will ever finish it. It is a difficult novel to read, crafted as such by the author, who himself declared ‘I’ve put in so many enigmas and puzzles that it will keep the professors busy for centuries arguing over what I meant, and that’s the only way of insuring one’s immortality’. Yet despite all this complexity tackling the greatest modernist novel of all is a rewarding experience.
On further inspection, the average time spent per patient at the bedside was under 2 min 30 s which is less than a third of the recommended average of 9–10 min to be spent per patient as proposed by the Royal College of Physicians guidelines . If it were to be enforced, a SWR for 20 patients would last approximately 3½ h. Understandably, the recommended average time spent per patient on a routine medical ward round is probably calculated based on the time required on a medical ward round whilst using a ward round checklist and need not apply to SWRs. In addition, patients are at increased risk of death if either admitted as an emergency during the weekend when hospitals are comparatively understaffed or if they underwent an elective surgical procedure at the end of the working week . Lack of a senior clinician-led WR on weekends imposes patients into “hibernation” ultimately leading to delays in investigations, diagnosis, treatment and discharge from the hospital .
Sadly trainees who miss PTWRs due to working hour restrictions fail to learn from their mistakes . The unpredictable and irregular availability of the members of the multidisciplinary team during ward rounds pose a challenge to share patient information and provide high-quality care. Until recently, pagers have been the sole means of communication between healthcare professionals when physical means are not possible. They are reliable, however, suboptimal and inefficient in that they deliver one-way communication, which result in workflow and ward round disruptions. In this review, we focus on the need for reforms, current characteristics of surgical ward rounds, obstacles encountered by competing interests and proposed solutions in delivery of effective ward rounds that can meet with newly laid guidelines. Therefore, WRs should be targeted for fostering effective collaboration and teamwork as drivers for good clinical care.
Toolkits have also been developed in the form of checklists to capture clinical skills, team interaction skills and doctor–patient interactions during a SWR . Recently, a Quality of Information Transfer Tool has been developed and validated to further improve and directly combat the communication failures within WRT members and poor escalation of care, which previous tools such as SBAR have failed to address . This objective training tool incorporates key clinical information and a solid presentation structure, whilst assessing the efficacy of communication skills training during escalation of care.
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