EDITORIAL
Ward Rounds and Patient Outcome: Be Attentive or Suffer the Peril Mary E. Klingensmith, MD
I
n this current issue of Annals of Surgery, Pucher et al1,2 report 2 separate studies on the impact of ward-based postoperative surgical care on patient outcome. This work is important to any of us involved in patient care, and especially important to those of us involved in training the future generations of surgeons. These studies allow us to acknowledge what we have long held to be intuitively true: patients who are attended by physicians who are diligent, thorough, and attentive in the conduct of their postoperative care have better outcomes than those attended by physicians who are inattentive. This study reminds us of the importance of postoperative care and allows us to continue to demand excellence from our trainees and ourselves. In the first study, the authors provide evidence that ward rounds (WRs) can be assessed in a high-fidelity, construct-valid, simulated setting.1 This work demonstrates the potential for teaching and assessing an individual’s ability to provide thorough and accurate patient assessment during the WR encounter. This is valuable but eclipsed by their work that demonstrates correlation between WR quality and patient outcome.2 This work adds to the increasing body of knowledge on how various phases of surgical care are correlated with patient outcome. We are now able to associate 3 important aspects in the provision of surgical care with patient outcome: operative skill,3 handoffs and team function,4,5 and now WRs. Collectively, these works stress the importance of high-quality instruction to our trainees in each of these areas of surgical care and serve to help focus our training efforts. At the same time, we must demand excellence in each of these areas not just from our trainees but also from all who care for surgical patients. Mentors must lead by example, and trainees must be attentive in all phases of operative care. Increasingly, our public will demand it, as we now are able to assess quality in each of these areas.3–6 Surgery now faces the real possibility that each phase of operative care (intraoperative through postoperative) can and will be assessed, with results shared publicly. The premise of the current studies is based on the failure-to-rescue concept,7 wherein complications result from poor-quality monitoring or ineffective actions taken once complications are recognized (or some combination of the both). However, this concept does have some limitations, and these are evident in the present study. Some aspects of WR quality are beyond control of the WR assessment with regard to patient outcome; for instance, the development of an anastomotic leak is not something the WR can prevent. Nevertheless, it is clear that attentive WRs could detect early signs of such a leak and mitigate the morbidity associated with such a complication. The current studies, although valuable and interesting, do have limitations. The authors chose to limit their WR observations (in simulated and real environments) to a single observed clinician and did not take into account the importance of the contributions of the entire health care team in postoperative care and assessment. Indeed, studies have shown the impact of nurses on surgical oncology patient outcomes, wherein staffing levels and educational preparedness of those nurses correlated directly with patient outcome,4 indicating the importance of the team (nursing and physicians) on patient outcome. Furthermore, it is striking that the incidence of pneumonia was so high (30%) in the observed patient cohort. The factors known to limit pulmonary complications, such as the use of incentive spirometry and early ambulation, are often tended to by attentive nursing practices. The current study implies that the surgeon’s failure on WRs to examine the chest led to the development of pulmonary complications, a loose association at best, yet once diagnosed, early intervention could improve overall outcome. In addition, the study was designed to observe certain areas of the physical examination (chest) but not others (extremities). It is not clear why the authors chose to not to quantitate assessment of the extremities, searching for such things as edema (suggesting volume overload) or deep venous thrombosis/phlebitis. These limitations provide opportunity to focus on thoroughness of postoperative assessments and contributions of team members on patient outcome. An additional factor, not included in either study, is the importance of handoffs and teamwork, which constitute another important aspect of postoperative care delivery. A study by Mazzocco et al5
From the Department of Surgery, Washington University in Saint Louis, Saint Louis, MO. Disclosure: The author declares no conflicts of interest. Reprints: Mary E. Klingensmith, MD, Department of Surgery, Washington University in Saint Louis, 660 South Euclid, Campus Box 8019, Saint Louis, MO 63110. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25902-0227 DOI: 10.1097/SLA.0000000000000493
Annals of Surgery r Volume 259, Number 2, February 2014
www.annalsofsurgery.com | 227
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 2, February 2014
Klingensmith
demonstrated that poor handoffs and poor team performance (including briefing, information sharing, inquiry, vigilance, and awareness) were associated with increased incidence of morbidity and death in surgical patients. Although the current studies were, by design, limited to the WR encounter alone, it is increasingly clear that good team function, by all members of the team, is crucial to good patient outcome. These studies were conducted in a teaching center, with level of resident training directly impacting the thoroughness of WR evaluations. It should be of no surprise that a more senior resident is likely to conduct a more thorough patient evaluation than a more junior resident, but this difference could be narrowed considerably by attention to this both informally (mentors leading by example) and formally (structured teaching and inclusion in teaching curricula). The ability to assess the quality of one’s WR ability is appealing, but how feasible this would be in widespread use remains unclear. This study should focus educators and mentors on the importance of the thorough, attentive, and consistent evaluation of patients on WRs. The authors point out that there is no formal curriculum for this provision of care, yet the hidden curriculum is alive and well in training programs across the world. Trainees know intuitively when they see an inattentive or lazy WR that patients subjected to such care are at risk. This study proves it and should serve as a clarion call to those who are in a position to educate the future generations of surgeons to emphasize compulsive and attentive WR conduct. This
228 | www.annalsofsurgery.com
is increasingly important in this era of reduced duty hours, which has impacted provision of care on both sides of the Atlantic. Trainees need to focus their efforts on key aspects of care, and we, as their teachers and mentors, need to help them properly focus in the time they do have on duty. Now that we have evidence that the quality of the WR can be assessed, and that quality impacts patient outcome, it seems to be only a matter of time before this is routinely done and publicly reported.
REFERENCES 1. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg. 2014;259:215–221. 2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 3. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New Engl J Med. 2013;369:1434. 4. Friese CR, Lake ET, Aiken LH, et al. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43:1145–1163. 5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678–685. 6. Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253:831– 837. 7. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250:1029–1034.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ward Rounds and Patient Outcome: Be Attentive or Suffer the Peril Mary E. Klingensmith, MD
I
n this current issue of Annals of Surgery, Pucher et al1,2 report 2 separate studies on the impact of ward-based postoperative surgical care on patient outcome. This work is important to any of us involved in patient care, and especially important to those of us involved in training the future generations of surgeons. These studies allow us to acknowledge what we have long held to be intuitively true: patients who are attended by physicians who are diligent, thorough, and attentive in the conduct of their postoperative care have better outcomes than those attended by physicians who are inattentive. This study reminds us of the importance of postoperative care and allows us to continue to demand excellence from our trainees and ourselves. In the first study, the authors provide evidence that ward rounds (WRs) can be assessed in a high-fidelity, construct-valid, simulated setting.1 This work demonstrates the potential for teaching and assessing an individual’s ability to provide thorough and accurate patient assessment during the WR encounter. This is valuable but eclipsed by their work that demonstrates correlation between WR quality and patient outcome.2 This work adds to the increasing body of knowledge on how various phases of surgical care are correlated with patient outcome. We are now able to associate 3 important aspects in the provision of surgical care with patient outcome: operative skill,3 handoffs and team function,4,5 and now WRs. Collectively, these works stress the importance of high-quality instruction to our trainees in each of these areas of surgical care and serve to help focus our training efforts. At the same time, we must demand excellence in each of these areas not just from our trainees but also from all who care for surgical patients. Mentors must lead by example, and trainees must be attentive in all phases of operative care. Increasingly, our public will demand it, as we now are able to assess quality in each of these areas.3–6 Surgery now faces the real possibility that each phase of operative care (intraoperative through postoperative) can and will be assessed, with results shared publicly. The premise of the current studies is based on the failure-to-rescue concept,7 wherein complications result from poor-quality monitoring or ineffective actions taken once complications are recognized (or some combination of the both). However, this concept does have some limitations, and these are evident in the present study. Some aspects of WR quality are beyond control of the WR assessment with regard to patient outcome; for instance, the development of an anastomotic leak is not something the WR can prevent. Nevertheless, it is clear that attentive WRs could detect early signs of such a leak and mitigate the morbidity associated with such a complication. The current studies, although valuable and interesting, do have limitations. The authors chose to limit their WR observations (in simulated and real environments) to a single observed clinician and did not take into account the importance of the contributions of the entire health care team in postoperative care and assessment. Indeed, studies have shown the impact of nurses on surgical oncology patient outcomes, wherein staffing levels and educational preparedness of those nurses correlated directly with patient outcome,4 indicating the importance of the team (nursing and physicians) on patient outcome. Furthermore, it is striking that the incidence of pneumonia was so high (30%) in the observed patient cohort. The factors known to limit pulmonary complications, such as the use of incentive spirometry and early ambulation, are often tended to by attentive nursing practices. The current study implies that the surgeon’s failure on WRs to examine the chest led to the development of pulmonary complications, a loose association at best, yet once diagnosed, early intervention could improve overall outcome. In addition, the study was designed to observe certain areas of the physical examination (chest) but not others (extremities). It is not clear why the authors chose to not to quantitate assessment of the extremities, searching for such things as edema (suggesting volume overload) or deep venous thrombosis/phlebitis. These limitations provide opportunity to focus on thoroughness of postoperative assessments and contributions of team members on patient outcome. An additional factor, not included in either study, is the importance of handoffs and teamwork, which constitute another important aspect of postoperative care delivery. A study by Mazzocco et al5
From the Department of Surgery, Washington University in Saint Louis, Saint Louis, MO. Disclosure: The author declares no conflicts of interest. Reprints: Mary E. Klingensmith, MD, Department of Surgery, Washington University in Saint Louis, 660 South Euclid, Campus Box 8019, Saint Louis, MO 63110. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25902-0227 DOI: 10.1097/SLA.0000000000000493
Annals of Surgery r Volume 259, Number 2, February 2014
www.annalsofsurgery.com | 227
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 2, February 2014
Klingensmith
demonstrated that poor handoffs and poor team performance (including briefing, information sharing, inquiry, vigilance, and awareness) were associated with increased incidence of morbidity and death in surgical patients. Although the current studies were, by design, limited to the WR encounter alone, it is increasingly clear that good team function, by all members of the team, is crucial to good patient outcome. These studies were conducted in a teaching center, with level of resident training directly impacting the thoroughness of WR evaluations. It should be of no surprise that a more senior resident is likely to conduct a more thorough patient evaluation than a more junior resident, but this difference could be narrowed considerably by attention to this both informally (mentors leading by example) and formally (structured teaching and inclusion in teaching curricula). The ability to assess the quality of one’s WR ability is appealing, but how feasible this would be in widespread use remains unclear. This study should focus educators and mentors on the importance of the thorough, attentive, and consistent evaluation of patients on WRs. The authors point out that there is no formal curriculum for this provision of care, yet the hidden curriculum is alive and well in training programs across the world. Trainees know intuitively when they see an inattentive or lazy WR that patients subjected to such care are at risk. This study proves it and should serve as a clarion call to those who are in a position to educate the future generations of surgeons to emphasize compulsive and attentive WR conduct. This
228 | www.annalsofsurgery.com
is increasingly important in this era of reduced duty hours, which has impacted provision of care on both sides of the Atlantic. Trainees need to focus their efforts on key aspects of care, and we, as their teachers and mentors, need to help them properly focus in the time they do have on duty. Now that we have evidence that the quality of the WR can be assessed, and that quality impacts patient outcome, it seems to be only a matter of time before this is routinely done and publicly reported.
REFERENCES 1. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg. 2014;259:215–221. 2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222–226. 3. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New Engl J Med. 2013;369:1434. 4. Friese CR, Lake ET, Aiken LH, et al. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43:1145–1163. 5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678–685. 6. Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253:831– 837. 7. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250:1029–1034.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
