50 Ward Round Documentation in Vascular Surgery – a Closed Loop Audit Cycle

Abstract Introduction Ward Rounds are a fundamental part of multidisciplinary team assessment, planning patient care and co-ordinating management decisions. Accurate documentation of patient assessment, relevant history and investigations, discussions with the patient and decisions made is crucial for continuity of patient care, medico-legally and overall patient safety. Despite the variety of record-keeping methods used throughout the NHS, it remains imperative that documentation remains accurate, contemporaneous, and can be used as a reliable source of reference throughout the patient’s journey. Method We used Royal College of Physician’s Ward Round Audit Standard 2015, with Cycle 1 of data collection from 17/5/21-23/5/21, followed by introducing interventions from 24/5/21-30/6/21. Interventions consisted of a Ward Round Proforma, displayed in each set of patient notes and communal ward areas. We completed Cycle 2 (31/5/21-6/6/21) using the same standard following which our results were analysed both individually and in respect to each other. Results Overall documentation improved by 14% across all domains from 67% to 81% following our interventions, in the 230 entries analysed (109 Cycle 2, 121 Cycle 2). Key areas included: Patient identification improving 25%, from 68% to 93%; Operation name and date improving 28% and 24% respectively and documentation of abnormal observations improving by 48%. Antibiotics and Thromboprophylaxis improved by 25% and 30% respectively, however remained under 50% in Cycle 2. Conclusions We conclude that simple, cost-effective interventions such as proformas & memory aids can significantly improve the documentation of ward rounds, thereby leading to improved patient care and safety and cohesive patient management throughout the multidisciplinary team.