Structured ward rounds

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 28Structured ward rounds

28. Structured ward rounds

28.1. Introduction

Ward rounds are critical to the smooth flow of the patient journey as they are the key method by which patients in hospital are systematically reviewed by the multidisciplinary team. During a ward round, the current status of each patient is established and the next steps in their care planned. The use of structured ward rounds is recommended by the Royal College of Physicians and the Royal College of Nursing.

Ward rounds are common practice in hospitals across the UK, but they vary in their method, membership and execution. The guideline committee wanted to find out if one method was more effective than others, or if their use has more impact on one patient population over another.

The committee wanted to determine if there was existing evidence to recommend particular practices for effective ward rounds that could be applied to patients with acute medical emergencies.

28.2. Review question: Do structured ward rounds improve processes and outcomes?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

28.3. Clinical evidence

Sixteen studies were included in the review; 2 RCTs, 2 prospective cohort studies, 9 before-after studies, and 3 non-randomised comparative studies;⁴^,¹¹^,¹³^,¹⁹^,²⁶^,²⁹^,⁵⁷^,⁶²^,⁶⁴^–⁶⁶^,⁸³^,⁸⁴^,⁸⁶^,⁸⁸^,⁹⁰ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3;Table 4;Table 5;Table 6;Table 7). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: Checklist versus no checklist.

Table 4

Clinical evidence summary: Daily rounding checklist-prompted versus daily rounding checklist-unprompted.

Table 5

Clinical evidence summary: Explicit rounding approach versus standard rounding approach.

Table 6

Clinical evidence summary: Structured interdisciplinary bedside rounds versus standard physician-centred rounds.

Table 7

Clinical evidence summary: Structured interdisciplinary rounds (SIDR) versus control (unknown).

Narrative data

Length of stay

One before-and-after study found that the average length of stay for all patients managed on a coaching model of structured, interdisciplinary team rounds was 4.23 days compared to 4.71 days (p=0.029) for patients managed on the unit before the introduction of this rounding model⁴.

Another before-and-after study found that a daily goals worksheet shortened the length of stay of patients in the intensive care unit (mean 4.3 days, SD 0.63 days) compared to not using a daily goals worksheet (mean 6.4 days, SD 2.5 days) previously.⁵⁷

ICU length of stay

One randomised controlled trial found that there was no difference in median for the length of stay of patients in the intensive care unit between prompted and electronic checklist groups (2.6 [1.5-6.9] days versus 2.8 [1.7-6.5] days).⁸³

Hospital length of stay

One randomised controlled trial found that there was a difference in median for length of stay of patients in hospital between prompted and electronic checklist groups (11.8 [5.9-22.8] days versus 9.6 [5.9-15.8] days).⁸³

Staff satisfaction

A comparative study found that nurses’ ratings of teamwork climate was higher on a hospitalist unit where structured interdisciplinary rounds were used (median 85.7, interquartile range 75.0-92.9) compared to a control hospitalist unit (median 61.6, interquartile range 48.2-83.9; p=0.008).⁶⁶

28.4. Economic evidence

Published literature

No relevant health economic studies were identified.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

In the absence of health economic evidence, unit costs were presented to the committee – see Chapter 41 Appendix I.

28.5. Evidence statements

Clinical

Check lists versus no check-lists

Three studies comprising 2649 people evaluated check-lists to improve processes and outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that check-lists may provide a benefit in adherence to care (2 studies reported separately, very low quality). The evidence suggested there was no effect on mortality (1 study, very low quality).

Daily rounding checklist-prompted versus daily rounding checklist -unprompted

One study comprising 296 people evaluated daily rounding checklist- prompted to improve processes and outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that daily rounding checklist- prompted may provide a benefit in reduced ICU length of stay, ICU mortality and hospital mortality (very low quality).

Explicit rounding approach versus standard rounding approach

Two studies comprising 2966 people evaluated explicit rounding approach to improve processes and outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that explicit rounding approach may provide a benefit in improved patient satisfaction (1 study, very low quality) and staff satisfaction (1 study, very low quality).

Structured interdisciplinary bedside rounds versus standard physician centred rounds

One study comprising 62 people evaluated structured interdisciplinary bedside rounds to improve processes and outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that structured interdisciplinary bedside rounds had no effect on job satisfaction (very low quality).

Structured interdisciplinary rounds versus control

Four studies comprising 4333 people evaluated structured interdisciplinary rounds to improve processes and outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested structured interdisciplinary rounds may provide a benefit in improved staff satisfaction (2 studies, very low quality), adverse events (2 studies, very low quality) and reduced ICU length of stay (1 study, very low quality). The evidence suggested there was no difference on length of hospital stay (3 studies, very low quality), length of stay - unadjusted RCT (1 study, low quality) and adverse events (2 studies, very low quality).

Economic

No relevant economic evaluations were identified.

28.6. Recommendations and link to evidence

Recommendations	15. Use standardised and structured approaches to ward rounds, for example with checklists or other clinical decision support tools.^a
Research recommendation	-
Relative values of different outcomes	The committee considered mortality, avoidable adverse events, length of stay/time to discharge, quality of life and patient and/or carer satisfaction to be critical outcomes. Missed or delayed investigations, missed or delayed treatments and staff satisfaction were considered to be important outcomes.
Trade-off between benefits and harms	Sixteen studies were included in the review, 2 randomised controlled trials and 14 observational studies. There was a variety of interventions used to provide structure to the ward round. The evidence was presented across separate intervention types: Use of checklist versus no checklist The intervention for these studies involved the use of either a paper checklist/worksheet or electronic checklist. Outcomes were measured prior to implementation of the checklist and compared with results after the use of a checklist/worksheet. The evidence suggested that checklists may provide a benefit in adherence to care (a surrogate for missed or delayed treatments). The evidence suggested there was no effect on mortality. No evidence was identified for avoidable adverse events, quality of life, patients and/or carer satisfaction, length of stay and staff satisfaction. Daily rounding check-list -prompted versus daily rounding check-list unprompted The intervention for these studies consisted of a non-care providing or resident physician prompting the rounding team with questions about patients’ conditions in order to aid the ward round. This intervention was carried out in an ICU. The evidence suggested that daily rounding checklist-prompted may provide a benefit in reduced ICU length of stay, ICU mortality and hospital mortality. No evidence was identified for avoidable adverse events, quality of life, patient and/or carer satisfaction, missed or delayed investigations and staff satisfaction. Explicit rounding versus standard rounding These interventions involved using a flow chart demonstrating the ideal ICU ward round and how the processes that make up the ward round should be delivered for example, morning handover or bedside presentations. Actions were discussed in a team meeting. The evidence suggested that explicit rounding may provide a benefit in improved patient and staff satisfaction. No evidence was identified for mortality, avoidable adverse events, quality of life, carer satisfaction, length of stay/time of discharge, missed or delayed investigations, missed or delayed treatments and staff satisfaction. Structured interdisciplinary bedside rounding (SIBR) versus standard physician-centred rounding The intervention in this study consisted of a ward round involving all health and social care staff involved in the patient care including doctors, nurses, pharmacist, social worker and case manager. The SIBR was patient-and-family centred and this was compared with the standard physician-centric rounding. The evidence suggested SIBR had no effect on job satisfaction. No evidence was identified for mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, length of stay/time of discharge, missed or delayed investigations and missed or delayed treatments. Structured interdisciplinary rounding (SIDR) versus control (unknown) The intervention for these studies consisted of the use of an interdisciplinary team (including a consultant, nurse, social worker, pharmacist and case manager) for ward rounds. Three of the included studies for this comparison were before-and-after studies comparing outcomes prior to implementation of the intervention. The evidence suggested that SIDR may provide a benefit in improved staff satisfaction, adverse events (any) and reduced ICU length of stay. The evidence suggested there was no difference for hospital length of stay, length of stay (from unadjusted RCT) and adverse events. No evidence was identified for mortality, quality of life, patient and/or carer satisfaction, missed or delayed investigations and missed or delayed treatments. The committee felt that the evidence showed a benefit for structured ward rounds and made a recommendation for their use. The ward round is the key driver in the progression and management of patients. Although a routine part of clinical practice, rounds are nevertheless a complex intervention involving many components and multiple points for communication and data exchange, particularly for patients with complex conditions and multi-morbidity. It was felt that providing structure to the ward round would ensure that all aspects of care are delivered and this should result in better outcomes. The committee recommended that a checklist could be used as an option as there was some evidence of benefit. However, the committee recognised that checklists could also be a constraint and might add delays to an otherwise efficient process, particularly if they attempted to be too comprehensive, or inhibited the use of heuristics by experienced staff. For example, the care of low-complexity patients should not be delayed by completion of a checklist with redundant items. They should therefore be used as practice aids, not as rigid tools, to ensure harmonisation of best practice, promoting more reliable care throughout the whole patient pathway, reducing error, promoting timely discharge and minimising readmissions.
Trade-off between net effects and costs	No economic studies were identified. Unit costs of staff (Chapter 41 Appendix I) reported in the evidence were provided to aid consideration of cost effectiveness, although it was unclear from the evidence whether more or less staff time would be required. Interventions using structured ward round checklists and daily charts are unlikely to be resource-intensive compared with unstructured ward rounds. The main costs associated with these interventions are the initial implementation costs including staff training and designing and changing checklists and charts. For electronic checklists, this could include the cost of the devices and servers to store data. These costs are not standardised and would vary across trusts. Studies included in the evidence review show that these interventions may reduce the time taken to record and retrieve notes and could therefore potentially be cost saving. On-going training for new and existing staff must also be considered, as there will be a need to continually develop the checklist as processes change or evolve. Some studies also looked at interventions that would include changes to staffing and staff time. Major changes in staffing involved in ward rounds may lead to an increase in costs and uncertainty around the cost-effectiveness of the intervention. However, there is more likely to be a reallocation staff time, rather than the cost of additional staffing. A few of the studies suggested that length of hospital or ICU stay could be reduced. This would at least partially offset any increased costs. The committee concluded that structured ward rounds were unlikely to increase costs substantially likely to promote more reliable care throughout the whole patient pathway and reduce error, likely to promote timely discharge and therefore were likely to be cost-effective.
Quality of evidence	Fourteen observational studies and 2 randomised controlled trials were included. Nine of the observational studies were before-and-after studies. One of the randomised controlled trials was very low quality (downgraded due to risk of bias and imprecision). The other RCT was low quality (downgraded due to risk of bias). The 14 observational studies were very low quality; reasons for downgrading included risk of bias, imprecision, inconsistency and indirectness of outcomes. Some studies reported adherence to care, which was used as a surrogate outcome for missed or delayed treatments but downgraded for indirectness. Much of the positive evidence came from ICU ward rounds where the nursing and medical staff to patient ratio is high, the patients have high acuity, direct communication with patients may be impaired, and decision-making involves consultation with families. However, the committee felt that the evidence could be extrapolated and the principles could be adapted for medical wards. There were no economic studies included in the review.
Other considerations	The committee agreed that a standardised checklist could be incorporated in structured ward rounds, but the format and the way in which such lists might be used should be determined by local experience, and preferably following a gap analysis to determine maximal opportunities for process improvement. The committee noted that the studies comparing prompting to non-prompting had done so as an adjunct to a checklist. The committee commented that other ‘tools’ for a structured ward round could include prompting: one way to achieve this in practice without employing a ‘prompter’ would be to ensure that all members of the team were focused on the task in hand, and were empowered to offer reminders. The committee recognised that introducing structured ward round models/tools effectively in routine practice would likely involve a change in attitudes and behaviours amongst clinical staff, including explicit support from senior staff, a willingness to adopt greater standardisation of processes amongst team members, and a flattening of hierarchies. A checklist on its own will not achieve much;¹⁰^,²⁵ conversely, once the value of a checklist as a decision-support tool has been recognised and incorporated in practice, the need to ‘tick off’ every component becomes superfluous, and indeed might even be counter-productive.

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Appendices

Appendix A. Review protocol

Table 8Review protocol: Structured ward rounds

Review question: Do structured ward rounds improve processes and patient outcomes?
Rationale	Often the way the ward rounds are performed is not efficient - ward rounds are often done in a geographical order rather than on the basis of patient priority. Each patient does not always get all the components of the ward round because generally there is no structure and it depends on individual preference, personalities and recall. The components of the ward round (for example, examination, VTE risk assessment or review, medication review or explanation to the patient) are the same for each patient thus the process of the ward round could be structured. The provision of a ward round checklists and/or daily goal charts will ensure all components are delivered and therefore should ensure optimum care is provided. We are looking at systems rather than conditions so we will not be looking at condition-specific checklists.
Topic code	T6-6.
Population	Adults and young people (16 years and over) admitted to hospital with a suspected or confirmed AME. No strata (checklists and charts).
Intervention	Structured ward round models including using: Ward round checklists (generic checklists, not condition-specific). Daily goals charts.
Comparison	No ward round checklists or daily goal charts.
Outcomes	Mortality during study period (Dichotomous) (critical) Avoidable adverse events during study period (Dichotomous) (critical) Quality of life during study period (Continuous) (critical) Patient and/or carer satisfaction during study period (Dichotomous) (critical) Length of stay/time to discharge during study period (Continuous) (critical) Missed of delayed investigations (important) during study period (Dichotomous) Missed or delayed treatments (important) during study period (Dichotomous) Staff satisfaction (important) during study period (Dichotomous)
Exclusion	Operating theatres (surgical literature can be referenced in other considerations if necessary).
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library. Date limits for search: 1990. Language: English.
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data. Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included in subgroup analysis: No sub-groups identified. In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included in the subgroup analysis. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.
Exclusions	Countries: Non- OECD.
Key papers	None identified.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of structured ward rounds

Appendix C. Forest plots

C.1. Checklist versus no checklist

Figure 2Adherence to care – adjusted OR (Missed or delayed treatments)

Figure 3Adherence to care – unadjusted (missed or delayed investigations)

Figure 4Adherence to care – unadjusted (missed or delayed treatments)

Figure 5Mortality

C.2. Prompted versus unprompted

Figure 6Mortality (adjusted OR)

Figure 7ICU length of stay

Figure 8Hospital mortality

C.3. Explicit rounding approach versus standard rounding approach

Figure 9Staff satisfaction

Figure 10Patient satisfaction (overall)

C.4. Structured interdisciplinary bedside rounds versus standard physician-centred rounds

Figure 11Job satisfaction

C.5. Structured interdisciplinary rounds (SIDR) versus control (unknown)

Figure 12Teamwork climate score (staff satisfaction) – unadjusted (score 0-100)

Figure 13Length of stay (unadjusted) – RCT

Figure 14Adverse events (adjusted rate ratio)

Figure 15ICU length of stay

Figure 16Hospital length of stay

Appendix D. Clinical evidence tables

Download PDF (729K)

Appendix E. Economic evidence tables

No relevant health economic studies were identified.

Appendix F. GRADE tables

Table 9Clinical evidence profile: Checklist versus no checklist

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Checklist versus no checklist	Control	Relative (95% CI)	Absolute	Quality	Importance
Adherence to care - unadjusted (Missed or delayed investigations) - Diagnosis (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	no serious imprecision	None	69/70 (98.6%)	40%	RR 2.46 (1.94 to 3.14)	584 more per 1000 (from 376 more to 856 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Adherence to care - unadjusted (Missed or delayed investigations) - Investigations (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	no serious imprecision	None	66/70 (94.3%)	57%	RR 1.65 (1.38 to 1.98)	370 more per 1000 (from 217 more to 559 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Adherence to care - unadjusted (Missed or delayed investigations) - Further tests (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	serious³	None	55/70 (78.6%)	52%	RR 1.51 (1.21 to 1.89)	265 more per 1000 (from 109 more to 463 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Adherence to care - unadjusted (missed or delayed treatments) - Management plan (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	serious³	None	70/70 (100%)	81%	RR 1.23 (1.12 to 1.36)	186 more per 1000 (from 97 more to 292 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Adherence to care - unadjusted (missed or delayed treatments) - DVT prophylaxis (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	no serious imprecision	None	37/70 (52.9%)	6%	RR 8.81 (3.93 to 19.74)	469 more per 1000 (from 176 more to 1000 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Mortality (follow-up 3 months)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	very serious³	None	7/653 (1.1%)	5.3%	RR 1.13 (0.38 to 3.34)	7 more per 1000 (from 30 fewer to 124 more)	⨁◯◯◯ VERY LOW	CRITICAL
Overall adherence to care - adjusted (missed or delayed treatments) (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	serious²	no serious imprecision	None	-	0%	OR 6.38 (5.06 to 8.05)	-	⨁◯◯◯ VERY LOW	IMPORTANT

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgrade by 1 increment if the majority of evidence had indirect outcomes.
3: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 10Clinical evidence profile: Daily rounding checklist-prompted versus daily rounding checklist- unprompted

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Prompted versus unprompted	Control	Relative (95% CI)	Absolute	Quality	Importance
Mortality (adjusted OR) - ICU mortality (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	serious²	None	-	0%	OR 0.36 (0.13 to 1)	-	⨁◯◯◯ VERY LOW	CRITICAL
Mortality (adjusted OR) - Hospital mortality (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	serious²	None	-	0%	OR 0.34 (0.15 to 0.77)	-	⨁◯◯◯ VERY LOW	CRITICAL
ICU length of stay - ICU length of stay (follow-up not stated)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	140	125	-	MD 1.4 lower (2.82 lower to 0.02 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Hospital mortality (follow-up 6 months)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	None	30/171 (17.5%)	24%	RR 0.73 (0.47 to 1.15)	65 fewer per 1000 (from 127 fewer to 36 more)	⨁◯◯◯ VERY LOW	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias. All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 11Clinical evidence profile: Explicit rounding approach versus standard rounding approach

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Explicit rounding versus standard rounding	Control	Relative (95% CI)	Absolute	Quality	Importance
Patient satisfaction (overall satisfaction) (follow-up unclear)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	serious²	None	341/472 (72.2%)	48.6%	RR 1.49 (1.05 to 2.1)	238 more per 1000 (from 24 more to 535 more)	⨁◯◯◯ VERY LOW	CRITICAL
Staff satisfaction (follow-up 12 days before and 19 days after)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	1467/1544 (95%)	790/915 (86.3%)	RR 1.1 (1.07 to 1.03)	86 more per 1000 (from 26 more to 60 more)	⨁◯◯◯ VERY LOW	IMPORTANT

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 12Clinical evidence profile: Structured interdisciplinary bedside rounds versus standard physician-centred rounds

Quality assessment

No of patients

Effect

Quality

Importance

No of studies

Design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

Structured interdisciplinary bedside versus standard physician-centred rounds

Control

Relative (95% CI)

Absolute

Job satisfaction (follow-up not stated; Better indicated by higher values)

observational studies

very serious¹

no serious inconsistency

no serious indirectness

no serious imprecision

None

MD 0.76 higher (0.49 to 1.03 higher)

⨁◯◯◯

VERY LOW

IMPORTANT

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.

Table 13Clinical evidence profile: Structured interdisciplinary rounds (SIDR) versus control (unknown)

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Structured interdisciplinary rounds (SIDR) versus control (unknown)	Control	Relative (95% CI)	Absolute	Quality	Importance
Teamwork climate score (staff satisfaction) - unadjusted (follow-up 6 months and 2 years; range of scores: 0-100; Better indicated by higher values)
2	observational studies	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	303	231	-	MD 3.15 higher (0.84 to 5.45 higher)	⨁◯◯◯ VERY LOW	IMPORTANT
Adverse events (adjusted rate ratio) - Any adverse events (follow-up 5.5 months and 2 years)
2	observational studies	very serious¹	serious²	no serious indirectness	very serious³	None	-	0%	0.78 (0.39 to 1.53)	-	⨁◯◯◯ VERY LOW	CRITICAL
Adverse events (adjusted rate ratio) - Preventable adverse events (follow-up 5.5 months and 2 years)
2	observational studies	very serious¹	serious²	no serious indirectness	very serious³	None	-	0%	0.55 (0.15 to 2.01)	-	⨁◯◯◯ VERY LOW	CRITICAL
Adverse events (adjusted rate ratio) - Serious adverse events (follow-up 2 years)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	very serious³	None	-	0%	0.86 (0.39 to 1.9)	-	⨁◯◯◯ VERY LOW	CRITICAL
ICU length of stay (follow-up 1991 - 1995; Better indicated by lower values)
1	observational studies	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	469	469	-	MD 4.2 lower (5.8 to 2.6 lower)	⨁◯◯◯ VERY LOW	CRITICAL
Hospital length of stay (follow-up 1991 – 1995, 6 months and 24 weeks; Better indicated by lower values)
3	observational studies	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	1966	2253	-	SMD 0.03 lower (0.09 lower to 0.03 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Length of stay (RCT) (follow-up (baseline); Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious³ imprecision	None	42	42	-	MD 0.34 higher (0.43 lower to 1.11 higher)	⨁⨁◯◯ LOW	CRITICAL

1: All non-randomised studies automatically downgraded due to selection bias. Studies may be further downgraded by 1 increment if other factors suggest additional high risk of bias, or 2 increments if other factors suggest additional very high risk of bias.
2: Downgraded by 1 or 2 increments because the heterogeneity is I²=87%, unexplained by subgroup analysis.
3: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 14Studies excluded from the clinical review

Study	Exclusion reason
Al-mahrouqi 2013²	Inappropriate study design- audit of post-acute consultant ward round before and after introduction of a proforma
Alamri 2016³	Inappropriate study design- clinical review of surgical ward round checklist
Aung 2016⁵	Inappropriate study design- quality improvement project to improve prescribing in the elderly.
Anonymous 2008B¹	Commentary; no data
Baba 2011⁶	No outcome data
Bhamidipati 2016⁷	Systematic review. Two references ordered
Blucher 2014⁸	Evaluation of ward safety checklist for the morning post-take ward round Incorrect study population (acute surgical unit)
Boland 2015A⁹	Inappropriate study design- audit to measure the impact of a ward round checklist.
Butcher 2013¹²	Intervention does not meet inclusion criteria, there is not a distinct difference between the intervention and comparator
Calder 2014¹⁴	Survey conducted before and after the development, implementation, and evaluation of a rounds model No relevant outcomes
Carlos 2015¹⁶	Study on physician compliance with checklist use No comparison and no relevant outcomes
CAO 2016¹⁵	Abstract only
Ciccu-Moore 2014¹⁷	Description of a checklist No outcome data in analysable format
Cohn 2014¹⁸	Narrative review
Cook 2015A²⁰	Not related to structured ward round. A study about urgent and emergency referrals from NHS direct within England
Cornell 2014²¹	Before-and-after study of implementation of situation-background-assessment-recommendation protocol No relevant outcomes
Cornell 2014A²²	Study on interdisciplinary rounding and structured communication (no physicians involved) No relevant outcomes and no relevant comparison
Damiani 2015²³	RCT but from a non-OECD country (Brazil)
Dhillon 2011²⁴	Incorrect study population (surgical ward) No relevant outcomes
DuBose 2008²⁸	Evaluation of a daily quality rounding checklist Incorrect study population (trauma intensive care unit)
DuBose 2010²⁷	Incorrect study population (trauma intensive care unit)
Ham 2016³⁰	Incorrect intervention- effect of ‘rounds report’ on surgery residents
Hasibeder 2010³¹	Narrative review
Hale 2015³⁸	Inappropriate study design- quality improvement project involving the introduction of a ward round check list for daily use.
Have 2014³²	Study on interdisciplinary rounds No relevant outcomes
Henneman 2013³³	Description of development and reliability testing of checklist No intervention and no data
Herring 2011³⁵	Description of ward round checklist No data
Herring 2011B³⁴	Qualitative evaluation of development and testing of checklist for ward rounds No quantitative data
Hewson 2006³⁶	Pilot study to evaluate the use of a checklist No comparison and no relevant outcomes
Hoke 2012³⁷	Description of a perioperative paradigm used in interdisciplinary rounds Incorrect study population (post-anaesthesia care unit)
Holton 2015³⁸	Brief summary of initial findings of a survey No relevant data
Huynh 2016³⁹	No extractable outcomes
Jacobowski 2010⁴⁰	Before and after study of introducing structured interdisciplinary family ward rounds versus structured interdisciplinary normal ward rounds Incorrect comparison (ward round was the same apart from attendance of the family who was able to ask questions and received a summary by the physician in lay language)
Jitapunkul 1995⁴¹	Incorrect intervention. Study aimed to evaluate the effect of a MDT approach. Study considered for inclusion in the MDT review.
Karalapillai 2013⁴²	Development and pro-forma of a daily care plan; targeted at nurses only No relevant outcomes/data
Krepper 2014⁴³	Incorrect study population (vascular surgical unit)
Lehnbom 2014⁴⁴	Slides of a PowerPoint presentation No relevant outcome data
Lepee 2012⁴⁵	Incorrect study population (paediatric ward)
Levett 2014⁴⁶	Survey of views post-induction of a structured checklist No comparison
Mansell 2012⁴⁷	Summary of an audit after introduction of a ward round checklist No comparison and no data
Mant 2012⁴⁸	Systematic review; protocol only
Mathias 2014⁴⁹	No comparison No outcome data
Meade 2006⁵⁰	Unable to extract outcome data as patient numbers are not provided
Meade 2010⁵¹	No relevant intervention, comparison and analysis (Three types of ward rounds introduced on ED but treated as one intervention in the analyses and compared to before introduction of any ward round. Also, no variation data presented so would have been narrative results only.)
Mercedes 2015⁵²	Highly relevant planned systematic review but at protocol stage only
Mitchell 2014⁵³	Systematic review (references checked)
Mohan 2013⁵⁴	Description of a checklist No data
Monaghan 2005⁵⁵	Not relevant comparison (study compares ward rounds with different types of structured forms but no comparator of unstructured ward rounds)
Mosher 2015⁵⁶	Quality improvement intervention of interdisciplinary rounds No relevant data in analysable format
Newnham 2015⁵⁹	Evaluation of a mnemonic, created to reflect the aspects of care that should be documented after every ward round, on the completeness of note keeping Incorrect study population (paediatric ward)
Newnham 2012⁵⁸	Evaluation of standardised documentation on post take ward rounds Incorrect study population (paediatric ward)
Norgaard 2004A⁶⁰	Description of development and validation (content and construct) of checklist No comparison and no relevant outcomes
O’Hare 2008⁶¹	Narrative review of ward rounds
O’Leary 2012A⁶³	No relevant outcomes to extract
Pitcher 2016⁶⁷	Incorrect intervention- structured checklist in a surgical ward round. Incorrect study design- quality assurance project
Pucher 2014A⁶⁸	RCT but incorrect environment and patient population (simulation on post-surgical ward)
Reimer 2014⁶⁹	Narrative review of rounding strategies
Richmond 2011⁷⁰	Observational study of a centralised whiteboard handover followed by a multidisciplinary review of each patient No relevant intervention
Savel 2009⁷¹	Literature review
Sharma 2013⁷²	Observational study investigating impact of checklist on ward rounds Incorrect study population (paediatric ICU)
Shaughnessy 2015⁷³	Qualitative study after induction of a new ward round approach No quantitative data
Shoeb 2014⁷⁴	No relevant outcomes No extractable data
Simpson 2007⁷⁵	Description of development and implementation of a checklist No data
Sobaski 2008⁷⁶	No extractable data
Teixeira 2013⁷⁷	Quality improvement using a daily quality rounds checklist Incorrect study population (surgical intensive care unit)
Thomas 2005A⁷⁹	Correction for the Thomas 2005D paper No data
Thomas 2005D⁷⁸	No relevant outcomes
Thompson 2004⁸⁰	Brief summary of post-take ward round proforma implementation No relevant outcomes (only changes in rates of documentation)
Van Eaton 2010⁸²	Evaluation of a computerised rounding and sign-out system Not relevant study population (more than 50% surgical patients, trauma and paediatrics)
Van Eaton 2005⁸¹	RCT evaluating a computerised rounding and sign-out system No relevant outcomes
Weiss 2012⁸⁵	No extractable data
Wilson 2009⁸⁷	No extractable data
Wild 2004⁸⁶	Incorrect intervention. Study evaluated the effect of interdisciplinary ward rounds. Study considered for inclusion in the MDT review
Wright 1996⁸⁹	No outcome data No relevant comparison
Zhang 2015⁹¹	No relevant outcomes

Appendix H. Excluded health economic studies

No health economic studies were excluded from this review.

Footnotes

(a): NICE’s guideline on medicines optimisation includes recommendations on medicines-related communication systems when patients move from one care setting to another, medicines reconciliation, clinical decision support, and medicines-related models of organisational and cross-sector working.

Bookshelf ID: NBK564898

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