What
follows below is an original version of the WhatsApp conversational review that
began with an invitation statement from the teacher and each participant
critically appraised and reviewed the Title "How to conduct medical ward rounds". As the discussion progressed, dialogue
between the moderator students and a professor centred around study, and a
review report was summarized (the moderator is indicated by the title “teacher”
and/or initials (R.B.) and student reviewers are indicated by their initials).
VP: What kind of study is this? The
article has made a typical medical ward structure, how it functions and
executed with multidisciplinary team members ensuring patient safety, dignity
and confidentiality; role of different members; enhancing teaching activity for
the members and also importance of all of these for the patient.
VP: This is a very typical description
of a medical ward round. Though I learned from its description, but could not
learn anything new from it which we could have followed in medical wards or
something that we don't practice.
VP: I do have few clarifications
needed eg, In the section "conducting ward rounds"- the following
acronym need more explanation "Using the ‘situation, background,
assessment, recommendation’ (SBAR) structure, the team should discuss the
clinical scenario"
VP: "A structured approach to
discharge is essential (e.g. a pre-discharge board round)."- what are the
different structured approach and any specific elaborated examples for that.
VP: Medications and outstanding issues
should be carefully reviewed using a checklist method- what can be those check
list methods. Would love to learn these general phrases with specific
elaborated examples.
VP: The article could emphasize more
on the aspect of teaching opportunity for trainees through medical wards and
how they play critical role in learning and if that is happening. If not, how
can it improved with some examples.
VP: They could also discuss about use
of technology in the conduction of medical ward rounds.
VP: Role of patient and carers should
be more explained and emphasized.
AKG: Lucky that you practice and
nothing new in this, good for them who don't do in such good ways, this gives
idea to improve.
AKG: I don't think need more
explanation, but an example case will clarify better.
AKG: Already discharge have a structure
in various hospitals, pre discharge board rounds is a useful recommendation.
AKG: Mostly there are no such
checklists available, sometimes there are, like one we recently learned from
case going viral in news, primary physician doing IV must check what's the drug
and dose before administering, this is also a checklist step.
AKG: Article topic is about how to
conduct so i think good being short and specific.
For improvement , teaching opportunities
etc. Have scope and that may be extra addition or something new knowledge than
what already there in practice added by this article. Lot can be done, but by
only telling how to do rest is on trainers to adapt and improve in their way as
per case and audience.
AKG: Yes that may also be something
new addition but i think this is not a research article for improving rounds
but only a standard plan to do it well so fine this way also.
AKG: Patient => agree. Carer =>
its fine.
AKG: "Pre round should be done by
the trainees or junior doctors5. Bed allocation should be done for trainees by
the team leader who is the senior most among the consultants."
No need to write senior most...
AKG:
https://en.m.wikipedia.org/wiki/SBAR
AKG: Patients = not only provide but
also ask for concerns and help in deciding care choices they prefer, understand
the possible complications and help themself by following/suppprting treatment
(adherence)
AKG: This is very useful article for
me, to know what exactly to expect from a ward round.
AKG: Reference 5 used is also to a
pilot checklist.
So this idea should be removed, how
can use such checklists if not existent mostly. If any then please tell.
AKG: Rest all seems fine to me.
RB: Yes it gives us an opinion (not
sure about the quality of evidence that it references unless we go through
them) but it doesn't tell us why we should do what it tells us to do. What
impact will it have if we don't follow this opinion but adopt a different
strategy? What other strategies exist for the clinical ward rounds?
AKG: 1st = comparison and analysis
will tell sir, strategies should vary based on patient needs + audience needs +
trainers style for maximum benefits of patient and then all.
2) another strategy as we have in
electives,
Lot many variations possible sir.
AKG: 16 strategies by NICE on Page 6
to 12,
AKG: Not 16 types but 16 studies
AKG: For various ways of ward rounds
RB: Very valuable for the current
authors to go through and incorporate in their review article to convert it
from opinion to review
AKG: Link to pdf for authors
https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.nice.org.uk/guidance/ng94/evidence/28.structured-ward-rounds-pdf-172397464641&ved=2ahUKEwjyuuOA0uLhAhWkW3wKHRElAaE4ChAWMAB6BAgBEAE&usg=AOvVaw2kDBY79mVey4_2-rQH6gHi
RB: Good this can come in our review
recommendations
VP: Yes that is fine. But it should
have new learning insights for those who knows and who does not know about it.
For example- you can write a case report just simply stating the clinical
presentation and some discussion and many readers can still learn from that.
But that does not give new learning insights unless one highlights that. I have
learned a lot from this article but most of it I could recall taking place
typically in wards.
VP: Yes, the explanation can be given in
different ways. Example of a case would be one of the ways
VP: I meant that why check list method
is useful need more elaboration. I know it may be good but would like to know
evidence that shows it really does. This will build confidence on following
that recommendations
AKG: Think globally act locally.
Author wrote a good one to impact
locally where its not going so good.
We added recommendation to let author
do even better for same.
Agree that new knowledge should be
there , but also as its *not a research* but an opinion or recommendation and
useful (for those who don't have this good ward rounds and can't recall
things), i am ok with even this being a good submission.
VP: I am not questioning their
recommendations but want to know if that is really useful and few examples of
such kind of rounds.
AKG: Any ideas or opinion or
recommendation etc. Which is *new* but not tested, better to avoid when he is
guiding all to do a common thing in a standard nicer way.
VP: You mean this opinion article can
be accepted in its current form?
AKG: Yes very useful for my college.
VP: How? Explain
VP: Does that improve patient outcomes
and compliance?
AKG: Yes. In my opinion. For
improvement there is always scope left and upto authors and editors to balance
that.
AKG: Not all colleges have ward rounds
like you have there. Some are not doing so well.
AKG: Not all teachers even doing so
well..some may wish to improve by following a structure which may help improve.
AKG: Explain, i will try.
VP: I am not reviewing based on what I
have in my college or not.
AKG: Does that not improve patient
outcomes and compliance where rounds are not done?
(Or done badly or occasionally)
VP: Please provide evidence. What you
are talking generally make sense but when we are reviewing or evaluating the
work of authors we need to see through the lens of evidence
AKG: Imagine how rounds are done in
aiims and how done in kims, ucms (mine),
yours.
Gap may be there, this guides to do a better way where the gap is huge.
VP: Where?
VP: How do you know this opinion is
particularly going to do better?
AKG: 1) author haven't added anything
new
= but its not research, can be
editorial or opinion or whatever, so editor will decide there.
2) its impact, i believe it helps to
improve system where its not done well.
=To realize that you need to see /
visit/ know where its not done well. Without such experience you may not be
able to compare and appreciate how important such guidance can be to improve
system in an instute for teachers, patients and students, all.
AKG: How do you know it won't?
Answer this and it will be very easy
for me to explain correctly.
VP: I am not saying it wont. I am
waiting for the evidence to believe whats the truth and I need authors to
explain that.
AKG: Imagine the worst ward rounds you
ever had.
Will this improve that?
AKG: Take it to bottom.
AKG: Experiential evidence.. so not
shared any reference.
VP: Not sure unless I know particular the strategy helps and that I can understand if they substantiate that with
evidence.
AKG: When this applied and tested at
higher levels in the pyramid, it will give evidence of benefits if any or none.
Till that on this opinion i am giving
my opinion. References in article support my opinion saying these inputs in
article will help.
AKG: There are 16 ways and there may
be many ways..all have pros and cons, better ways also possible, newer ways and
research also possible.
I am supporting this article because i
find it useful, with positive comments and recommendations for improvements.
Rest on editor and author to update / revise/ accept.
VP: Avinash, my questions are just to
help authors improve their paper. I have no issues with what they are writing.
I may enjoy reading something and can agree with that. But I need to comment
based on what the global readers would love to learn from them. SBAR is a new thing
for me and many might know it well, few might know a little. So, the authors
need to explain that so everyone reading can equally understand. You may not need
to defend all my comments but a discussion for which one is most useful to
authors for improving their paper.
AKG: Abstraction is also fine.
Means to explain to some depth and
leave rest on readers depending on level of comprehension of expected readers,
like in this case medical journal readers.
For specifically clarifying SBAR ,its
fine if you recommend. In collective review we may differ and both can be
inputs saying 1:1 for yes/no to explain the terms or any such issues.
1yes, 1no or 10yes 12 no and like
this.
AKG: Yes we differ here in our review
in basics, while both also trying to improve it.
What to do in this case? 😬 @8801733506870
MSS: I finished reading the paper.
I noticed that this is personal
opinion of the authors how the ward rounds should be done. There is no
experimental evidence in it. They have just told their opinion on the medical
wards may this is what it is followed in their respective college/hospital. We
really cannot measure impact from this paper.
The important point in this paper they
have used many vague terms like checklists, but what are the checklists contain?
Haven't stated any.
VP: We don't need evidence if medical
ward rounds are helpful or not. But need
more information on specifics eg, check lists, pre round evaluation,
sbar etc
MSS: This paper is not about
experimenting which one is better. It just shows that they are conducting their
ward rounds in this way.
In some places, I know the word boys
and nurses allocate the bed (unlike here interns will be assigning them)
In that case there will be new
methodology for it. So it would be extremely difficult to tell whether which one is more impactful or not.
This paper is more of just showing how
ward should be conducted and at some places they have lacked clarity.
MSS: Like Checklist, what is
structured and pre-structured review.
AKG: For Checklists.. surely yes. i
added point for that.
MSS: An example of what happens when a
patients admit to the ward could be a nice way to put in the paper with
explaining each and every sub-heading in it.
AKG: 👍🏻
VP: Yes that is where I asked
clarification and where possible to provide evidence of benefits. That is a
different thing if there is a lack of it. It will just strengthen their
opinion.
AKG: Single pt. Example While
discussing a topic of ward rounds may create confusion by missing many
important points.. so better if the structure only or detailed examples to
not miss important aspects.
MSS: Why would they miss it. They will
need to include a complex case with all the features if missed any they can
explain in the scenario
AKG: I disagree this way.
AKG: When trying to help authors to
bring out best from their idea and my suggestions
MSS: I feel that checklists should be
more towards local care and the standardization should not be done. But love to
see if there is a evidence based check list tool
VP: This is what I am trying to
explain. Why should we do what it tells is to do.
AKG: So its just an opinion..very very
low in the pyramid
AKG: There are not many so not
practical suggestion.
MSS: 👍🏽. As
a reader I feel reading that way would make me understand in a much better way.
Like the one sir has shared about UDHC.
MSS:
http://userdrivenhealthcare.blogspot.com/2015/06/use-case-scenarios-for-user-driven.html?m=1
AKG: Yes, so directly replying to
disagree. Keeping my opinion honestly as i believe on studying this article.
And eqully respect opinions of all here.
At the end there have to be a summary,
and may be rather than saying +ve or -ve we may need to say, 5 agree while 5
disagree and like that.. or like 5 recommend for this suggestion while 3 said
its fine.
While when editor writes or may be
even the team leader/ reviewer (summary writer) in our discussion decides any
one way when there are differences.
summary will be useful but also convo
will be shared for exact details.
AKG: Seems fine?
MSS: I suggested that
I would have enjoyed reading it like that. Now along with the other group
members see who likes the idea or not. If not liked the ldea by most disagree
and not mentioning in the revision points
AKG: Its upto editor to select or
reject paper, and upto us to find faults and suggest improvements.
So this way i think for article.
MSS: U can also reject the paper by
giving the solid points why do u think that this paper is not valuable for
publication.
Then it's in the hands of the editors
to follow or not.
VP: We also need to your review inputs
around this short opinion paper.
BU: Firstly what is the
definition of Your MEDICAL ward
BU: Corporate big hospitals Vs Medical
College Vs JIPMER Ward - the
concept of the ward is different
BU: Where do u have pharmacists
joining
BU: I guess u need to contrast the
existing vs the ideal
BU: Involving the patient varies at different centres
and so does their relatives involvement
BU: Emergency ward round is
different from ICU Vs General Ward
BU: What is the exact time which
should be given ??
BU: Time given to each patient ????
RB: Very valuable inputs from
Boudhayan. Vivek please incorporate these points into your review summary to
the editor
Final recommended revisions for the authors which
transpired from conversational review by the team:
1. In the
section "conducting ward rounds"- the following acronym need more
explanation "Using the ‘situation, background, assessment, recommendation’
(SBAR) structure, the team should discuss the clinical scenario"
2. "A structured approach to
discharge is essential (e.g. a pre-discharge board round)."- what are the
different structured approach and any specific elaborated examples for that.
3. Medications and outstanding issues
should be carefully reviewed using a checklist method- what can be those checklist methods. These general phrases can be used with with specific elaborated examples.
4. Could also discuss the use of
technology in the conduction of medical ward rounds.
5. Role of patient and carers should
be more explained and emphasized.
6. This link provides the authors a guidelines
of structured ward rounds. They should incorporate it and try to amend catering
to the local needs.
7. A clinical complex case with a scenario
can make this look better.
8. Definition of a Medical ward is
missing and also no proper classification of the emergency ward vs ICU ward or
others.
9. Are the pharmacists joining in
every medical ward rounds?
10. Corporate big hospitals Vs Medical
College Vs Premier institutions the concept of the ward is different so what are the authors referring to?
11. What impact will it have if we don't follow this opinion but adopt a different strategy? What other strategies exist for the clinical ward rounds?
11. What impact will it have if we don't follow this opinion but adopt a different strategy? What other strategies exist for the clinical ward rounds?
Comments
Post a Comment