The pre-round: what are junior doctors doing before handover?

Abstract

Many readers of the Internal Medicine Journal (IMJ) may not be familiar with the term pre-rounding. It is a term that refers to the practice of junior doctors performing reviews, tasks or other preparation directly prior to a ward round from their consultant or other lead clinician.^{1, 2} Pre-rounding is a heterogenous practice that varies between hospitals, departments and even within departments. It may include a traditional full physical round of patients, as is more common in North America, or, more simply, in Australia and New Zealand, it may be a review of key test results, observations and vital signs using the electronic medical record (EMR).^2-4 Multiple factors affect how pre-rounds occur in each area. Many senior staff may not be aware of what their juniors are doing before the ward round.

Several factors influence the structure of a junior doctor's pre-round. Each individual will have their own preferred approach and structure, and variation in this between doctors may in part reflect the absence of formal medical school education on pre-rounding.^{1, 5} External factors will also influence structure. Individual senior clinicians will vary in the information that they require from the juniors on the round and the manner in which they wish it presented. This will drive differing pre-rounding practices among the hospital and medical teams. The hospital's systems and EMRs will affect the approach to pre-rounds between hospitals. A junior doctor's job is therefore to be adaptable and pre-round in a manner to maximise efficiency in collating the information that is expected.

In current practice, getting the full information together in time for the senior round often relies on the junior doctor arriving at the hospital ahead of the prescribed ‘start time’. This is especially the case when the round begins immediately after the start-of-the-day handover. With ever more complex patients and increasing health information in the system, this can lead to earlier and earlier start times. Efficiency is the goal, with the cost of inefficiency being measured in lost minutes of sleep. Simply arriving with the senior medical officer is commonly no longer achievable, particularly during breakneck pace surgical rounds where time at bedside may be measured in seconds. However, as it is with almost every area of healthcare provision currently, time remains a luxury, necessitating efficiency.

Each consultant or lead clinician for the round will have an expectation on what information the junior staff should have available, varying among case presentations, current vital signs, recent test results and event recorded by the overnight nursing shift. These expectations are often shaped by doctors' personal practice and the information each uses to formulate ongoing management plans. Traditional structured teaching might struggle to provide a ‘one best approach’ with such variation required in output through different areas. Each junior may have a different approach to arrive at the same outcome, but questions remain whether structure could aid in efficiency.⁵

There are no studies of pre-rounding practice in either Australia or New Zealand. It is worth noting that employment law and contracts differ between the two countries and this may impact junior doctors' work patterns. In Australia National Employment Standards apply limiting rostered hours (38 with additional reasonable hours) and there are structures in place to pay overtime in most locations.⁶ This is not the case in New Zealand, where the contracts only cap rostered hours to 72 h (commonly 50–60 h) and payment for overtime hours beyond those rostered is limited. It is not known to what extent pre-rounding is limited by the employment relationship and to what extent it is undertaken unpaid.

In this issue of the IMJ, Ng et al. proposed a structure, using PREROUND as a simple mnemonic to prompt their recommended approach to the preround.⁵ This structure suggests a linear progression of tasks that follow what could be seen as a logical structured approach. Analysis of this may have junior readers finding similarities to many areas to their own approach, while also reflecting on some differences. Similarity in structure can be drawn to the well-known DRS ABC of first aid.^{7, 8} In particular, in PREROUND the E stands for escalation, which functions as the S of ‘send for help’, which in both mnemonics follows after assessment of patient's acuity status. Perhaps what the PREROUND structure does lack is expressed flexibility and an understanding that in the age of the EMR, elements of a pre-round may be undertaken simultaneously.

There is limited scope for seniors to provide feedback or teach on the preparation aspects of a pre-round. Only the results are visible. Feedback following a case presentation will include positive reinforcement for included information or advice on missed aspects, but this is little of what may be encompassed in a pre-round. Feedback on the process is impossible when the process is invisible to the senior clinicians.

An efficient pre-round can allow the junior doctor to guide the consultant and team to the patients in the appropriate order. This will be especially important when a team has patients spread over many wards. This junior will combine their up-to-date electronic checking on their patients with their knowledge of the geographic location of the patients, where the consultant needs to be after the round and perhaps on occasions the coffee shop. Patient acuity may trump all, but in otherwise stable patients, retracing your steps would indicate an underprepared round. Leading a ward round to end near outpatient clinics, surgical theatres or a coffee shop is often an acquired skill requiring delicate balance.

The role of the pre-round is to facilitate a smoothly run ward round that supports the best outcomes for patients. There are many factors that influence pre-rounding but perhaps, as Ng et al. suggest, structure and education could improve the efficiency of rounds.⁵ However, it will still rely on the junior clinicians to be flexible in their approach, adapting to the needs of the team, department and patients.