ABSTRACT
The role of a junior doctor involves preparing for the morning ward round. At a time when there are gaps on rotas and doctors' time is more stretched, this can be a source of significant delay and thus a loss of working time. We therefore looked at ways in which we could make the ward round a more efficient place by introducing specific electronic, printed ward round proformas. We used the average time taken to write proformas per patient and the average time taken per patient on the ward round. This would then enable us to make fair comparisons with future changes that were made using the plan, do, study, and act principles of quality improvement. Our baseline measurement found that the average time taken to write up the proforma for each patient was 1 minute 9 seconds and that the average time taken per patient on the ward round was 8 minutes 30 seconds. With the changes we made during our 3 PDSA cycles and the implementation of an electronic, printed ward round proforma, we found that we were able to reduce the average time spent per patient on the ward round to 6 minutes 32 seconds, an improvement of 1 min 58 seconds per patient. The project has thus enabled us to reduce the time taken per patient during the ward round. This improved efficiency will enable patients to be identified earlier for discharge. It will also aid in freeing up the time of junior doctors, allowing them to complete discharge letters sooner, order investigations earlier and enable them to complete their allocated tasks within contracted hours.
ABSTRACT
BACKGROUND: Patients undergoing radical cystectomy have associated comorbidities resulting in reduced cardiorespiratory fitness. Preoperative cardiopulmonary exercise testing (CPET) measures including anaerobic threshold (AT) can predict major adverse events (MAE) and hospital length of stay (LOS) for patients undergoing open and robotic cystectomy with extracorporeal diversion. Our objective was to determine the relationship between CPET measures and outcome in patients undergoing robotic radical cystectomy and intracorporeal diversion (intracorporeal robotic assisted radical cystectomy [iRARC]). METHODS: A single institution prospective cohort study in patients undergoing iRARC for muscle invasive and high-grade bladder cancer. INCLUSION: patients undergoing standardised CPET before iRARC. EXCLUSIONS: patients not consenting to data collection. Data on CPET measures (AT, ventilatory equivalent for carbon dioxide [VE/VCO2] at AT, peak oxygen uptake [VO2]), and patient demographics prospectively collected. Outcome measurements included hospital LOS; 30-day MAE and 90-day mortality data, which were prospectively recorded. Descriptive and regression analyses were used to assess whether CPET measures were associated with or predicted outcomes. RESULTS: From June 2011 to March 2015, 128 patients underwent radical cystectomy (open cystectomy, n = 17; iRARC, n = 111). A total of 82 patients who underwent iRARC and CPET and consented to participation were included. Median (interquartile range): age = 65 (58-73); body mass index = 27 (23-30); AT = 10.0 (9-11), Peak VO2 = 15.0 (13-18.5), VE/VCO2 (AT) = 33.0 (30-38). 30-day MAE = 14/111 (12.6%): death = 2, multiorgan failure = 2, abscess = 2, gastrointestinal = 2, renal = 6; 90-day mortality = 3/111 (2.7%). AT, peak VO2, and VE/VCO2 (at AT) were not significant predictors of 30-day MAE or LOS. The results are limited by the absence of control group undergoing open surgery. CONCLUSIONS: Poor cardiorespiratory fitness does not predict increased hospital LOS or MAEs in patients undergoing iRARC. Overall, MAE and LOS comparable with other series.