1. Learning to Round Before Rounds
Good Morning everyone, my name is Shabnam, PGY 2 at WHC, and I’m presenting on behalf of my co-resident Dr. Yi. I’d like to thank the Consortium for allowing our team to present our work today- Learning to Round Before Rounds
William S Yi, Shabnam Hafiz, Jack A Sava
Medstar Washington Hospital Center
March 16th, 2013

2. The Life of an Intern… 6:00am 6:30am 7:00am 7:30am
Obtain signout from the night resident about any acute events with your patients (list can vary from 5-20pts)
Begin obtaining vitals signs and I/Os from the last 24hrs
Check medications administered
Talk to Nurse
6:30am
Assess each patient, subjective and objective measures
Examine devices
Examine wound
Address patient concerns
7:00am
Round with Senior resident
Team comes up with plan of care for the day
7:30am
Be prepared to go to the OR
Imagine yourself, way back when, you were an intern on your first day on the wards-
The time you showed up in the morning varied depending on how big your patient census was, but there were and still are standard expectations for your daily rounds.
You obtain signout from the night team, gather all objective data which now manifests itself both electronically and in the paper chart. Evaluate meds. Then you are tasked with the duty of evaluating your patient at the bedside. Depending on the size of your list, this can be anywhere from a few patients to some services being greater than 20. An intern must assess the patient each morning, obtaining the patient’s subjective report, addressing pain, diet, and surgery specific symptoms. Then address wounds and medical devices. In addition to all this, the patient might have a concern that he/she has been meaning to ask the team.
And after all of that, you are expected to present the various data points that you have gathered, synthesize it into a coherent and comprehensive format so that the team can coordinate a plan of care for the day.
All of this in less than an hours time. I leave you with the picture of an overwhelmed intern with 15 patients on their list, many of which have drains, chest tubes, wound VACs, and an intern that just started yesterday isn’t quite sure what to make of the new 250cc of blood in the pleuravac or determine whether or not it is to suction?, the green fluid in the wound VAC, or the surgical wound that just doesn’t look right. How does one organize all these elements to the patient’s care? And most importantly, would you admit that you don’t know how to interpret the data you’ve gathered?

3. Medical Informatics
The collection, classification, storage, retrieval, and dissemination of recorded knowledge
I would like to introduce to you a definition of medical informatics- it is the collection, classification, storage, retrieval, and dissemination of recorded knowledge. This truly encompasses that of what is expected of a junior resident- collecting various amounts of data recorded for the patient the day prior as they prepare to present a patient to their senior residents or attending.
In today’s age where information is abundant and in various parts of the medical record, incoming interns have to be able to not only find the pertinent data, but put together a comprehensive and cohesive plan with the gathered information.

4. Why A Session on Information Management?
Interns have difficulty with:
Identifying and collecting important information
Surgical care devices and their management
Synthesizing a comprehensive report using that data
So do we really need to train incoming interns on information management?
Some may argue that was the purpose of their clinical years in medical school, but, we still found that interns still struggle to identify and collect appropriate information regarding floor patients, they are unfamiliar with surgical devices, and find difficulty in interpreting and synthesizing the data gathered into an action plan.

5. Boot Camp
Most surgical programs have instituted an orientation program, often termed “boot camp,” that provides a crash course for interns on what they need to know to survive inpatient care at their institutions. Many of these boot camps are designed to target clinical knowledge base like how to manage oliguria or hypotension or how to place a central line.
Didactic and Simulation training on critical bedside clinical evaluations
Hypotension, AMS, Oliguria, Hypoxemia
Handoff Training
Professionalism
Rounding Training?
Rarely is there any emphasis on the management of medical informatics and how to go about gathering, synthesizing, interpreting, and reporting pertinent data.

6. Rounding Simulation Paper Chart / EMR Nurse Patient 1 Patient 2
Our team designed a module in which 3 patient scenarios were given with a total of 6 minutes time to gather pertinent patient data and assess the patients. They had access to a bedside nurse, paper chart, and EMR. The clinical presentations varied from management of an ostomy and post operative ileus, assessment of chest tube output, and evaluating a foley in a patient with oliguria.
Paper Chart / EMR
Nurse

7. Methods 35 surgical interns Pre Survey / MCT Didactic Simulation
Our study involved 35 surgical interns from two institutions. It was held during our intern orientation “boot camp” session. Interns completed a pre-simulation survey and multiple choice test that assessed clinical knowledge.
They then had a didactic session where pertinent medical informatic tools were taught and discussed.
After this, they went through the simulation I mentioned.
After the completion of this simulation, they completed a post-simulation survey and repeated the same multiple choice test.
We then reassessed the interns 3 weeks later with a survey and repeat of the multiple choice test.
Post Survey / MCT
3 Weeks of Clinical Service
3 Weeks After Survey / MCT

8. Question Pre Post P value (pre-post) 3 weeks post (post- 3 wks post)
I think training specifically on data collection for rounds is important
<.0001
0.56
I can effectively prepare for rounds on 6-12 patients in a period of 30 minutes
0.23
I know what pertinent information to collect for rounds on the typical general surgery patient
0.0008
I need more training on how to effectively and efficiently manage and prioritize clinical data
Data collection and information management skills are best learned in the course of clinical duties
0.0003
0.002
I found this didactic and simulation training on data collection and information management for rounds to be a valuable educational experience NA
0.57
Using a likert scale, 1 being strongly disagree and 5 being strongly agree, we were able to find statistically significant changes in intern perception on their comfortability and knowledge of managing medical informatics.
They found that this sort of training was felt to be useful by trainees.
They realized after the simulation, that they were not prepared to round on 6-12 patients in 30 minutes. It just wasn’t enough time.
They also found to be less confident in knowing what pertinent information to collect on the typical general surgery patient.
As you can see, incoming interns feel as though they know how to evaluate patients, what to look for and how to find it, but when a typical morning was simulated for them, they found that they needed more training on how to effectively and efficiently manage and prioritize clinical data.
While they felt the best place to learn was still during the course of clinical care , they nonetheless clearly felt the training was a valuable training experience.

9. Scores on Information Management Improved After Training
Here are the results of the clinical multiple choice test. These questions addressed assessment of clinical problems with patients and what necessary steps need to be made in assessing or addressing the issue. Y axis reflects proportion correct. Interns averaged roughly 44% correct prior to the didactic/simulation session, and then markedly improved immediately after the session to 80% correct which was statiistically significant. 3 weeks later, they remained roughly the same at 79% correct.

10. Conclusion
Interns find medical informatics training necessary and useful
Training needs to cater to intern specific knowledge gaps in order to effectively prepare them for clinical care
In conclusion, our team found that it was useful for interns to obtain medical informatics training. Further efforts need to be individually focused in order to better assess knowledge gaps so that we can effectively prepare them for improved and efficient patient care during morning rounds.

11. Thank You
Special thanks to the dedicated staff at MedStar Health’s SiTEL Clinical Simulation Lab
I would like to take a moment to thank our dedicated team at MedStar Health’s SiTEL Simulation Lab who work tirelessly to bring us the most advanced, comprehensive simulation training that has now become the cornerstone of our general surgery education model. Thank You.