Title : Improving orthopaedic ward round documentation using the rcs shine toolkit - A quality improvement project
Abstract:
Background: High-quality ward round documentation is essential for patient safety, multidisciplinary communication and continuity of care. Within the Orthopaedic department at Walsall Manor Hospital, ward round entries were documented using a sticker-based template. However, concerns were identified regarding incomplete documentation, lack of clarity around clinical plans and potential risks surrounding patient handover.
Aim: This quality improvement project aimed to standardise and improve Orthopaedic ward round documentation through the implementation of a structured proforma based on the Royal College of Surgeons of Edinburgh SHINE surgical ward round toolkit.
Methods: An initial quality improvement PDSA cycle was undertaken using 30 patient case notes to assess compliance with key documentation standards, including date, time, clinician details, diagnosis, operative status, venous thromboembolism assessment, antibiotic status, blood results, NEWS, current issues and management plan. Feedback was also obtained from multidisciplinary users of the existing template, including consultants, resident doctors, advanced clinical practitioners and nurses. Following this, the ward round template was redesigned to include patient identification details, clearer documentation sections, increased space for issues and plans, and pre- and post-operative checklist components. A second PDSA cycle was completed using 60 case notes to assess the modified template.
Results: Baseline data demonstrated variable documentation quality, with notable deficiencies in recording VTE status, antibiotic status, current issues and clinical plans. Following implementation of the modified template, documentation improved across several key domains. VTE documentation increased from 0/30 cases at baseline to 60/60 cases following intervention. Documentation of clinical plans improved from 29/30 to 60/60 cases, while
recording of current issues improved from 13/30 to 33/60 cases. Improvements were also observed in documentation of operative status and antibiotic status. Feedback on the modified template was generally positive, although further areas for refinement included increasing space for blood results and diagnosis, improving filing efficiency, and encouraging routine completion of peri-operative checklist sections.
Conclusion: Implementation of a structured ward round template based on the RCS SHINE toolkit improved the quality and consistency of orthopaedic ward round documentation. This project highlights the value of iterative multidisciplinary quality improvement in enhancing communication, handover and patient safety in Orthopaedic ward care.
