How to prioritise your ward tasks

One of the main skills to pick up as a fresh junior doctor is the ability to prioritise and complete your ward jobs effectively. This is especially important if the workload for the day is heavy and/or if the ward if heavily understaffed. Knowing how to prioritise tasks will allow you to work safely and effectively. You will notice that at the beginning of every placement, there are more doctors in the room than required, but as you reach the later stages of the placement you will notice that the number of doctors in the room mysteriously dwindle down. The main reason is because most people will try to take out a whole chunk of their annual leave right at the very end to go travelling.

In 2017, Royal College of Physician London published a report entitled "How to prioritise effectively" (I have inserted the link below if you are interested in reading). Unfortunately there is no fix formula on how to prioritise your tasks, which means this is the time for you to utilise your SJTs (Situational Judgement Tests) ability to ensure patient safety is maintained.

*Remember, whatever you do the GMC will always expect you to carry out steps to maintain patient safety to the highest standard.

In general, your priority should be as follows:

Unwell patient > urgent bloods/urgent referrals/urgent investigations/discharge letters for patients going home today > Bloods for today > Referrals > Investigations > Preparing discharge letters for patient going home this week

As I have mentioned this is not a fixed rule but rather a general guide I use. If you are working as a team, some of these urgent tasks can be completed at the same time. When you have spare time, it doesn't hurt to prepare discharge letters in advance if you know that they are expected to be discharged a few days later.

Unwell patients

Your main priority in any clinical situation is to manage the unwell patient(s), regardless of whether you have yet to start work or you have just finished your work. Please remember to treat your patients like how you want your relatives to be treated. Never ever walk away from a deteriorating patient. If in situations where there are more than one deteriorating patient, either prioritise the most unwell patient first or ASK FOR HELP! No one will reprimand you for getting help. It does not show weakness, incompetence in doing your job as a doctor or that your lack of knowledge/skills.

Once the patient has been stabilised, remember to re-review the patient at a later time to check for improvement. This is another example of maintaining continuity of patient care.

Bloods

If the patient is unwell or looks like they have the possibility to deteriorate, urgent bloods should be taken to allow a decision to be made quickly. Otherwise, try to ensure that bloods are taken before the clock strikes 12pm or 1pm. The main reason for this is because it takes up to 3 to 4 hours for a routine blood test results to appear on the system. If you send it off as urgent, it will take about 30 minutes to 1 hour. But please don't make it a habit to send off every set of bloods as urgent (This is your ability to effectively utilise limited resources appropriately within a trust). Avoid asking the on-call team to check routine bloods if possible because of reduced staffing at night.

Discharge letters (TTOs)

Urgent discharge letters should be prioritised as well because it takes time for the nursing team, pharmacists and the social discharge team to ensure a care plan is available for the patient for a safe discharge. By care plan this includes medications, district nurses, transport, nutritional plan, care package, discharge locations (own home, care home, hospice, intermediate medical care, rehabilitation ward), and/or safeguarding plan.

Remember, patients do not just disappear forever once they are out of the hospital. Steps to ensure safe discharge is as important as their care within the hospital. Make sure they have an appropriate follow up plan in place if required, and make sure that they have all their relevant medications available on discharge.

On average a good discharge letter should take about 10 to 20 minutes to type up and should never be a task for the on call team. Mainly because you know the patient and their plan better (i.e. follow up plan can be put in place). The importance of discharge letters tend to be overlooked, and you may wonder "staying an extra night in the hospital will not hurt". Keep in mind that, bed blocking means another more unwell patient will not have the bed available and an extra night in the hospital is equivalent to increased risk of hospital associated infections/complications.

Referrals

In some hospital, referrals can be made via the computer system which as expected would take time for it to happen. If urgent advice is required from a different specialty (which is very common), calling the SHO or registrar would be the most appropriate step to do. If you are filling up the referral online via a software, please make sure that you provide as much relevant information to the other specialty as possible. This allows for a better and more accurate triaging of the patient. A low quality referral will likely be met with a low quality response. Hence, please take 5 to 10 minutes to read through the patient notes or examine the patient for relevant signs before making a referral. This important step will save an immense amount of time for you and for the other specialty.

**Referrals can usually be done during the ward round!! Especially if there are more than one doctor following the ward round or if you are good at multi-tasking.

Investigations

Same advice as the "referral" section, prioritise the urgent scans such as, but not limited to, CT-head, urgent x-ray for an unwell patient and CT-abdo/pelvis for a patient expected to have emergency surgery. Please also ensure that all the information given when requesting for an investigation is as complete and accurate as possible. This will ultimately encourage safe triaging of the investigations for the patient. If an urgent investigation is required, this may require you to go down to the radiology department to discuss it with a radiologist. Also ensure that the correct investigation is requested for the patient, this saves costs as well as protect the patients from unnecessary complications.

**Investigations can usually be done during the ward round!! Especially if there are more than one doctor following the ward round or if you are good at multi-tasking.

Ultimately, I can't stress this enough but make sure that your actions are in line with the GMC's expectation of a safe doctor. Work within the limits of your ability and prioritise tasks to ensure patient safety is always kept to the highest of standards! It will be difficult for the first few weeks to even months!! When in doubt, please discuss with a senior or your clinical/educational supervisor for any advice.

And also another hot tip - work as a team and delegate tasks appropriately. Everyone has their own strengths and weaknesses, utilise it to the maximum for the best result!!

My tips for everyone

As healthcare professionals, we work as a team, together with nursing members, nutritionists and dietitians, the speech and language team, pharmacists, physiotherapists, occupational therapists and complex care managers to ensure patient's wellbeing and safety is maintained. Hence, ensure that open and honest communication is available at all times with everyone. Last but not least, keep your mind and skill sets flexible. There will always be unexpected scenarios happening, so make sure you are flexible to changes and tackle them appropriately. If you don't know how, ask and learn!! We are not born to run in one day!

References

https://www.rcplondon.ac.uk/projects/outputs/how-prioritise-effectively