How Hospitalists Can Improve Efficiency on Inpatient Wards

How Hospitalists Can Improve Efficiency on Inpatient Wards

At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.

This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.

Pre-Rounding

While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:

  • For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
  • For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
  • Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.

Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.

Rounding (The Patient Encounter)

Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.

Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.”

Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.

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