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.
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.
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.
Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”
For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.
Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.
Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.
Post Rounds (Follow-Up Care and Planning)
Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.
Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.
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.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!
“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.
Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.
Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.