There were different categories of patients: new admits from the previous night, discharges, routine patients, and critical patients. Critical patients received my highest priority, and discharges received the least priority. I was looking at critical patients differently than my discharges. Processing the ICU patients meant more thinking, diagnosing, and reviewing, whereas discharging meant dictating, writing prescriptions, educating patients, and making PCP call-backs. I wasn’t looking at each process in terms of time; rather, I was looking at discharges as a final step and the ICU as a place where all my energy had to be placed. I wasn’t making the connection with time and how I was comparing patients being discharged with patients in the ICU.
Energy level and task demands, in relationship to productive time, can be graphed (Figure 1). Energy level is highest in the morning, and tasks march out throughout the day. At the intersection, the time is usually noon for hospitalists. Energy level begins to dip after this time. The most productive time is in the early morning with a plateau around noon. This is why I felt tired in the afternoon, having important discharges to finish.
Once I made the connection that discharges take time and ICU patients take time, I knew I had to revamp how I saw patients. The most time-consuming patients need to be seen first when my energy level is high.
My new routine was to see the ICU patients first, new admissions second, and discharges third, all before noon. This new plan allowed me to begin seeing routine patients earlier. For my routine patients, I review the chart, look at lab and imaging tests ordered, and then go into the room and examine the patient. The difference with these patients is that I wait to write my final impression and discussion section until after I’ve seen all the routine patients. Then I go back and write my final notes. The rest of the day is concentrated on finishing notes, PCP call-backs, billing, family conferences, new admissions, and emergencies.
A good way to look at inpatient work is in sets of blocks. (Figure 2) Within each block are the duties of the hospitalist. Blocks are prioritized in order of importance. Within the prioritized blocks are the “absolute” duties that a hospitalist must perform each day. They include patient care (new and existing), billing capture, and multidisciplinary care conferences. After the absolutes come duties that are routinely performed, including patient and nonpatient functions such as PCP call-backs, family conferencing, resident teaching, and time interrupters. Inpatient blocks can be stacked, with the first layer containing the absolutes and the subsequent layers containing the regular duties or tasks.
Interrupters are time delays that take a busy hospitalist away from absolute and regular work tasks. They are polygonal and can be placed anywhere along the blocks. Interrupters may be new patients, an established patient with an emergency, an outside physician trying to contact the service, a spouse, the medical records department, a funeral home inquiring about a death certificate, a home health agency trying to get certification for a patient’s wheelchair or a subspecialist, for example.
An ideal day shows the blocks in perfect formation, pyramid style. A day with interruptions will result in the blocks appearing disorganized. The ability to recognize time interrupters and to have a plan to deal with them is the key to managing a busy inpatient service. Any plan developed must use patient care as the focus. Everything the hospitalist does is centered on this block, and priorities can be developed to keep it focused.