Practice Management

Unit-based rounding in the real world

Balance and flexibility are essential


 

Many hospitalists agree that their most productive and also sometimes least productive work can happen in the setting of interdisciplinary rounds. How can this paradox be true?

Dr. Tresa Muir McNeal, division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.

Dr. Tresa Muir McNeal

Most hospitals strive to assemble the health care team every day for a brief discussion of each patient’s needs as well as barriers to a safe/successful discharge. On most floors this requires a well-choreographed “dance” of nurses, case managers, social workers, physicians, and advanced practice providers coming together at agreed-upon times. All team members commit to efficient synchronized swimming through the most high-yield details for each patient in order to benefit the patients and families being served.

Of course, there are always challenges to this process in the unpredictable world of patients with acute needs. One variable that is at least partially controllable and tends to promote a more cohesive interdisciplinary experience is that of hospitalist unit-based rounding.

The 2018 State of Hospital Medicine (SoHM) survey reveals that 68% of hospital medicine groups serving adults with greater than 30 physicians employ some degree of unit-based rounding; this trend decreases with smaller group size. About 54% of academic hospital medicine groups use some amount of unit-based rounding. Not surprisingly, smaller hospitals are less likely to have this routine, likely because of fewer total nursing units.

One of the most obvious benefits to unit-based rounding is that the physician or advanced practice provider is more reliably able to participate in the interdisciplinary discussions that day. When more of the team members are at the table each day, patients and families have the best chance of hearing a consistent message around the treatment and discharge plans.

There are challenges to unit-based rounding as well. If patients transfer to different floors for any variety of reasons, strict unit-based rounding may increase handoffs in care. If a hospital has times when it isn’t completely full and nursing units have a varying percentage of being occupied, strict unit-based rounding can cause significant workload inequities among physicians on different units, depending on numbers of patients on each unit.

If there is no attempt at unit-based rounding in larger hospitals, some physicians may be running among five or more units. They work to find different care managers, nurses, and pharmacists – not to mention the challenges of catching patients in their rooms between their departures for diagnostic studies and procedures.

It is often good to balance the benefit of promoting unit-based rounds with the reality of everyday patient care. Some groups maintain that the physician/patient relationship trumps the idea of perfect unit-based rounding. In other words, if a physician establishes a relationship with a patient while they are in the ED being admitted or boarding from overnight, that physician will continue seeing the patient regardless of the patient being assigned to a different unit. It can help for groups to agree that the pursuit of unit-based rounding may create some inequity in the numbers of patients seen each day because of these issues.

In a larger hospital, certain units are often dedicated to specialty care such as cardiac or stroke care. While most hospitalists want to maintain general medical knowledge, there are some who may enjoy having portions of their practice devoted to perioperative medicine or cardiac care, for instance. This promotes familiarity among hospitalists and groups of consultant physicians and nurse practitioners/physician assistants. Over time this allows for enhanced teamwork among those physicians, the nursing team, and the specialty physicians.

Depending on the group’s schedule, patients can be reassigned coinciding with the primary change of service day. This resets the physicians’ patients in the most ideal unit-based way on the evening prior to the first day of rounding for that week or group of shifts.

No matter how you do it, the goal of unit-based rounding is time efficiency for the care team and care coordination benefits for patients and families. If you have other suggestions or questions, go online to SHM HMX to join the discussion.

Take-home message: Unit-based rounding likely has its benefits. Don’t let the inability to achieve perfection in patient distribution to the physicians each day lead to abandonment of attempting these processes.

Dr. McNeal is the division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.

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