Tuesday, January 14, 2014
The ideal hospital rounding model
Hospitals across the country are grappling with the consequences of health care reform. The drive towards quality, value-based care and the need to control costs has brought the practice of hospital medicine to the forefront of American health care. Once seen as a mere stand-in for the patient’s primary care physician, hospital medicine doctors are uniquely placed to drive process improvement, using their complete helicopter perspective of the hospital system. Initiatives are underway nationwide to determine ways to optimize care and deliver excellent patient experience. One of the most important of these is determining the best way for patient rounds to work. Right now, there is no defined process or “gold standard” for how this should happen. Patients hospitalized on the medical service can be seen by their doctors at completely random times according to the way that individual physician works. One patient may be seen at 7 am, and another at 3 pm. Often there will be no communication between doctor and nurse either before or after the patient is seen. This is not an acceptable situation, and needs to improve.
The concept of multidisciplinary rounds as a way of standardizing the rounding process is gaining increased traction nationwide. These are rounds conducted by the entire healthcare team—including doctors, nurses, and usually case managers. Having practiced hospital medicine for over five years in several different hospitals, I’ve seen this approached in a number of different ways. Here are the broad principles of how ideal multidisciplinary rounds should work:
• The entire care team meets at a defined time. Any urgent events are discussed first;
• Each patient is discussed one by one, with the discussion taking place outside the patient’s room;
• Utilize a checklist, so that certain information is always communicated, such as vital signs, ins and outs, and whether a Foley catheter is in place;
• Go into each room together. See and examine the patient, with the Attending physician leading the team. Interns and residents will also be present in teaching hospitals;
• Debrief after leaving the room. Go over the pending tests, the plan for the day, and the likely discharge plan;
• Start around 7 am to 8 am, and see all the patients in about 2 to 3 hours, assuming a census of about 15 patients;
• During the rounds, place all necessary orders needed for patient care, e.g. laboratory tests and radiology investigations; and
• Following rounds, the hospital doctor should address any immediate patient problems and then focus on discharges.
This system works best when hospital medicine doctors are floor-based in a geographical model, working in defined “team units” with nurses typically having all their patients with a certain attending physician. A version of multidisciplinary rounds already works well on ICUs, particularly in teaching hospitals.
There should be minimal interruptions during rounding. In an ideal situation, the doctor should not be getting calls from the ED for new admissions (the best groups will have a dedicated admitter stationed in the ED).
Having multidisciplinary rounds within the framework of a planned day restores order to what is a typically chaotic day for the hospital medicine doctor. It is better for doctors, nurses, and patients. A major sticking point is whether or not the team should actually see patients during rounds, versus doing the patient examination part separately, as currently happens the majority of the time. The argument against going into patient rooms is that it obviously takes longer and that the patient may feel “intimidated” in front of the whole care team. Having worked in health care systems that utilize this method of rounding, I’m of the opinion that this concern is overstated. From the point of view of the doctor’s workflow, it makes sense to see the patient at that time, while leading the care team. The patient is also more likely to have a better experience when rounds are taken into the room by feeling that a whole team is looking after them. Further time in the afternoons can be reserved for going back and seeing certain patients again, and also for having family meetings.
So what are some other advantages of multidisciplinary rounds?
• The entire care team is on the same page because there is direct communication between them. The nurse will fully understand the plan for the day;
• It enhances efficiency and clinical workflow by reducing a lot of the frontline repetition that currently takes place;
• It achieves better hospital metrics including early discharge times and patient satisfaction scores; and
• There will be fewer pages and calls to the doctor, because more issues are dealt with during rounds, rather than at random times afterwards.
Hospitals in many countries are already well versed in doing multidisciplinary rounds. Part of the problem over here stems from the traditional fragmentation of the U.S. medical system. Having gone to medical school in the United Kingdom and subsequently worked in the National Health Service, as well as an elective experience I had in Australia, this is something that is done very well in those countries. In fact, when I first arrived in the U.S. to start my residency, I was surprised by how we didn’t all do rounds together and instead worked in a system that involved so much repetition and individual workflows.
Over the years, I’ve become immersed in my new adopted system and have to remember how good formal multidisciplinary rounds was! You feel part of a team in an atmosphere of collegiality. Even though the documentation requirements in those systems are much less and patient load much higher (which isn’t necessarily a good thing), there’s a lot we can learn from other countries that do this successfully. Of course, the process will have to be modified to suit our healthcare system, but the broad principle can stay the same: namely to round together as a team.
Implementing multidisciplinary rounds in hospitals that don’t currently utilize them will require a great deal of planning and collaboration. Because everyone has a completely different workflow, it’s not an easy thing to do. Getting it right is key, as it isn’t just a case of saying that you “do multidisciplinary rounds” to satisfy a tick box. Poorly designed multidisciplinary rounds models will result in the major stakeholders, be they doctors, nurses or other key staff, not seeing any advantages at all in doing them. In the ideal scenario, everyone should find them beneficial, nobody more so than the patient.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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