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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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
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.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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