Hospital Docs: To round on Only One Floor, or Not to?

A major debate taking place in the hospital medicine community over the last several years concerns the way in which we cohort patients on the medical floors. The traditional way is to have patients belonging to each doctor scattered across the hospital on several different floors. This is in contrast to designing a geographical system where all the patients for any one doctor are located on a single floor. On the surface, it seems like a good idea to have this latter model, which is why some people are advocating for it. Theoretically, rounding in this manner will be more efficient and the amount of pages and calls from nurses should be reduced.

As someone who has worked in both extremes as an attending physician, I have had the opportunity to experience the pros and cons of both types of rounding—which I’m going to call geographical versus traditional. I believe that both have their own advantages, and I’ve witnessed some interesting quirks to each one. Here is my informal and honest summary of the geographic model of rounding, with 5 pros and 5 cons:

Pros

1.  Having all patients located on one floor saves both time and energy, and reduces the amount of walking we do in-between floors.

2.  Doctors are always closer to their patients and will be quick to get to them if and when the need arises.

3.  It’s easy for nurses to locate doctors if they have a question. The same applies to any other staff who may need to speak with the doctor.

4.  It fosters more of a “team-based” environment, where doctors get to know the floor staff, including the nurses and case managers.

5.  May be easier to assign patients to each doctor within the group when making the list.

Cons

1.  Reduces the amount that doctors walk at work (I deliberately listed this as a con as well as a pro, because walking a lot at work may not necessarily be a bad thing for our cardiovascular health according to some studies!).

2.  It can cause a feeling of monotony and “being stuck on one floor for the whole day.”

3.  Doctors are more inclined to leave things waiting that don’t seem urgent, and then get to them later in the day. When rounding on different floors, the inclination is to try to finish everything before moving on to the next floor.

4.  Loss of continuity. If a patient who a doctor knows very well is readmitted to another floor, they will not see them in a strict geographic system.

5.  Will likely need to incorporate “floor rotations” into the program, which could complicate scheduling. On each particular floor (e.g. cardiac, neurological, etc.) the hospital doctor may see less variety of patients and interact with fewer specialists.

Neutral

Supposedly, geographical rounding reduces the number of pages and workflow interruptions, but in my experience this may not always be the case. Doctors are very easy to find as soon as a question arises! Questions that may have been thought about more carefully by the nurse or case manager if the doctor wasn’t geographically present.

Those are my 10 cents having worked in both types of systems. I’ve heard colleagues vouch for each model, with its fans and detractors. I’ve also heard some members of the hospital medicine community advocating for standardization of a floor-based system as an “ideal state” for hospital physicians and groups to aspire to. This needs to be thought through very carefully. Unlike nurses, typically hospital doctors (including specialists) do not work on one particular floor only—unless of course they are Emergency Room or ICU physicians. Should the gold standard future hospital medicine physician be located on one floor for the whole day? I’m not so sure. For me personally, the ideal is somewhere in between the two. Maybe two or three floors a day­—not just one—but not more than a half dozen either!

2 Comments

  1. SDaniels on June 30, 2014 at 11:53 am

    Con 4 is not really relevant given that continuity is lost is those programs here hospitalists balance daily assignments.
    Con 5 floor rotation not necessary if floor is designed by hospitalist rather than disease category. A patient should only be moved to a critical care area and if then, an intensivist is the most appropriate medical resource.

    Here’s another pro….Having a hospitalist assigned to a unit which definitely fosters a team approach, is the first step in developing an Accountable Care Unit – a formal delivery of care model with requisite evidence based guidelines, outcome metrics and incentives. Team typically made up of physician, nurse manager, care coordinator, & pharmacist with other disciplines (social service, UR, PT, dietary, etal) participating more informally.

  2. Seref Bornovali, MD on July 6, 2014 at 11:57 pm

    I have been a hospitalist since 2004. Based on experience, my take on this issue is very simple: The only time floor-based rounding works well is when the whole hospital consists of one floor.
    As with every hospitalist team, there will be days everything works, and there will be days when all your plans will be worthless. There will be surges, multiple consults, transfers, sonmetimes all at one time.
    Patient distribution to floors depends on nursing staff, not on doctors. Depending on staffing, some floors may be busier than the others. Based on that, doctors or midlevels assigned to other floors may be asked to help. The day after such a shuffle, the team may have to make choice between multiple signouts or following patients on different floors.
    Even on a regular day, based on the intensity of the servgice, every floor may have different demands. Some are predictable: ortho floors’ demand is high on Monday and very little on Friday. Some, like tele floors are unpredictable.
    I see the ability to deal with the admission and discharge “surges”, such as SNF discharges after a weekend, or multiple admission calls close to ED shift change times, more important than having some particular hospitalist at a particular floor a;ll the time.
    Geographic trounding may have a few good days, but will be compromised after the first two or thre days due to the factors that do not alays depend on hospitalists.
    Regardless of the number of the floors covered, the nurses, social services and pharmacists will cooperate with a particular hospitalist as ateam based how approachable that person is, not based on which floor they sit on a particular day.

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