Hospital Medicine Community: How do we instill some order into the daily chaos? – Part II

By  |  August 26, 2014 | 

Yesterday I highlighted and identified that the daily chaos that has come to characterize hospital medicine needs to be changed. The problem, in a nutshell, as a specialty colleague remarked to me one morning, “I don’t know how on earth you can do this. You are getting called and paged from all directions at the same time about admissions, discharges and urgent floor situations!” We hospitalists need to find order in the chaos, do what we do best, and modify the systems within which we work to improve hospital medicine and patient care. The fact is that you take even the best job in the whole world and instill complete chaos and disorder into it and people will eventually leave that job. So how can we instill and establish some order? I don’t pretend to have all the answers, but here are some ideas:

  • ·Impose stricter limits on the daily patient census. This goes without saying. I question how any hospital doctor can regularly see 20+ patients a day, and the ideal limit should be much less
  • ·Have a specific time to answer all non-urgent questions during the morning, which can also be accomplished with some form of (efficient) multidisciplinary rounding. Collaborate with nursing regarding appropriate pager-callsOrder-Chaos
  • ·Organize the day by allocating time slots to every patient  (e.g. Mr. T. gets seen from 9 – 930 AM; Mrs. H. from 9:30 – 10:15 AM (anticipated discharge); 2 – 3 PM family meetings, etc.). Not as difficult as it sounds.
  • ·Spice up hospital medicine by incorporating rotations every few months around different types of floors/patients.
  • ·Separate the rounding from the admitting process and having a dedicated “Admitter” in the Emergency Room. This enables the doctor to more accurately plan their day without the eternal question of “How many admissions will I get on my already overloaded day?”

Of course, we are in the unpredictable environment of a hospital and unforeseen events will occur—that’s impossible to control completely. But on comparison with other generalist specialties, there’s no reason why we can’t improve how we do things. It’s not just a case of handling the heat in the kitchen (especially if a kitchen has air conditioning). Take the intensive care unit, despite the fact that urgent situations occur all the time, the environment still seems much more controlled than the medical floors. The Emergency Room, as busy as it undoubtedly is, allows for sequential processing of patients. Primary care sees patients in allocated time slots. Such order is possible for hospital medicine, too.

In my opinion, this issue is so important that there should be some type of “national hosptialist task force” to talk about how we can solve this challenge. A more predictable and organized day will result in increased job satisfaction, higher retention rates and better patient care. The cliché about something at its best making you and at its worst destroying you, holds true for hospital medicine. If our specialty is to thrive, we must instill order into the daily chaos. We can indeed do much better. The future of our specialty may well depend on it.

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One Comment

  1. Ronald Hirsch, MD August 27, 2014 at 9:31 am - Reply

    Your plan sounds good for the hospitalists but sure does not sound like it’s good for anyone else. No urgent calls except in the morning? Is a potassium of 5.1 urgent enough for the RN to call in the afternoon and get an order to stop the potassium supplement or should the RN wait until the next morning’s non-urgent call time frame? Allocate slots for each patient? And if the ICU calls because Mrs. Smith is crashing, do you wait until her 2 pm slot to see her, or see her now and take the time from Mr Jones’s slot?
    You may think that PCPs have it good with our “dedicated time slots” but then the ED calls to tell me they saw my patient, a pharmacy calls with a prescription that needs precertification (it was given to the patient by the hospitalist and when the pharmacy called that doc, they were told the patient is discharged and to call the PCP), the endless forms for DME, home care, refills and our dedicated slots get ruinedall day long as patients are squeezed in for same day apppointments.

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