Hospitalists are under an ever-increasing amount of pressure these days.
Their performance is being heavily scrutinized by their employers as it pertains to early discharges, patient satisfaction scores, mortality percentages, readmission rates, etc. At the same time, their census continues to spiral out of control. Faced with all these challenges, they must structure their daily rounding routine in a way that allows them to be most productive.
If you are a hospitalist, do these six things at the beginning of your day. I have implemented these strategies in my practice and have benefitted from them immensely. They will ensure superior patient safety and improve quality of care delivered.
1. Review all your patients’ lab reports and radiographic images. This is very important to do early on. You absolutely don’t want to miss a life-threatening lab or radiographic abnormality. What if one of your patients has a potassium level of 7.5 mEq/L but is asymptomatic? If you sit too long on it, he/she can go into asystole. What if a patient has a pneumothorax on a morning chest radiograph but is asymptomatic? You can’t wait for the pneumothorax to increase in size to cause respiratory distress. View this activity as putting out small fires early on before they turn into a blaze.
2. Review the nurses’ notes from the previous night on all your patients. Often times, patients undergo rapid responses on night shifts, and they needed to be stabilized. It is obvious that these patients are sicker than the rest. You maywant to prioritize seeing them early to prevent further complications.
3. Talk to your case managers/social workers for patients pending placement. I cannot stress how important it is to do early. Transferring a patient to SNF/LTAC/Rehab/Nursing facility is a time and labor-intensive process. If you wait too long in the day to tackle this, the patient may not get discharged and your length of stay will suffer. Furthermore, the patient will be in the hospital one extra night which will put him/her at risk of getting a hospital acquired infection or some other complication.
4. Pending overnight admissions. It is quite common for most hospitalist practices to employ nocturnists. Often, the nocturnists receive more admissions than they can see on their shift. The excess patients get passed on to the day shift hospitalists. The day hospitalists’ top priorities are early discharges so often this creates a gap in care that can create a big patient safety hazard. The ER doctors put skeleton orders on these patients. In most cases, these orders are not adequate once the patient reaches his/her floor bed.
For example, many sepsis patients receive IV fluid boluses in the ER to supplement their blood pressure. However, sometimes the ER doctors forget to write for maintenance IV fluids for these patients. As a result, when these patients reach the floor, the blood pressure slowly starts tanking once the bolus effect wears off. If this is not paid attention to, then the patient can go into septic shock and code.
5. Review to make sure appropriate consultants have been notified. Sometimes, when patients are admitted at night, the consult order is not put in because the patient’s condition is not critical. For example, it could be a patient with a GI bleed that is not critical. However, the patient probably still requires work up with an endoscopy. If you make sure to call the consultant upfront in the morning, you are making sure that appropriate care is not delayed, and your length of stay will improve too.
6. See the discharges. Once you have taken care of the above, please see and take care of you discharges. I cannot stress the importance of patient safety over early discharges. You don’t want to get into a situation where you let a patient deteriorate and die on your service while you were focusing on an early discharge. This increases the risk of malpractice lawsuits and frankly, quality of care should not be jeopardized because that is our most important task and we took an oath to protect our patients.