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The pros and cons of geographic rounds

Hospitalist Management Advisor, November 1, 2008

The pros and cons of geographic rounds

Programs shift to hospitalist-assigned units

In many hospitals, hospitalists are like sojourners, moving to wherever they need to be. On average, hospitalists spend 5% of their day simply walking from one part of the hospital to another without actually doing any work, says Eric Siegal, MD, a fellow in critical care medicine at the University of Wisconsin Hospital and Clinics in Madison, who conducted a survey of his 400-bed facility.

In some big hospitals, hospitalists might walk up to four miles per day, Siegal says. To complicate matters, hospitalists rarely have an ideally located office to catch up on paperwork. Often, offices are located at one wing of the hospital or in an area away from patients altogether.

For years, continual walking was considered the best way to conduct hospitalist work. But there are drawbacks, such as inefficiency, taking time away from patients, and failing to build localized teams.

Time-saver

Now, many hospitals have decided the roaming system doesn’t work. Some hospitals are electing to use hospitalist-assigned units, giving hospitalists a home base for treating patients.

Known as geographic rounds at larger hospitals, these hospitalist-assigned units can reduce travel time to see patients.

“It can be tough to do your work when you have 18 patients scattered throughout a facility,” Siegal says.

If a hospitalist has 12 patients on one wing and six patients on the other wing, the hospitalist will likely see all the patients in one wing before seeing the other patients. “You end up not treating the patients who need your attention first, but who are closest together,” Siegal says. “Obviously, if there’s an emergency, you’ll see the patient. But that could mean that by seeing one patient later, you don’t get to perform a test as early as you’d like.”

The pros: Winning with less walking

Tip: When deciding to make the jump to geographic rounds, consider the benefits you’ll see with hospitalist-assigned units. Hospitalists will:

  • Cut down on walking time
  • Set up a multidisciplinary care system
  • Develop better relationships with nurses, case managers, social workers, etc.
  • Enhance effectiveness by focusing on change in a smaller area
  • Create a feeling of community that other specialties often enjoy

Geography and teamwork

One benefit of hospitalist-assigned units is the ability to offer more multidisciplinary care, says Julia S. Wright, MD, hospital medicine section chief at the University of Wisconsin School of Medicine and Public Health in Madison. This may be the biggest benefit as far as patients are concerned.

“You get your nurses, pharmacists, case managers, social workers, and other clinical staff all working on one unit along with your hospitalists working as a team,” Wright says.

Medical staff members become familiar with each other and their working styles, allowing for better communication, says Siegal. “Instead of having snippets of conversations before you’re paged, you can do rounds together. Instead of trying to figure out what the therapist did by reading her notes, you can either be there or have a full conversation,” he says.

No place like home

Another reason some hospitals like the hospitalistassigned units is the sense of investment they feel in a single place and team.

“General internal medicine is one of the only specialties that doesn’t always have a home,” says Siegal. “You’d almost never see cardiology, obstetrics, pediatrics, or neurology without a home base. Assigning hospitalists a unit creates a sense of pride.”

You’ll also gain the trust and respect of the nursing staff members who will see how committed you are to that unit.

“You can function and not have your own unit, but to be able to identify with home base gives them an identity and builds cohesiveness,” Wright says.

The cons: Fighting for space

There are advantages to hospitalist units, but there can be drawbacks too. Hospital real estate is valuable. It’s not always easy to assign a unit to hospitalists; sometimes, it means taking a unit away from another group.

“Every specialty wants its own unit, so you don’t want it to turn into a turf war,” Siegal says. “One of the big drivers for who gets that unit is money, and hospitalists typically don’t bring in the most money.”

Additionally, the battle for space is typically fought between hospital departments and administration, Wright says.

In hospitals where beds are limited, the administration wants to maximize the throughput of patients, says Siegal. For example, hospital administrators want to make sure an emergency room (ER) patient can be moved to another unit without worrying that the hospitalist unit may be full. To gain administrative support, Siegal suggests the following strategies:

  • Get the nursing department and pharmacists behind the plan
  • Focus on the benefits of multidisciplinary care
  • Be prepared to talk about potential pitfalls, regardless of whether you have all the answers

Not for everybody

Although hospitalists might love the idea of being assigned an area, it doesn’t always work according to plan, says Aaron Gottesman, MD, FACP, CHCQM, director of hospitalist services and associate director of internal medicine residency at Staten Island (NY) University Hospital.

In 2005, the Staten Island academic hospital attempted several hospitalist-assigned units (e.g., general medicine, crucial care, consultation and inpatient rehabilitation, ER, and geriatrics) in an effort to reap the benefits that other programs enjoyed.

But it wasn’t long before Gottesman and other hospitalist leaders realized they were having a tough time maintaining equal distribution of care; some units were consistently busier than others. Even though hospitalists shifted units every two months, that didn’t help them handle the patient load.

“There was a lot of frustration that some hospitalists would be free half the day and others would be overloaded with patients,” Gottesman says. “But we wanted to keep [the schedule] rigid for the units to work.”

Although some of the hospitalists, case managers, and nursing staff members said the geographic rounds allowed for better monitoring of patients, the Staten Island hospitalist program abandoned the hospitalist-assigned units plan in less than two years. Some hospitalists missed walking around and seeing a diverse patient mix. Some also felt that there was too much of a break in continuity of patient care, as patients were passed between units with changing conditions.

“I can see how it would work well for some hospitals, but I don’t see it ever working here, partly because of our academic nature,” Gottesman says, adding that trying to balance the program with the needs of the residents made everything that much more complicated.

Initiating innovation

When deciding on implementing hospitalist-assigned units, evaluate the pros and cons. Hospitalists became popular because they were working for the hospital day in and day out, always loyal to the interests of their institution. Hospitals often rely on hospitalists to observe work flow trends, be innovative, and create better procedures.

There can be drawbacks to hospitalists confined to one area, says Siegal. One of the reasons hospitalists have been so influential in hospitalwide changes is because they see patients in all parts of the hospital. By reducing the time hospitalists spend in some locations, you risk losing their institutionwide viewpoint.

That said, hospitalists units often work well at piloting new programs because of their program size relative to the rest of the hospital, says Siegal. “It’s easier to standardize an order set or test a theory in a confined group,” he says. “New ideas are sometimes destined to fail, and if you keep rolling them out on a hospitalwide basis, people will get tired of the challenges.”

Wright has set up a model for piloting new programs and ideas on her hospitalist unit; once something is found to be a success, it is often incorporated into the rest of the hospital, she says.

“The real challenge is not trying to create totally separate units, but trying to find a balance,” says Siegal. Determining how to give your hospitalists a home to increase efficiency, build relationships, and feel respected while allowing flexibility in scheduling, patients’ needs, and patient flow will determine the success of the program.

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