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Giving hospitalists their space

From the February ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Beth Thomas Hertz

Cleveland Clinic’s division of general internal medicine decided to try “geographic rounding” after a patient satisfaction survey revealed that many patients were unhappy that “my doctor is never around.” That sentiment is starting to change now that hospitalists spend more time actually talking with patients and less time getting to them.

“If a family came in and wanted to talk to us, it could be a 10- to 15-minute walk to the room, 10 minutes to talk and another 10 to 15 minutes to walk back to where you were. We were spending 45 minutes just to talk to one family,” said Robert Patrick, MD, an associate staff member in the clinic’s department of hospital medicine. Before the clinic implemented geographic rounding, which assigns hospitalists to one unit per shift, there were five hospitalist teams, each with an average of 12 patients spread over seven floors, said Dr. Patrick. Most hospitalists had fewer than 30% of their patients on any one floor.

Physicians and nurses at the clinic love the new arrangement, he said. “Nurses can get hold of doctors when they need them because they may be on the floor for six hours at a time. Doctors get fewer pages and they are no longer wearing out a pair of shoes every six months walking all over the hospital,” he explained. Also, length-of-stay is down dramatically and patient satisfaction seems to be up.

Other benefits cited by hospitalists who have tried such geographic rounding include being able to talk to specialists face-to-face and perform multidisciplinary rounding with nurses, social workers, physical therapists and others. However, the system doesn’t always run smoothly, with barriers ranging from physician complaints about feeling isolated or overworked to problems coordinating physician shifts with bed assignments. If you can overcome those problems, however, the system can boost morale and energize staff, said Douglas J. Apple, ACP Member, who practices at Spectrum Health’s Butterworth Hospital in Grand Rapids, Mich. “It really empowers them [nurses] to have us there,” he said. “And that happiness carries over to us.”

Coordinating bed assignments

The toughest implementation barrier cited by all experts was bed assignment.

“Getting emergency patients to the floor in a timely manner is always a challenge and when you enter in the variable of hospitalist assignments, it can be even harder,” said Amy E. Boutwell, ACP Member, a hospitalist at Newton Wellesley Hospital in Cambridge, Mass., and content director for the Institute for Healthcare Improvement. “If you get a patient through the ED but all the beds on your ward are full, you must have a mechanism to also admit to another floor. Do you hand them off to a colleague or do you travel to see them? It’s a question that has to be resolved.”

Various hospitals resolve it differently, though. Daniel J. Brotman, FACP, director of the hospitalist program at Johns Hopkins Hospital in Baltimore, said the challenge is greatest at hospitals that function at or near capacity.

“You can’t run a hospital like a hotel and force patients to vacate their beds after three days,” he said. “The ED has to send patients somewhere, and you either have to be willing to place patients elsewhere or give the hospitalist covering a geographic unit the ability to say ‘no’ to getting new patients. We are fortunate to be able to cap our service when our beds are full.”

In addition to being allowed to turn down new patients, hospitalists never get boarders on the dedicated unit at Johns Hopkins. “If you are on our unit, you are our patient,” he said. Having a large house staff program helps such restrictions to exist, Dr. Brotman noted, since they can absorb the extra patients.

He also stressed that proper physician-to-patient ratios must be maintained. “We have to get past the expectation that hospitalists will keep taking overflow patients, because it can reach unsafe levels for a single provider, particularly when geographic dispersion is thrown into the mix,” he said. “Larger teams—such as those with housestaff or physician extenders—are better equipped to handle overflows and to cover a geographically dispersed group of patients. Single hospitalists are not.”

Like Johns Hopkins, Cleveland Clinic often is filled to capacity and Dr. Patrick reiterated the importance of not putting incoming patients just anywhere. One mechanism that helps preserve the geographic unit is to hold six beds starting at 5:00 p.m. for patients assigned to that unit’s hospitalist. Also, specialists had to accept that not all of their admissions would go to one floor anymore.

“The institution had to take a risk in giving us preference for the beds on our unit and it didn’t work out well at first, but by making the people in charge of bed assignment accountable, we are finally getting more than 70% of a hospitalist’s patients on one floor and the other 30% divided between two additional floors, not the 14 that they could possibly be on,” he said.

The rotation is shuffled every two weeks, which brings that number closer to 90% of a hospitalist’s patients on one floor. Also, all hospitalist patients are on just four floors, so when a hospitalist has to accept patients who cannot be placed on their unit, they are not spread all over.

“This dramatic improvement was achieved without any statistically significant change in daily census equity amongst the five teams. The dramatic variations in team census that we feared never actually materialized,” he said.

Dealing with isolation

Physician isolation has been the only real problem at Butterworth Hospital, a 500-bed facility, since it started a hospitalist-based unit in July, said Dr. Apple. The program began by assigning one hospitalist to cover about 16 to 20 beds on a specific 33-bed unit for seven days at a time. (The seven-day model eliminates weekend handoffs, resulting in better continuity of care, he explained.)

“Physicians also had concerns that being the only health care provider on the unit would cause them to be interrupted more frequently than usual as ‘easier’ access to them would allow RNs, case workers and families more occasions for inappropriate stoppage of work flow,” he said.

Dr. Apple hopes to address this issue by getting all 33 beds under the hospitalist service and staffing it with two doctors at a time. “We would like to give the hospitalist a partner so that when he or she is swamped and an urgent task arises, there is someone there to help them,” he said. “They are not handling everything on their own.”

He explained that all hospitalists within the Michigan Medical P.C. Hospitalist Division have been involved with the scheduling process and the work flow of the unit.

“This has become a rounding pattern that is owned by the group, not just my pilot. The physicians have taken this new change with an open mind as it was clear to them that we needed a more efficient way to round in order to improve patient satisfaction and build a stronger culture of relationships with nursing and case management staff,” he said.

“Once the scheduler had everyone’s recommendation, we implemented the seven-day week that follows an admitting shift of M-F 2:00 p.m. to 10:00 p.m., with the following Monday becoming the unit-based week. This way everyone can plan which week is their unit-based week.”

The new system has been well-received, even by the most skeptical physicians, he said. “Once their turn has come up, most of them enjoy it and even offer ideas on ways to make it work even better,” Dr. Apple said.

One such idea that has been implemented: adding photocopiers and printers to the hospitalists’ “bullpen” area so they don’t have to walk back and forth four times just to discharge a patient. The idea was so popular that several other units in the hospital have adopted it, too.

Pilot plans are under way to use geographic rounding in other areas of Butterworth Hospital, such as the ICU step-down unit.

Failed experiment

Staten Island University Hospital in New York City had a very different experience with geographic rounding. After implementing it three years ago, its hospitalists scrapped the plan after about 18 months. Aaron L. Gottesman, FACP, director of hospitalist services, calls it “an unfortunate experiment that failed miserably” for reasons that he describes as specific to his facility.

“Keeping the work load balanced meant more than one doctor saw patients on each floor. This lopsided distribution meant that as each week went on, hospitalists had to be moved to other floors to keep their load even,” he said.

Also, he said the system seemed to lead to hospitalists receiving less respect. “We got treated as everything from the intern to the attending and were expected to take care of all problems on the unit,” he explained.

Hospitalist satisfaction was further hurt as some nurses would wait until the housestaff was in conference and bring their problems to the hospitalist. Resident education was disrupted as well. “The usual line of teaching was not being followed. PGY2s forgot what their role was,” said Dr. Gottesman.

His associate director, Mona Patel, DO, added that she and her colleagues missed the variety of patients seen on a typical day when the hospitalist is not limited to a particular unit. She also said that Staten Island University Hospital is not as spread out as some facilities and her colleagues tend to cherish the time spent traveling between units as a chance to ponder and decompress.

During their short foray into the geographic model, “vigorous” arguments about it were held monthly. “It was the single largest source of dissatisfaction and aggravation for our staff,” Dr. Gottesman said.

His advice to others hoping for a more successful outcome? “Think this through carefully for all stakeholders and make sure everyone’s roles are well-defined.”

Beth Thomas Hertz is a freelance writer based in Copley, Ohio.

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Tips to make geographic rounding work

Get support from the highest levels of the institution and full buy-in from top administrators before proceeding.

Set limits. Don’t accept an unlimited number of patients. Don’t do the work that interns should be doing. Don’t let boarders take up beds in the dedicated unit.

Partner with nurses. They want this to work even more than you do, so listen to their concerns and work together to develop guidelines that help the unit function optimally.

Commit to change. If change is a priority for everyone it is more likely to work.

Avoid wasted beds at all costs.

Facilitate multidisciplinary rounding to produce greater staff satisfaction and better patient care.

Do a cost-benefit analysis. In smaller facilities where patients are only located on a few floors anyway, the institutional changes required to make this work might exceed the benefit.

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