Published in the March 2013 issue of Today’s Hospitalist
“If I’d known he was that sick, I could have had him in the OR by noon.”
“The patient was approved for rehab Friday, but she had to wait for insurance company approval and got a hospital-acquired infection … ”
“That procedure is available only on weekdays.”
“Why wasn’t there anything on the rounding list about that CT result?”
WE CAN’T DO MUCH to control either our consultants or the radiology department, but hospitalists can influence weekend and holiday care for the better. Most of us already have a list of tricks for speeding up discharges, shortening length of stay and improving our call schedule. But there are also ways to avoid the worst of those dreaded weekends.
Slogging through the list?
When you’re the weekend hospitalist, it’s tempting just to start at one end of the hospital and work down to the other, or to finish at one facility before even thinking about the other one. But this can lead to delays in recognizing emergencies, especially if the ED or last night’s covering doctor failed to pass on key findings or complaints.
Resist the temptation to dive in and instead sit down to look over your list. Pay attention to the patients you don’t know, and check lab and X-ray reports. Now decide who should be seen first, such as people who left the ICU yesterday and those who may have new findings or labs requiring immediate attention.
Keep in mind that patients still in the ICU generally have ICU consultants, and you know that ICU nurses keep a closer eye on their patients than do nurses on the floor. So leave those patients for later in the day. And if the night doctor’s notes point out the need for a new consult or further testing, don’t save those requests for when you get to the bedside. Consultants are both happier and more effective if they know about the patient before noon.
Try to set a policy in your group of making weekend discharges easy, with prescriptions and med lists already on the chart and discharge summaries dictated a day early, whenever possible. While some groups insist on oral signouts, a written list (kept in your office or sent via HIPAA-compliant e-mail) with warnings and results to be checked will help you decide who needs to be seen early and who can wait.
My own list generally has “KCOW” next to a few names, meaning “Keep comfortable over weekend.” Those can usually be the last patients I see that day.
“But the consultant said …”
Subspecialists who work with you regularly know that you’re trying to reduce length of stay, and you can train them to write discharge criteria a day or two early. On weekends, though, even these doctors will probably see your patients later than usual. Even worse, they might be replaced by a total stranger.
Here are a few simple rules:
- Call new consults early in the day.
- Dr. Cardio may be visiting three different hospitals, and an early call helps him avoid having to backtrack.
- Use the telephone.
Even if a consultant is being covered by somebody who has no privileges where you work (yeah, it happens), a short conversation can allow you to start tests and/or treatments a few hours earlier. And if you need an X-ray or echocardiogram checked, this can probably be done remotely.
- Instead of “Discharge if OK with Dr. Consultant,” write “Discharge and notify Dr. Consultant.”
The specialist can call you up to prevent a premature discharge, but 95% of the time, he or she will go along with your plan.
Getting the hospital to help
If you’ve been a hospitalist for more than a month, you know that discharges move more slowly and length of stay bumps up on weekends.
Why not start a list of avoidable days and the reason for them? A hospital administrator who understands that staffing a half day of CT angiograms on Saturday and Sunday can improve revenues will be motivated to offer techs incentives to come in. And administrators who remember your help will be much more amenable the next time your group needs a favor.
If a test or procedure simply cannot be done when the patient needs it, you may have to transfer the patient to another facility. Start the phone calls and sign the paperwork, but be sure to notify the administrator on call of the problem.
If you are transferring an insured patient, odds are the hospital will lose money. Even if the people in charge don’t hear about it until Monday, they may be motivated to make changes.
“It’ll be over in a couple of days”
Yes, that tiresome weekend or holiday will eventually end for you. But the problems that made it frustrating will still be there next time, so take steps now to address them. You may not be able to secure a Sunday stress test for your patient this weekend, but if the nuclear cardiology department gets enough incentives, it may be more obliging for the next few chest pain patients.
Hospitalists are increasingly recognized for our ability to offer solutions to problems, and this is one that affects everybody in our hospitals. Some creative thinking and teamwork can make those holiday and weekend rounds not only easier for us, but safer for our patients.
Stella Fitzgibbons, MD, has been a hospitalist since 2002 and estimates that she has worked at least 300 weekends in that time. She gets tired thinking about it.