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Charge forward with change management

Finding opportunity in a low census

July 2020
hospitalist value during covid

COVID HAS DEMONSTRATED—more than ever—how critical hospitalists are to a hospital’s daily operations. At Missouri Baptist Medical Center in St. Louis, my hospitalist program was used to a starting census of 145 patients, roughly half of all medical/surgical patients in our community hospital. Due to coronavirus, our volumes dropped by half, and we became the sole admitters to our covid/covid rule-out unit.

Key physician leaders did daily doomsday planning. We created a novel staffing model in the event that we exhausted our intensivist or ICU capacity, with hospitalists, anesthesiologists and private internists working in the ICU to support the intensivists. Advanced practice clinicians and primary care physicians were trained to backfill as hospitalists.

Our covid volume peaked April 6, two weeks after St. Louis County issued its stay-at-home order. My hospitalist group decided to use this window of low census to aggressively change how we communicate with the ED and nursing. The operational changes we made improved efficiency without adding costs, and we focused on initiatives that boost our group’s value and influence in the hospital.

Target #1: On-call communication with the ED and nursing.

Though hospitalists have been available in the hospital 24/7 for several years, we continued our after-hours exchange, even though it cost five figures every year and the service was subpar. Three years ago, we purchased a group “on-call” phone that we intended to transition to. But due to competing priorities and time constraints, those plans never materialized.

We used this window of low census to aggressively change how we communicate with the ED and nursing.

Before covid, the ED secretary cycled through a list of hospitalist rounders; with covid, we have one dedicated admitter we call the “HIC,” or hospitalist in charge. That provider takes the cell phone and all ED calls. For admissions, the ED physicians now text the HIC directly rather than go through the secretary, shaving between five and 10 minutes off the time they have to wait for a callback.

Having the call phone has also improved our after-hours communication with nursing. Before coronavirus, nurses called the exchange, which in turn paged the hospitalist. Hospitalists calling back always had to wait for someone at the nursing station to answer or for the nurse to come to the desk.

Now, nurses are encouraged to text. Those texts are more informative than the messages they used to leave through the exchange, allowing the on-call hospitalist to easily prioritize requests. Sometimes, that physician can enter an order through the EHR without having to return the call.

Target #2: Admission orders and ED throughput.

Before coronavirus, the ED physicians entered transition orders and completed medication reconciliation on all hospitalist patients. We knew we had opportunities to improve. We would still, for instance, see IV fluids being ordered for heart failure patients and home meds such as ACE inhibitors continued for patients with acute kidney injury.

Given our drop in admissions, we realized the on-call hospitalist had more capacity to write orders, so we piloted that innovation on all our ED admits. To make those easier, a group of hospitalists developed diagnosis-specific order sets for common diagnoses. We also created an order set for common PRN medicines the night nurses request. These should produce fewer errors and disruptions, and happier hospitalists.

These innovations helped nursing staff and bed management streamline the ED-to-floor process. The on-call hospitalist writes transition orders, and the assigned hospitalist completes the medication reconciliation when the patient arrives on the floor. Bed assignments can now be made faster, and patients are not held captive in the ED until medrec is complete.

Target #3: “Pods” and care rounds.

Covid also changed the way we approach care rounds. 

We couldn’t maintain social distancing with a care team gathered around a table. Instead, we moved care rounds to the nursing station, and the hospitalists—who previously were not involved in these rounds—became critical participants on the covid floor (called the “covid cove”). The hospitalist and nurse discuss a discharge-focused care plan, and non-essential participants are not invited. The charge nurse then disseminates a plan summary to case management, social work and therapy. Most everyone thinks his or her time is now better spent.

We’ve wanted to involve the hospitalists in care rounds for years, and we’ve experimented with participating with varying success. Geography has been our greatest challenge, as bed management was not able to significantly cohort hospitalist patients. Another problem: Nursing assignments weren’t based on the attending physician.

But due to our success on the covid floor, nursing leadership is now making that type of assignment a higher priority. They are considering specialty-driven units and coordinated nursing assignments between nursing and hospitalists.

A nurse would have at most only one or two hospitalist attendings. Each hospitalist would have a “pod” of between 15 to 18 patients, with between four and six nurses covering those patients. Such a model will be more conducive to daily care rounds, which would in turn improve relationships, communication, morale and patient care.

Taking momentum
Most of these projects were going to happen regardless. But given the negative financials associated with low hospital volumes, my hospitalist group saw this as opportunity to lead. We decided to not focus on banking shifts and waiting for volume to come back. Instead, we charged forward, realizing we had some momentum and fewer barriers to overcome.

Hospitalist value goes well beyond what individual physicians bring to patient interactions. We succeed by championing innovations that eliminate waste and reduce costs.

Such a pace may not be the best approach to change management, but the timing may be right for you to be bullish as well. With financial realities now a challenge for administrators, we can improve our hospitals’ bottom line and outcomes and highlight hospitalist value.

Matt Reuter, MDMatt Reuter, MD, is medical director of Missouri Baptist Medical Center Hospitalist Services in St. Louis.

Published in the July 2020 issue of Today’s Hospitalist
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Elizabeth Dunbar, MD
Elizabeth Dunbar, MD
July 2020 8:23 am

So is the idea here that the hospitalists are discovering that ED throughput is improved when the hospitalists do their own work versus waiting for the ED docs to do it for them? Not to undermine too much but is this article from 2005? Are diagnosis specific order sets novel?

Frank Farkash, Twitter
Frank Farkash, Twitter
July 2020 8:25 am

Exactly! Dx specific order sets have been around since the days of paper and a pen…

Manny Kohli, Twitter
Manny Kohli, Twitter
July 2020 7:53 am

The community hospitals [where] I’m at, ED docs have not put in ANY orders for admitted patients since I started practice about 20 years ago. Always up to attending physician. Nowadays they won’t even put in an admit to “inpatient” or “observation” order.

Matt Reuter
Matt Reuter
July 2020 4:29 pm

Writing orders using order sets is just an example. Not all programs or systems have the same maturity or resources of other programs, and I recognize my hospital is not at the early adopter end of the spectrum on this one.

Culture change is hard to move regardless of the intervention. The point is that COVID has eliminated many barriers to help innovate patient care and increase the Hospitalist influence within a hospital or system.