Published in the May 2012 issue of Today’s Hospitalist
SEVERAL YEARS AGO, the hospitalists at ThedaCare “an integrated health system in Wisconsin with two main hospital campuses “started looking for a better way to deliver care.
“Our traditional way of rounding was dysfunctional,” says James McGovern, MD, the hospitalist group’s lead physician. Every department, from the physicians to the nutritionists, had a different care plan for each patient. “My plan was in my head,” Dr. McGovern recalls, “and nurses would find out that a patient was being discharged when they walked into the room and the patient was dressed.”
The fix was an ambitious, 18-month effort to redesign how clinicians at both centers work together. The result was what’s known as the “Collaborative Care” model.
First piloted in 2007, the model consists of a suite of innovations that includes daily rounding with team members, a unified care plan for each patient on the system’s EMR and even unit redesigns to stock nursing supplies next to each patient room. Backed by ThedaCare executives and a $1 million investment, the collaborative care model has grown from one unit with 14 beds to half of the units on both campuses, with more on the way.
But the starting point of the entire model is an admission process in which a nurse and pharmacist accompany a hospitalist for each admission.
“The entire process has multiple pieces and should be taken as a whole,” explains Norma Turk, MD, ThedaCare’s associate medical director. “But the most crucial thing we did was to partner the doctor and nurse and have the nurse there when the patient is admitted.”
Now, Dr. Turk adds, “nurses go over the exam findings, hear the whole history, and hear what the doctor explains to the patient and family. That’s probably the one piece that is the most important.”
Admissions within 90 minutes
The team admissions, which take place 24/7, are also on a clock, Dr. McGovern points out: The admitting team visits the patient on the floor and has a care plan in place within 90 minutes. Neither hospital has a dedicated hospitalist admitter; instead, the three daytime hospitalists take turns doing admissions. (The hospitalist program as 15 physicians and six midlevels.)
To make that work, the doctors rely on alphanumeric pages that warn them when a patient is coming up from the ED or is expected from an outpatient office.
“We then have a phone number the doctor calls to say, ‘Hey, I can be there in 15 minutes’ or ‘I won’t be there for 45 minutes,’ so the rest of the team can prepare,” Dr. McGovern says. With most admissions coming later in the afternoon, the hospitalists also know to try to finish their rounds by 2 p.m. to be ready for the onslaught.
Meanwhile, the nurses “ping-pong the admissions as well,” he adds. “If the floor nurse is tied up, we have a resource nurse for each unit that’s the go-to person. The resource nurse can take the admission, then sign out to the floor nurse who will be rounding on that patient.”
An admission trio
Why have this “admission trio”? For one, says Dr. Turk, the hospitalists recognized that “medicine has to be a team sport and not just physician-driven.” She says the reality is that doctors aren’t present for 99% of a patient’s hospital stay.
“It’s the nurses who are captains of the ship,” she says, “and they weren’t being endowed with the knowledge or information to really drive care in the doctor’s absence.”
Now, Dr. Turk notes, the trio makes sure that all the patient’s orders have been entered, as has “one single, unified plan of care driven off the physician-generated problem list. That’s on the computer so everyone can see what the primary issues are and how those need to be addressed.”
Taking a team approach to admissions brought the doctors some immediate wins. They no longer get calls from nurses who don’t know how to prioritize tests that have been ordered or from pharmacists who announce, six hours after an admission, that a particular antibiotic is out of stock.
“Delays in care have been reduced substantially,” says Dr. Turk.
Nurses’ critical thinking
That team model is carried through the entire hospital stay, Dr. McGovern points out, with hospitalists now rounding with nurses, pharmacists and care managers.
“Physicians are thinking out loud a lot more while rounding with the team, which is new,” says Dr. McGovern. “The biggest advantage for me is that I now have a team
that knows what I’m thinking.” Pharmacists immediately intervene, he says, if he orders a contraindicated drug. Nurses now know after rounds that a patient who can ambulate around the unit can be discharged that afternoon.
And getting bedside nurses up to speed much more quickly at admission allows those nurses to take a more prominent role in directing patient care. The hospitals have adopted the Lean concept of “tollgates,” which Dr. Turk explains as “regularly scheduled times when bedside nurses look at what we are doing for the patient’s care plan and make sure that everything that’s supposed to happen is happening.” When an item hasn’t occurred ” such as a scheduled CT scan “the nurses are charged with investigating the root cause.
As a result, RNs “have been elevated to much more critical thinking,” says Dr. McGovern, a process that’s “probably a six-month adjustment for them” when the model is rolled out in a new unit. To give them time for that critical thinking, bedside nurses have been relieved of many day-to-day tasks, including bathing patients and changing dressings. Those tasks are now done by LPNs.
Those changes, Dr. McGovern says, enable nurses “to practice to the maximum of what their license allows. The level of nurses’ skills and clinical thinking improved noticeably, and nurses now feel that doctors are more approachable.”
The collaborative care model has encountered some bumps in the road. Like other institutions, the ThedaCare hospitals find it hard to schedule daily multidisciplinary rounds.
While an admission trio pulls a nurse away for only a short time, Dr. McGovern explains, “rounding requires you to free up the nurse for a couple of hours. “When one nurse needs to round with two physicians, Dr. Turk adds, “collisions occur.” In such situations, other team members know to prioritize patients in terms of who is the sickest or which issues are the most acute.
As for the hospitalists, says Dr. Turk, “doctors have to give up some primacy and responsibility” in exchange for “a much more cohesive plan of care.” While a few hospitalists initially were skeptical about the project, Dr. McGovern notes that most have been won over, and that the model is now an integral part of their practice.
“When we’re hiring, recruits see collaborative care,” he says. “We tell them, ‘This is the way we do things. If you can’t function as part of a team, this probably won’t be a good fit for you.'”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.