Implementation

It takes a team

It takes a team

1.    Appropriately allotting time to each activity

Mondays, Wednesdays and Fridays (Team resident morning report)

  • 6:30-7am – Interns see potential discharges then go to IMC
  • 7am – Resident goes to IMC to get debrief from Night Team
  • Before 8am – Residents sees potential discharges
  • 8:45 – Attending sees discharges with interns (the team does not round on these patients during regular work rounds
  • 9:00-11:00 AM rounds starting in IMC, determine at what time each patient will be seen, and prearrange for the caring nurse to be present to discuss the care of each patient. The attending should encourage the presenting student, intern and the team resident to first describe their impressions and plans and follow these presentations with a summary and additional suggestions or modifications.
  • 11:00-11:30 am – Teaching session is encouraged except for days when the team has over 14 cases. A Student succinctly presents a case for discussion. Whenever possible a scientific, peer reviewed paper related to the patient should be distributed to the team by the student presenter. Alternatively the attending and team resident can select 2-3 patients as teaching cases and add 10-15 minutes to the discussion of these cases on walk rounds. The key is to dedicate a minimum of 30 minutes specifically to teaching. If this alternative is chosen walk rounds should start at 9AM
  • 11:30-12:00 –  work done before noon conference. All consults and tests should be ordered. Complete all progress notes .

Tuesdays (intern moring report)

  • Discharge paperwork completed by interns before their morning report, and usually the night before discharge
  • Interns see patients and progress notes completed except for plans before morning report

Thursdays (Grand Rounds 11 AM)

  • Rounds 8:00-10:00 AM, no teaching session.

Newly admitted patients

  • Remember all members of the team need to introduce themselves to the newly admitted patients. Example: “Hello, Ms. Jones I am Dr. Jim Smith, and I am a first year resident on the team. Our team will include our senior physician who is our coach, other residents, your bedside nurse, case manager, and pharmacist as well as several medical students.  We will be arriving at your bedside at a specific time each day. We regard you as our team owner, and we welcome and encourage your questions. We want you to understand your daily management plans and will be discussing your case by your bedside. Do you feel comfortable with this arrangement? We look forward to helping you in any way we can, and to making your stay in the hospital a positive experience. Please do not hesitate to contact any member of the team at any time if you have any questions or concerns. Your bedside nurse is a great resource and will be able to answer many of your questions about our treatment plans.”

2. Know each team member’s roles and reporting responsibilities (See playbooks)

3. Use of Rounds and Admission presentation protocols to maximize efficient communication (See Communication protocols). The attending should be prepared and have read all the admission notes before rounds. With the exception of the 1-2 teaching cases, the presenters should only present the key points in the history, physical and laboratory data and focus primarily on their impressions, plans and disposition issues.

4. Specific scheduling of bedside rounds allows the nurses to participate on rounds (eliminates the requirement to constantly page the interns with questions, allows the team to understand any problem nursing has encountered, and creates a consistent management plan) and for interested family members to be present (family members need to understand your management plans because they will often be responsible for the daily care of the patient upon discharge).

5. During rounds new plans are established and each intern creates a “To do” list. These lists are reviewed by the attending and team resident. If one intern has a disproportionate amount of work the team resident and attending can assist with the work. The work load is shared among team members.
All new orders are entered in the EMR at the beside, and consultants can be notified electronically during rounds (whenever possible consults should be called before noon to assure a timely response). The pharmacist should assist in selecting the best medication and the appropriate dose prior to electronic order entry. 

Typical Rounding Schedule

Census of Active Patients: (12 patients)
8:45-9:00 AM Attending sees patients to be discharged before 10AM

9:00-11:00 AM Bedside Rounds
There are several approaches to completing rounds on time, and allowing the nurses to actively participate on rounds. Each patient can be specifically scheduled or alternatively the start time for each floor and hallway can be determined. This will depend on the attending and resident. Some attendings are highly disciplined, and don’t require very exact timing, while others require more structure to achieve these goals. The schedule is created by the Team resident the afternoon before rounds. The Case Manager relays the schedule to the charge nurse who relays the schedule to the bedside nurses allowing them to arrange their work schedules so that they will be present for bedside work rounds.

11:00-11:30 Teaching session in the room. Students present a case in detail. Emphasis on pathogenesis, clinical manifestations, diagnosis (differential diagnosis whenever possible), and treatment. Alternatively bedside rounds can be extended to 11:30 and 10-15 minutes specifically devoted to teaching at the bedside for 2-3 selected patients.

Example of patient specific scheduling (devote an average of 10 min/patient
Times will vary from patient to patient depending on the complexity and severity of illness; however, assigning 10 minutes per patient will provide a reasonably accurate schedule for the bedside nurses. The schedule serves as a guideline)

1.     9:00-9:10 Bed 9410 IMC case
2.     9:10-9:20
Bed 9430 IMC case
3.     9:20-9:30
Bed 7501
4.     9:30-9:40
Bed 7505-B
5.     9:40-9:50
Bed 6515-A
6.     9:50-10:00
Bed 6423  (go from 23 to 58 not 40 for efficiency)
7.     10:00-10:10
Bed 6458-A
8.     10:10-10:20
Bed 6454-B
9.     10:20-10:30
Bed 6450-A
10.   10:30-10:40
Bed 6448-B
11.   10:40-10:50
Bed 5510-A
12    10:50-11:00
Bed 5540-B
Teaching session 11:00-11:30 AM

Example of floor and hallway scheduling.
1. 9:00
9410 IMC
2. 9:20
Floor 75
3. 9:40 Floor 65
4. 9:50  6423 (left hallway)
5. 10:00 6458-6448 (right hallway)
6. 10:40 5510A
(done 11:00)
Teaching session 11:00-11:30 AM

  • On completion of rounds interns shares their “To Do” lists with the team resident who distributes the work evenly among the team members.
  • Immediately following teaching rounds the attending meets with any patients who have questions or concerns that were not fully addressed on rounds. This conversation should include interested students, interns, and team resident. (VERY IMPORTANT to remember the patients are our customers!).
  • The attending also assists with any administrative impediments including resistant or delayed consultations. It is critical that the attending properly orchestrate the input of all consultants and accurately relays this coordinated plan to the patient and the patient’s family.
  • One intern serves as scribe while the other presents. He or she enters new orders in the EMR at the bedside. When new medications are ordered the pharmacist should provide input with regards to the best medication and appropriate dosing. Consults should be decided during rounds and ordered electronically. Immediately following the teaching session the intern should page all new consultants or call the designated number.  Progress notes should reflect the changes in management decided during rounds, and be completed by noon. The attending then writes his/her note.
  • The attending reviews all new notes by the interns and consultants, and in less stable patients interacts with the nurses, patient, and patient’s family a second time to assure that all plans have been enacted properly (A second check)
  • All notes including the attending notes should be entered by 1 PM, leaving the remainder of the day for problem solving, new admissions, and discharge planning.