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Hospitalist Playbook (player coach)

Basketball Coach Mike White

You are the player coach – you write the orders and also coach the nurses by explaining the daily management plan of the day

To assure the coordination of care you should try to maintain a reliable and predictable schedule.

REMEMBER THESE ARE GUIDELINES AND CAN AND WILL BE IMPROVED OVER TIME. (We will continue Friday Huddles with nurses and physicians to review what went well and what could be improved. And based on this feedback the guidelines will be adjusted. The nurses and physicians are creating these guidelines and this website is serving to document your plans.)

  • This will allow the nurses to round with you at the appropriate time.
  • The schedule is a guideline and when unforeseen events occur the schedule will need to be altered.
  • The 5 hospitalist on the team can modify the schedule to improve their workflow at anytime, but it will be important for everyone to try to follow the same schedule to assure predictability. 
  • From 7AM-9AM 
    • For each patient you the most recent:
      • Nursing and consultant notes
      • Laboratory data
      • Images
      • Vital signs, daily weight, and Rothman Index
    • See you newly admitted patients. Review:
      • Admission notes
      • The history and physical examine and personally verify
      • The laboratory data and imaging
      • Create a plan for the day and explain this plan to the patient
    • See patients to be discharged
      • Notify the case manager and bedside nurse of the imminent discharge
      • When possible prepare the discharge summary and pend the discharge orders the night before.
      • Reconcile medications
      • Write the discharge orders before 9AM
    • From 9-9:15 AM
      • Meet at the nursing station with the case manager, charge nurse and/or clinical leader and discharge technician
      • Discuss the equipment and post hospital needs of each patient
      • Plan discharges for the subsequent day
      • Anticipate the discharge needs of all your patients beginning on Day #1 of hospitalization
    • From 9:15-10:15 AM
      • Bedside huddles around the beds of all established patients. The team members should include
        • The patient (and when available the family)
        • The charge nurse (when the nurse is not available can also serve to find each bedside nurse),
        • Bedside nurse
        • When possible the case manager and pharmacist.
      • Coordinate your rounding with the other hospitalists to assure you are rounding on a different hallway (eliminate scheduling conflicts for individual bedside nurses)
      • On average devote 5 minutes per patient  (because you have a schedule to guiding your use of time if a patient or family member has too many concerns and requires additional time you can the tell the patient you are scheduled to see other patients, and inform them you will return upon completion of your bedside rounds (approximately 11 AM).
        • Ask the patient and nurse about overnight events (use SBAR, see communication protocols under implementation)
        • Discuss the plan for the day
        • Review with bedside nurse TEMP
          • T – tubes IV lines, bladder catheter (are they needed, should they be changed
          • – Eating, exercise (activity, bed to chair, ambulating with assistance, need for PT), sleep and bowel movements
          • M – monitoring frequency  Vital signs Q4H or Q8H, when possible avoid during sleeping hours. Do the patient need telemetry? Does she require daily blood drawing?
          • P – Is the patients pain controlled? And finally does the patient understand the plan for the day? (teach bac)
      • When possible write all orders at the bedside (avoid order batching)
      • Try to round using the same path each day to provide predictability for the bedside nurses.
      • At the end of rounds ask the charge nurse “What went well? and What could be improved?
    • From 10:15 AM -3:00 PM
      • Write progress notes
      • Order consults before Noon.
      • Problem solve and interact with patients and their families, nurses and consultants as required to enhance communication and to monitor the progress of patients whose condition is changing (watch for changes in the Rothman Index).
    • From 3:00- 3:15PM
      • Meet at the nursing station with the case manager and charge nurse to review discharges for the following day this will allow the charge nurse to predict bed availability for the following morning.
        (the charge nurse on each floor will text or page you to remind you)
      • Review other social and medical needs for all other patients to anticipate outpatient needs
      • Pharmacist will join the rounds and identify low health literacy patients who are going to be discharged the next AM and provide patient education on their medications.
    • From 3:15-End of the Day
      • Prepare discharge summaries and patient instructions for the next day’s discharges, pend discharge orders
      • Continue problem solving and interacting with nurses, consultants, patients and families
      • Clean up any miscellaneous tasks