Treating 1 patient at a time


Where: Virginia Mason Medical Center, a 330-bed teaching hospital in Seattle.

The issue: Increasing intern efficiency to make hospital beds available and reduce resident duty hour violations.

Background

About 30% of the patients who are seen in the emergency department at Virginia Mason require admission, and many of them arrive in the middle of the day. Before 2012, often those new arrivals would be waiting for hospital beds while the medicine service was still working to discharge the patients leaving that day.

“A lot of people would be waiting around on stretchers in the ED waiting for a bed, [or] waiting to come out of the OR or the [post-anesthesia care unit] to get a room,” said hospitalist Daniel Hanson, MD, ACP Member, during a session at Hospital Medicine 2015. “We knew that we were having a hard time getting our discharge orders in, in a timely way.”

Residents were also having trouble meeting the requirement to take 10 hours off between shifts, because it took them a long time to finish their work for the day. “It takes them about to rotation 5 or 6 before they get efficient enough where they stop having these violations of the 10-hour rule,” said Dr. Hanson. “We are scrutinized by the [residency review committee].”

The hospital tried solutions to speed discharges, including moving morning report from 7:30 a.m. to noon and prioritizing visits with patients who were expected to be discharged that day. “But it still wasn't enough,” said Dr. Hanson. “We wanted to redesign rounds. This was an intern workflow problem. How do we gain efficiencies for them so that their workday goes better?”

How it works

The hospital's academic service is typically staffed with a hospitalist, a senior resident, and 2 interns. Under the old system, the whole group would round together. The process would start with interns pre-rounding. “They'd sit down at the computer and look everything up. They would write on paper all the vital signs and labs … They would go see all their patients. Then they would staff all their patients with the attending and the senior resident, and then after all that was done, they'd go and do their notes and their consults and their orders,” described Dr. Hanson.

This “batching” system of work felt efficient to the interns, but it meant that if the first patient seen needed an order entered, for physical therapy or discharge, for example, it probably wouldn't be completed until after all the patients were seen.

The service tried a new system, in which each intern would complete all the work for 1 patient before moving on to the next.

“[The interns] pull up a computer in the hallway outside the room, [then] go see the patient. When they're done seeing that patient and coming up with a plan, then they come out in the hallway and they staff that patient with the attending and the senior resident. The senior resident and attending move on, and while [the intern is] still at the same computer, they finish their notes, finish their orders, and then they're allowed to go to the next patient,” explained Dr. Hanson.

The intern entered orders sooner, and the senior resident and attending efficiently alternated between interns. “There wasn't an intern standing next to us listening to another intern talk about a patient they didn't know and didn't have a lot of insight on,” Dr. Hanson said.

Results

“We started getting good success rates with getting the discharge orders in way earlier,” said Dr. Hanson. The percentage of discharge orders entered by 9 a.m. increased from 16% in August 2011 to 41% in July 2012, and the percentage entered by 10 a.m. went from 31% in September 2011 to 50% in June 2012.

At the same time, violations of the 10-hour break rule also went down by 50%. “The interns were no longer taking 5 rotations to become efficient enough to stop having duty-hour violations,” said Dr. Hanson.

Challenges

It was a challenge, at first, for interns to feel comfortable not becoming familiar with all of their patients first thing in the day, according to Dr. Hanson. However, he said, “They quickly learn that nurses will call with concerns and hold pages until the team comes to round.” Rounds may also go later into the afternoon. “But there is much less rework and when they are done, they are completely done,” said Dr. Hanson.

Next steps

The new system was so effective that program leaders decided to expand it to the nonacademic float teams. They hired medical assistants (MAs) to set up patients for hospitalists the same way the interns did for their attendings.

“An MA goes in and greets the patient, sets up the work for the hospitalist, sets up their note,” said Dr. Hanson. The hospitalist then hands over his or her pager and phone to the MA and goes in to see the patient. “When the physician comes out after talking to the patient, [the MAs] finish their orders, they may page consultants, they say, ‘Hey, these are the pages you got while you were in the room,’ and then they move on to the next patient,” Dr. Hanson explained.

Soon the float teams were matching the success of the academic team in discharging patients first thing in the morning.