Where: St. John's Mercy Medical Center, St. Louis, Mo.
The issue: Reducing the time required to identify the hospitalist on call for a particular patient.
In 2007, hospitalists at St. John's Mercy Medical Center were becoming increasingly concerned by the lack of a quick, reliable method of identifying the hospitalist attending for individual patients. The group has grown from six to 32.3 full-time-equivalent physicians since 1996 and now admits patients for more than 150 physicians.
“It used to be that one hospitalist's entire day was spent triaging phone calls,” said Brian Miller, ACP Member, division chief of general internal medicine. “We were constantly getting calls from nursing staff and consultants who were trying to find the doctor on call or, frequently, calling the wrong doctor. It was taking 35 minutes to an hour to get a callback from the correct doctor, and that caused a delay in patient care.”
The group needed a universally accepted electronic signout process consistent with The Joint Commission's National Patient Safety Goal 2E (“Managing ‘hand-off’ communication”) that would clearly identify the attending physician, Dr. Miller said. “We all had a different way of doing signout, and most of it was handwritten. So I and another physician in our group sat down with a representative from information technology (IT) to design an electronic system. I have some experience and background in general Web development, so I emailed back and forth with IT and spent nights and weekends for about a year putting the system together, trying things, discussing it with our group, and seeing what worked and what didn't.”
How it works
When a patient is admitted to a Mercy Hospitalist unit, usually through the emergency department (ED), the ED physician places a call to the on-call hospitalist. The hospitalist then logs on to the Mercy Hospitalists Web site, copies demographic information about the patient from the electronic medical record (EMR), and writes the admitting diagnosis, orders and other information in a free text field. Then the patient is either assigned to a hospitalist or designated as “admitted but not yet assigned.”
“That way, anyone who logs into the system can immediately see who's in the queue of patients needing to be seen, and in what order,” said Dr. Miller. “The physician who sees the patient will log into the system again and can pull up an online order set. If necessary, they can alter the signout information—maybe the initial diagnosis wasn't correct—and then designate the attending of record.” When a hospitalist goes off service, a designated individual (usually the night call physician) reassigns his or her patients to the incoming physician, and the name of the new attending physician appears instantly as part of each patient's entry to everyone involved in the care of that patient. Typically, 250 or more patients are in the system at any given time.
In addition to listing the hospitalists' phone and pager numbers, the Web site also features a paging system that allows nurses and consulting physicians to send text pages directly from the site. “Now they can access the system, text us and say, ‘This is Nurse Rogers, I'm calling about Patient Smith's blood sugar,’” Dr. Miller said. “So when I call back I know whom to speak to and whom she was calling about, plus I've already looked up the patient's glucose trends and formulated a plan of action.”
Other key features of the Web site include clinical guidelines, group policies and procedures, a “glitch book” for reporting problems with the site, meeting minutes, educational videos and internal group announcements. Hospitalists must view a page with group-related internal announcements before they can access a patient's signout information.
“Our system does not interface in any way with our hospital's electronic medical record systems,” said Dr. Miller. “Thus, some data such as patient name and date of birth have to be manually entered.”
Another challenge was getting everybody to agree on what should be included. “People didn't understand the technical obstacles we faced. Also, once the other groups realized what we had, they kept asking us to develop similar systems for their changeover and informational resources. And they were surprised to know that our IT department does not provide ongoing updates and support for this Web site,” Dr. Miller said.
“There was a little bit of pushback when we first started the system. Before, everyone was printing the EMR's patient record and writing signout information in the margins. Our nurse practitioners were at first hesitant about spending the time to manually enter demographic data into the system,” said Sally Petito, FACP, medical director of Mercy Hospitalists. “But once they learned how to use it, they realized that the system actually saved them time because they no longer had to field calls in search of the attending physician.”
Although the system was not designed to gather data and measure impact on patient care, Dr. Miller said heavy use of the Web site attests to its effectiveness. “We get about 17,000 hits to the Web site each month, and the signout component is accessed more than 200 times a day,” he said. Dr. Petito said the Web site is frequently praised by the nursing staff and contributes to nurse retention, according to the chief nursing executive.
“There can be a lot of resistance when people are used to doing things the old way, but if you can get buy-in from a couple of doctors, the nursing staff and the administration, the system will quickly demonstrate its value,” said Dr. Miller.
How patients benefit
“I know we're providing better patient care if nurses and consulting physicians can reach us within five minutes rather than half an hour to communicate urgent information,” Dr. Miller said.
“We're getting a new EMR system at the hospital very soon, and we're not sure how that will work with our current signout system,” said Dr. Miller. “If the new EMR system can do signout better, that's great. I think we'll still use the Web site as a resource for all the other information we need on a daily basis.”
Words of wisdom
“Dr. Petito told me at the outset that new processes like this will never be perfect, so don't wait to make it perfect before you implement it, especially if it helps in the care of the patient,” Dr. Miller said. “Just go for it.”