Interruptions are a part of any busy inpatient service. Interrupters need to be prioritized, and a system needs to be in place for handling them with any good time management plan. Code Blue response, emergency patient need, and new patients on the floor rank high in priority for interrupters. Phone interruptions and nursing questions are ranked based on urgency and patient impact. One of the best ways to avoid too many phone interruptions is to have a coordinator or secretary assist with filtering incoming calls. This person will have specific instructions on how calls are to be handled. Emergency calls and incoming calls from physicians are given priority. A call from a drug representative or friend can be postponed.
A good rule to have when seeing new patients on the floor is to visualize each new patient coming onto the service. ER physicians visualize each patient coming into the ED arena. By direct visualization of incoming patients, ER physicians determine what their level of involvement will be. A patient who appears ill will get a quicker evaluation than a patient who appears stable. Principles that underlie patient triage include meeting the patient and identifying oneself as the responsible physician, visualization of the patient even while interviewing others, and communication and delegation of work.
Talking to an ED physician about a patient or to a PCP at an outreach facility is helpful, but the direct visualization of the patient by the hospitalist when he or she arrives on the ward is key to managing floor time. This method allows for patients to be prioritized based on acuity. Direct visualization can also be performed before resident contact is initiated. A quick look at the patient and his or her vitals provides reassurance that nothing immediate needs to be performed. A brief hospitalist introduction gives comfort to the patient and family. Patients are impressed when you meet them in their room when they arrive.
Critical patients require more attention, and care can be started with a primary survey. Trauma services have modes of triage care and initial evaluations of trauma patients that can be modified by hospitalists.
The objectives of initial trauma care include 1) stabilization, 2) identification of life-threatening injuries and initiation of adequate supportive therapy, and 3) efficient and rapid organization of either definitive therapy or transfer to a facility that provides definite therapy. Within this set of objectives is a triage objective to prioritize patients with a high likelihood of early deterioration.
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Figure 3. Abbreviated Time Log
Direct hospitalist visualization of every patient coming onto the service accomplishes the objectives of initial care and triage. Of course, the hospitalist isn’t prioritizing a gunshot wound patient, but the principles are the same: visualizing the patient, determining a level of involvement, and initiating a primary survey for critical patients. This approach to patients can be adopted in the hospitalist patient-care repertoire.
As an example, I was asked to consult on a patient with a subarachnoid bleed to manage hypertension. The patient was already admitted into the ICU by the neurosurgeon. Subarachnoid bleed and hypertension are 2 urgent needs, and this was a new patient on my service. I went to visualize the patient. I finished my brief survey and was writing down some orders when the nurse came over to me and told me the patient was not responding to her the way he had earlier. The patient’s admitting blood pressure was 180/100 and when the nurse reported the change to me, the blood pressure was 230/106. The patient was obtunded and unable to protect his airway. In addition to intubating the patient and hyperventilating him, I contacted the neurosurgeon to notify him of the change in status, started intravenous mannitol, established large bore venous access, and started nitroprusside. The surgeon returned to the ICU and took the patient for corrective surgery.