Continuity rules

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at [email protected].