Hospitalist Workflow and Priorities

Overview

The inpatient/ward rotation can be extremely busy and organizational skills and multi-tasking are essential. It is best to begin rounds on the inpatients as early as possible as the health aide calls can begin to get heavy starting at 10am. You may have between 15 and 40 RMT consults-some routine, some urgent and some requiring long distance management/stabilization with initiation of transport (that may involve multiple call-backs) as well as a lot of other unexpected emergences, deliveries (FM), newborn resuscitation (peds), consults (peds) and other urgent demands (such as the rare “code blue”).

Rounds should begin with any potential discharges unless there is an unstable or concerning patient. All discharges will need to have discharge orders and discharge meds written (ideally) before noon and early enough for pharmacy to have time to fill the meds and for travel home to be arranged for the patient. Begin discharges as EARLY as possible so travel can be arranged or the room may potentially be available for a pending admission.

Often we are short nurses and patient beds are in short supply. We will sometimes treat patients on an outpatient bases that in the lower forty-eight would be treated as an inpatient. As an example, a patient with pneumonia is usually not admitted unless they require oxygen or require IV fluids, or occasionally, for social reasons i.e. care taker exhaustion or inability to care for the patient. Pneumonia patients that require IV antibiotics may receive IV ceftriaxone daily through one of our clinics or the ER.

If you are unsure if a particular patient can be treated as an outpatient or needs to be admitted, use resources in guidelines (example: Pneumonia Severity Index) and/or consult a more experienced YK physician. If there are no beds and a patient requires admission, the patient will need to be transferred to ANMC.

Getting the Day Set and Organized

• Get Sign Out from Night Float Doctor
• Meet with Nurses and RT to check on patients
• Let Charge Nurses know of any discharges
• Prioritize Patient Work Load
  • Take care of sickest patients or stage 2 labor patients that need attention/delivery
  • Get Discharges Completed before noon (as able)
  • Round on stable patients
  • New admissions
  • Finish rounding as early in the am as possible to leave time for RMT, consults (peds), emergencies, OB (FM), follow-ups, etc.

Hospitalist Pediatrician Night Float Order of Priorities

General Prioritization of Duties from 9/17/20 hospitalist meeting and follow up email discussion

1. Any unstable pediatric patients in villages, RMT, NW, ER, nursery, etc. including going on medevacs for possible preterm delivery
2. Chronic peds patients RMT
3. CPP admissions and non-CPP admissions if requested and able. Admission orders placed within 30 minutes of accepting patient admission.
4. North Wing pediatric service patients
   1. Rounding
   2. Assessments of patients
   3. Counseling of parents
   4. Support of nurses caring for these patients
5. Assist hospitalist and ER providers with:
   1. Consults
   2. Non-CPP RMT as requested by hospitalist
   3. Admission H&Ps on newborns as requested by hospitalist
6. Routine patients in the ER if needed after addressing other pediatric priorities
7. Dental Pre-ops
8. Chronic Care Case Management

Admissions

Admissions come from the outpatient clinics or the Emergency Room (and rarely from ANMC or an SRC). The provider seeing the patient in the ER or clinic contacts the inpatient physician to obtain accepting pediatric or FM physician and to discuss the workup, diagnoses, and plan for the patient’s admission. After the hospitalist physician accepts a patient, a pre-admit fin is created for the patient’s admission by registration. At that point, North Wing admit orders can be written.An admitting diagnosis is required before the patient can be transferred to NW. It is important that all documentation be created using that North Wing FIN, otherwise the billing and coding department can’t bill for our services.

The pediatrician admits all Chronic Pediatric Patients (CPP), patients they have been consulted on and agree to accept and sicker pediatric patients per family medicine request. Both services will help each other out as needed and able. The pediatricians do not admit BH/Title 47 pediatric/teen patients.

Admission Process

Admitting orders: Orders must be written (and accompanied by at least one admission diagnosis) before a patient can come to the floor. Orders can be written before or after going to see the patient in the ER or clinic.

Medication reconciliation: this process (w/ Order Reconciliation) must be completed following Nursing Initiation of orders to activate appropriate regular medications. The reconciliation process helps sort out any conflicting medication orders.

H&Ps : All admission H&P’s should be completed as early as possible after a patient arrives on the floor and must be signed and in the electronic chart within 24 hours of admission. You can use a Raven general admission note, create one of your own or use a shared pre-completed admission note. Ex: There is a shared admission note by McClure that has a prompt for the free text HPI and A/P and imports the last 24 hours of labs and limited summary vital data. If you choose to use a shared note, please save it as a new note with your new title. This keeps the shared notes from being changed.

E&M Charges: An appropriate level EM Order/Charge must be placed for every admission. These charges can be ordered in the power order section at the bottom of the Admission Orders or can be added to phase as a separate order.

Update Diagnoses and Problem List: All admissions must have at least one diagnosis. This is also a good time to review and update the Diagnoses and Problems after reviewing the patient’s history and EMR.

Immunizations and PPD Status: Please have NW clerk or nurse check Vac Trak (state immunization site) for all new admissions and propose any needed vaccines prior to discharge. For infants and children it is a good idea to give the immunizations at least a day prior to discharge so there will be no concerns about a fever after discharge.

PPDs that have not been done in the past 6 months can be repeated on admission. TB is a problem in the region and good surveillance is encouraged, especially for any patients admitted with respiratory illnesses.

Adult Admissions

There are a wide range of Adult Patients which often also include adolescents. As mentioned above (see Inpatient Unit), adult admissions must be stable and not require a large amount of resources to manage them.

At least one family member or escort can usually be accommodated with the patient. If the patient is breastfeeding, her infant can also usually be accommodated if there is a 3rd person present specifically to care for the infant.

If patients do not improve or if they worsen despite appropriate evaluation and treatment available at YLLHC, consult ANMC and transfer to a higher level of care as appropriate.

Pediatric Admissions

On the inpatient unit we are able to admit moderately sick pediatric patients, but if a patient is expected to need nebs q 2 hrs for more than 8 hours or require too much nursing care, the patient will need to be transferred to Anchorage directly from the ER. Any pediatric patient being admitted from the ER or the clinics must have a YKHC modified PEWS score calculated and reviewed per protocol. ER nurses can calculate a score in the ER and the NW nurses can calculate a score on clinic patients with information from the clinic nurses. Patients with a YKHC PEWS scores of greater than 5 require ER and Inpatient nurses, providers and RT (if indicated) to huddle a access whether the patient is stable enough for YKHC admission or whether they should be medevaced to a higher level of care.

In general, vital signs on the unit are done every four hours. Diapers can be weighed for strict I’s & O’s if necessary. The nurses are able to place IV’s and draw blood. Parents typically room in with their children; however, siblings under the age of fifteen are not allowed on the ward overnight. Children who require high flow O2, continuous IV drips, central lines, close monitoring, imaging or evaluation not available at YKHC or who require NICU or PICU level care are transported to ANMC or Providence Hospital in Anchorage. Occasionally we will admit a patient that is pretty sick, but is felt to have a good chance of improving. If this is not happening in the expected length of time, the nursing or RT staff is uncomfortable with the patient or if you feel the patient is getting worse—do not hesitate to transfer the patient to Anchorage. YKHC PEWS scores should be completed and reviewed on patients who worsen during their admission. This is done to identify, as early as possible, the patients who may need a higher level of care.

Rounding

Progress Note: Every patient must be rounded on daily and have a progress note completed. Daily progress notes must be written in a SOAP note format. There are templates and shared SOAP Note/Progress Notes to choose from and modify if desired.

All pertinent/interval labs should be included in addition to documenting interval history and patient/ parent teaching. It is helpful to have a free text assessment and plan with a clear explanation of the problems and plans for the patient daily. This will help the next provider/cross cover provider if they need a quick snap-shot of the patient and plans.

E&M Charges: An E&M charge order must be placed for each day a patient is seen. If you come on service and charges have not been entered by the proceeding physician, please back enter them for them :)

Hospitalist Documentation

Providers are encouraged to review other provider’s pre-completed notes in their free time and modify/create their own pre-completed notes when time allows.

Freetexting HPI and Plans is encouraged in all provider notes. A freetexted brief description in the HPI of the chief complaint and pertinent history plus a free text A/P with decision making info, plan and needed f/u will make the next provider’s job easier. Providers are also encouraged to use “Other Diagnosis” field to pull the Diagnoses in the note. This will be important for ICD-10.

Discharges

Remember that discharge planning should begin early to anticipate equipment, follow up, travel and other challenges. Interdisciplinary rounds can help with this process. Discharges should be done when the patient is well or stable enough to be supported at home in a village with health aide support. If the weather is bad in the village that a patient is returning to or if you need to monitor the patient closer to the hospital for another day or two, the patient can be discharged to Bethel to stay at the hostel or with family or friends. If needed the patient can be followed daily in the clinic or ER.

That being said, keeping a patient for an additional day or two may ensure the patient return soon to inpatient.

Follow the “discharge summary” process on Raven

(all buttercup-colored items need addressing or open circles filled in the depart process depending on the system you use for your discharges)

• Provide at least one discharge diagnosis
• Complete Discharge Instructions /Education. Raven has a lot or pre-completed education handouts that will be suggested OR you can chose ‘ALL’ patient education and type in what you want to search for. There are about 50 pediatric handouts that have been customized by the pediatricians and can be located by typing in “peds” or choosing education materials that are marked ‘PEDS custom’. There is also a Peds Discharge education handout that is a nice generic summary that is good to add to the pediatric discharges.
• Add follow up instructions with click and pick menu or with free text option.
• Order discharge meds— For chronic medications please give 11 refills
• Complete the medication reconciliation process
• Complete a discharge charge for greater or less than 30 minutes.
• Only order patient discharge when process is complete and you are ready to have the nurse print out discharge paperwork. Otherwise incorrect material may be printed out for the patient, thus confusing the discharge process.

Complete a Discharge Summary: Every patient discharged from the inpatient unit needs a discharge summary. You can use a general Raven discharge summary, create one of your own or use shared pre-completed template. Ex: Paster’s pre-completed note has incorporated all the required elements requested by our Chief of Staff.

In your discharge summary follow up and plan…Be sure to let the follow up providers know what the plan is and what to be concerned about. Make sure the follow up plan and any concerns are clearly documented in your discharge summary. Always let the family know that the patient (usually) is not completely well, but that we feel they have improved enough that we feel that they will continue to slowly get better at home. They should also be warned that there is a small chance that the patient will not improve and might have to return. Be sure to document that the patient/caretaker is comfortable with discharge and knows when to return to see the health aide if the patient should get sicker.

Note: For pediatric discharges there is a peds custom patient education sheet documenting this information that should be given to the parents/caretakers.

Update the Problem List: It is important to update the diagnoses and problem list for each patient on discharge. Think about what you would like to know, at a glance, about this patient for a future ER visit, RMT, admission etc. You can add additional to any diagnosis or for further detailed information. A well kept problem list, with notes on plan of care/therapeutic goals/important follow up needs etc provides ongoing continuity and good patient care.

Signing out a service

If a patient is admitted for longer than five days or has a complicated course, an off service note should be completed when ending your wards rotation. In place of the above, a detailed daily SOAP note should suffice.

Hospitalist Main Page
Pediatric Main Page