The emergency department (ED) is often a bit disconnected from the rest of the hospital. Once patients are admitted and leave the ED, we don’t usually have any closure or follow-up with them. And typically, our contact with inpatient nurses and providers is limited to responding to codes on the units.
I wanted to change that.
As ED medical director for Sequoia Hospital in Redwood City, Calif., I began an inpatient rounding program seven months ago. This involves visiting all of the patients who were admitted from the ED the day before.
The idea of inpatient rounding came from my ED colleague, Gary MacGregor, MD, one of the nicest, most caring people I’ve ever met. He’s one of those physicians who bring out the best in everyone around him. He truly loves being a physician and making his patients’ lives better.
Dr. MacGregor made it a point to visit each of his ED patients who had been admitted to the hospital, and I vowed that once I had the time in my career, I would follow his example and round on patients too.
Now that I’m medical director of the ED, I finally have the time to emulate Dr. MacGregor’s example and continue what he had started.
Informal Visits Improve the Patient Experience
My process for visiting patients is very informal. I don’t take notes or dictate the encounters. I simply introduce myself and ask patients about their experience in the ED. These are very open-ended conversations about what went well and what could have made their experience better.
For patients, my visit allows them to talk about an experience they’ve had once the smoke has cleared and they’re in a calmer, quieter environment. Most of the time, my encounters are very positive, and my visit is brief.
Other times we uncover bigger issues. Maybe the hospitalist hasn’t visited them that day, so they don’t understand what’s happening to them. Or maybe they had problems with parking. Sometimes I stay up to 25 minutes, listening to the patient and helping to make the situation right.
A few problems I’ve helped solve through rounding include:
Helping patients understand the plan of care. A common scenario is that patients are confused about what is going to happen now that they’re no longer in the ED. So, I’ll find their nurse and help the patient understand what the plan of care is for the day.
Managing expectations. Some patients have pretty high expectations and it’s nice to be able to talk with them about their experience. For example, a patient came into the ED with a uterine artery tear and was bleeding to death. Within 50 minutes of walking in, she was in the operating room having surgery and getting two units of blood. Fortunately, her vital signs quickly stabilized and she made a full recovery.
When I visited the patient the next day, she was upset at how long she had waited in the ED to be treated. I asked her if she had any idea what had happened to her in the span of 50 minutes. I walked her through all that had taken place and she totally understood. But if I hadn’t had a conversation with her, she would have left the hospital with a negative perception of her care.
An extra layer of safety. I visited a patient who had had a stroke and was ready to be discharged soon. In talking with her, I learned that she was scheduled for a breast biopsy the next day. I told her that since she was now on blood thinner for the stroke, she would need to postpone the biopsy. Because her biopsy was scheduled at another facility, this issue could easily have been missed if it hadn't come up in our conversation.
So, these visits have great potential for service recovery and patient and family education. The bottom line is that I never know where an encounter will go when I walk into a room, but I’ll do whatever it takes to improve the experience for the patient.
Bringing Staff Together
As I’ve said, my system for inpatient rounding is very informal. I often say to the ED staff, “I’m going to walk around. Who wants to come with me?”
If the ED isn’t too busy, I’ll take the PA/NP or nurse who cared for the patient the previous day. The nurses and PA/NPs love it. And the patient feels pretty special when two people from the ED visit them. It’s a huge win for everyone.
I’ll sometimes bring other nursing staff and leaders into the visits, including the service line nurse manager, the nurse director, or the education coordinator. When I’m rounding on an ICU patient, I often bring a critical care nurse along. It allows me to gather a lot more information about the patient’s situation, making it a more valuable encounter for all of us.
The patient feels pretty special when two people from the ED visit them. It’s a huge win for everyone.
Another great aspect of inpatient rounding is the opportunity to see the nurses and other staff upstairs. As ED providers, we don’t regularly interact with these folks, unless there is a code. It brings us all a little closer together.
During the course of talking with patients, I also hear so many great stories about unsung heroes within the hospital. Maybe it was a transporter who took the patient to his CT scan and up to the floor and really made him feel cared for. Or a nurse who offers comforting words during a difficult time. It gives me a chance to bring back a lot of really positive feedback that providers, nurses, and staff wouldn’t otherwise hear.
In my experience, inpatient rounding is always time well spent. I almost always enjoy it and when I don’t, I’m glad I’m there to find out about an issue, address it, and improve the patient’s experience.
You don’t need to establish a formal inpatient rounding process or document your encounters. The important thing is to get started and stick with it. Your efforts will yield far-reaching benefits for patients, family members, and staff.