A Better Way To Round
People have said it before, and will continue to say it, but there’s got to be some better way to collect and review data for medical and surgical teams. Let’s brainstorm and figure this out, people; the current system just ain’t so hot. And if grocery stores and airlines can get themselves electronic and digital, we in the medical world should be able to, too.
I’ll first describe how we collect data nowadays, and then suggest some improvements. I welcome yours in the comments.
“Rounding” is where medical teams review a patient’s course and data over the last 24 hours and decide what to do or not to do. In order to do this, someone has to go around and actually collect the data, see the patient, etc. This is called “pre-rounding.” Currently a medical student, intern, or resident walks around to all their patients, with a sheet of paper in his or her white coat pocket for each patient. You either go to the computer or the chart, and copy down the patient’s vital signs (BP, Pulse/Heart Rate, Temperature, Respiratory Rate, and Oxygen Saturation), labs, and study results from the master copy in the chart or computer onto your dinky little piece of paper. Then you go see the patient, ask how he or she is feeling, if there were any problems or complaints, and examine the patient. (This is usually very early in the morning; you have to wake up the patient.)
You then write a note on the patient, which is a “master copy” that goes in the patient’s chart of everything you’ve just written onto your own sheet, but in a more standardized format and also includes what you’re going to do for the patient based on his or her problems. (Sometimes people just photocopy their note and use that as their pocket reference, but then you end up with a ton of papers per patient.)
Your own little piece of 8 1/2 by 11-inch paper is your lifeblood. It usually lists all of the patient’s medical problems, the medications they’re taking, their intial labs, their story of why they came into the hospital, etc. It also lists all the labs they’ve had while they’ve been in the hospital (sometimes this spills onto a 2nd page if they’ve been in the hospital awhile). If you lose this, you are screwed.
Why do we need this sheet? Because the note we write has to stay in the chart–either electronically or physically. But we also need to have quick access to all the patient’s data throughout the day, in case someone needs to double-check something, or the patient gets very sick during the day, you can recall what happened before he or she got sicker.
Then when you actually round, you sit down with your team (or walk around to each patient’s room) and discuss each patient. You repeat aloud everything you’ve already written down twice (once for your own sheet, once for the official chart note), and discuss what you think should be done for the patient.
It’s an incredibly inefficent system, especially when you consider how busy doctors are and how much time is spent doing it. It hasn’t changed in years–have we been rounding like this since 1900?–and maybe it’s time for a medical culture shock?
The problems:
- We need to have immediate, constant access to patient data.
- We also need to have a centralized source of patient data and care plans so that everyone caring for the patient can access it and see it.
- We need to be able to have access to all data, but be able to filter it or customize it based on what is important to us (a surgeon cares about different data than an infectious disease doctor).
- We have to go see each patient every day to re-assess them, see if there were any problems that we didn’t hear about over the last day.
Some ideas:
- What if we just wrote a note once, but we could access it remotely? So you would write your full note, in official form, but then on a Palm-pilot device (or even more simply, a Nintendo DS or PSP), your note is also saved onto your own device as well, just in short form. I know, I know, everyone has their own system for how they track patients and labs, but perhaps it’s at the cost of efficiency?
- What if we just rounded with a laptop or other wireless device that was hooked into all the other systems? So just one device per team, and you could automagically tap into all the data available at the hospital?
- Both systems would allow templates and customization to some degree, so you could say, exclude certain types of data or organize it more efficiently.
- What if outside every patient room, a one page, formatted, color-coded summary was shown (password-protected or something). So you could walk up to the room, see if there were any events or complaints, quickly skim lab values and x-rays to see if there was anything relevant you needed to ask the patient about? You would know that all the lab values were already pulled and ready for you, so you wouldn’t have to write them down twice.
- Or perhaps the concept of a “note” is the entirely wrong format now that we have technology. (I’m just waiting to hear the cries and screams from the old-school.) Maybe it makes more sense to have a centralized patient “databoard” or “notebook” or “daily summary” that everyone accesses. It would list any new labs (with trends) over the last day, links to Xrays or reports, new complaints, new procedures done and the results, etc. And then from that patient databoard, you build a streamlined note that references the data. Drag and drop. Want to comment on a patient’s rising potassium? The note makes a link to that lab value, and you say what you want to do about it. Instead of seeing what a particular doctor or service would like to do, you could look at the data based on each problem (a high potassium, a consolidation in a chest film) and see what people are suggesting to do based on that problem.
Some of these suggestions are probably just because I’m on a consult service this month and don’t have my own patients, but I’d love to hear your thoughts on other problems with rounding and any ideas for solutions.
A major problem with “rounding,” as you describe it, is the lack of the patient perspective—other than “you have to wake the patient.” It strikes me that you talk about consequences for yourself if you lose your note, vs consequences in patient outcome.
Patients in teaching hospitals frequently complain that they have been seen by dozens of people, but they cannot get some small need taken care of. To an ill, likely frightened person, this is confusing, tiring and seems lacking in respect. Some people aren’t sure who is their doctor and why others are asking them to repeat information.
It might help to look first at the patient needs–which include rest and a sense that the last person who asked questions actually listened. And YOU are now here BECAUSE…..?? Do you care about the patient or are you asking because you want/need to practice interviewing? Or is it because no one around here communicates?? That thought is reassuring! Consider the hospital experience for the patient in order to come up with a physician and patient friendly method that can convey caring and respect while promoting healing and comfort.
M3/M4 here (one more day!) We actually do round with ‘COWs’ at my hospital – computers on wheels. People are still getting used to it and feel like they have to look up and record most of their labs ahead of time, but it’s catching on – we put in all the orders during rounds as we walk (the resident/student(s) who’s not presenting). We can also check on all the labs we forgot to follow up on and get up-to-date culture results (since they often don’t get updated daily until 10:30 or so). It definitely needs the kinks worked out, but is working pretty well so far. Only problem is that we can’t be forced to take six flights of stairs – we all have to wait for the elevator while going between wards. But that’s not really a problem for those of us who are lazy. =)
The tablet PC is a wonderful thing. Why shouldn’t patients have the same level of technology available to them as an Avis car rental customer?
From a UK perspective:
Firstly we don’t “pre-round” the blood results are written in the day before as soon as they become available. I’ve worked in different hospitals which have had tablet PCs and “COWs” The cows were better as they had space to lean on, and a larger screen which was better for reviewing XRs etc on. So we could access radiology and bloods/microbiology quite easily. We could also enter our orders as we went round so saving more time.
The other added bonus is having a computer allows you to pull up info sheets, diagrams and print these out after annotating them to give to the patient.
As part of the automatically generated “ward list” ie all the patients in the hospital under my respective consultants we also put in a summary of the past history, important drugs ie metformin, summaries of scans etc, and tasks that need doing, normally running to a few lines.
Because this automatically printed out each day no lengthy copying out each time.
On the round itself the house officer (intern) would lug the computer, find the notes in the trolley and run the jobs list. The Senior house officer (resident) would write in the medical notes or alternate with the house officer and the registrar (fellow?) would either be taking the round or just looking important next to the consultant. The nurse would bring up any concerns they had and note diet changes, taskings for physio/OT, mobilisation status etc.
Ok thats gone quite long…
I don’t know about you but I also re-rounded in the early afternoon to check things had been done, check blood results, make sure fluids were written up, pain relief sorted and obs up to date. Also at my own pace chat to the patients and answer any questions they’ve got.
Out of interest how many patients do you have on say a medical firm and a surgical firm in the US?
I’d average 30-40 surgical and between 10 and 60 on a medical firm.
I think that thinking about improving is a good start! It is just going to take time. The last 2 ideas you listed sound great to me: centralized documentation. On that note, the hospital where I work has computerized documentation and everyone seems to use it except the MDs. They are still handwriting orders and hand writing notes. Centralized documentation will be a huge improvement in communication, and one day physicians will be able to enter in orders from outside the hospital: imagine…the nurse needs orders for something…anything say pain medication she can page the doc, leaving the pt name, the doc can quickly look up the note from his/her access device and then order as appropriate! I would like as a nurse to spend more time in the rooms with my patients and less time worrying about if everyone is on the same page as far as consults and attending etc.
Again, I think it is just going to take time but we will get there soon.
Like Wanda, I also was struck by your solutions seeming to mention nothing about wanting to talk to the patient directly. Instead, it sounds like you would rather have centralized information on the door to the patient’s room and from that you would determine if it was really necessary to actually TALK to the patients. As someone with a life threatening illness, I fight to feel like I am a PERSON and not just a “medical thing” with doctors. Yes, we are woken up early during pre-rounding, but that is actually one of the few times we actually SEE doctors while in the hospital and are able to ask them our questions. In addition, I cannot even tell you how many times actually TALKING to the doctor during pre-rounding has highlighted critical mistakes in the chart which the doctor has only learned from directly hearing from me (for instance chart saying an MRI was done…it never was and the results were someone else’s – I had to point that out, chart saying EKG was done (never was), chart saying one med when it fact I had been switched to another, chart saying I WAS HAVING SURGERY THAT MORNING, when in fact surgery had been moved to two days after that (and the pre-rounding doctor had no clue). Paperwork and technology are not fool proof. Please remember that you are working *with* PEOPLE, not just patients who are a collection of numbers, complaints, and data points.
Our EMR allows MDs to access their patients’ info remotely from home with a special network thingy (not sure what it is) and their own laptop/computer. If they’re on call, for instance, and a nurse calls them for an order, they can order stuff from home, read all the labs, read all the vitals/patient history, etc, and notes (ie, the entire chart, including past visits/clinic notes if applicable) in real time. I suppose, if they wanted to, they could wake up a little early and read all their patients’ charts from the comfort of home before going in and plan their attack based on acuity or whatever.
It seems the doctors like this.
The VA has had the answer for years.
The EMR that the VA uses is fairly efficient, easy to navigate, and extremely useful.
It’s not a perfect answer, but it is much more efficient than paper charting.
Do you realize that on all postings except this one you have “Comments OFF?” I mean it is your blog, but it definitely makes it difficult to respond.
if this post seems myopic in regard to talking to patients, it is only because graham is trying to work out a technology that would *improve* patient care and reduce medical errors. undoubtedly graham recognizes the importance of speaking to patients and resisting the idea that they are “medical things”. an improved rounding system would allow more doctors to do just that. the less time they spend checking values, rewriting notes, and transferring content from one place to another, the more time they have to spend with patients. (we would hope!)