Authors reply: wide-reaching effects of and concerns regarding geographic localization of hospitalist units

KEYWORDS:

• Geographic rounding
• geographic admitting
• multidisciplinary rounding
• hospital medicine

We thank the authors for their thoughtful commentary on our paper [1]. In our article, we described our institution experiences, challenges, and successes in creating geographic rounding (i.e. hospitalists assigned to a particular nursing unit or geographic assignment) for the hospital medicine program.

Dr Wang and Dr Nguyen illustrate the struggles their program has had implementing a similar model and provide an excellent analysis as to the difficulty of this model when taking into account the work flow of an entire hospital [2]. In regard to some of their specific concerns, we would add the following.

In terms of resident buy-in, we were successful in achieving this as our residents on wards work exclusively with academic hospitalists who are part of the larger hospital medicine team. We intentionally placed an academic hospitalist with a resident team and a nonteaching hospitalist on each floor to account for the excess volume over resident caps. We have struggled operationalizing geographic admitting with resident teams due to fluctuating unit capacity for new admits and time constraints for duty hours.

The writers outlined concerns about the geographic rounding and admitting process causing bottlenecks for the emergency department and intensive care units. Like all large hospitals, our patient volume from the emergency department and intensive care unit does vary. We have a max census for each hospitalist per day, which usually includes one admission to their floor. Once that admission is received by the hospitalist on the geographic unit, further admissions go to a backup admitting team. We would agree that patients who bounce back should ideally go to the discharging physician; both bed availability and our provider schedule (7 on/7 off) limit our ability to do so.

In terms of evening and overnight coverage of admissions, the off hour teams admit all patients no matter which geographic area they are being admitted to. Admitted patients from the prior evening and overnight are then assigned in the morning to the appropriate geographic hospitalist. If patients are in queue to be admitted, those patients are also assigned in the morning if possible to the geographically assigned hospitalist.

Nurse staffing is also a legitimate concern. In our institution, we have the ability to open extra floors when the volume is high. Nurse staffing is taken into account by the administration when those floors are opened. We then assign hospitalists to that floor if possible or assign those patients to flex teams. As discussed in our paper, we do have flex teams which by definition are not geographically assigned and are used to either see patients when hospitalists in a geographic area are capped or when we have surges in census.

Lastly, we agree that multidisciplinary care is the expectation and standard of care for all our patients and that high patient volume can limit the abilities of our colleagues including social work, case management, pharmacists, and physical and occupational therapists, leading to bottlenecks and delays in discharge.

Again, we thank Dr Wang and Dr Nguyen for their commentary and would agree there remains work to be done to ensure patient and physician continuity and overall work flow in the hospital.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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Funding

This paper was not funded.