INPATIENT WARDS: WORKFLOW AND ORGANIZATION

The inpatient medicine wards are where you will be spending most of your time during your intern year. While a lot of learning can happen, the floors can also feel overwhelming, disorienting and frustrating, especially at the beginning of the year. This is completely normal to feel this way! Your seniors are there to support you in developing systems for managing the workload of the floor and to make sure you are learning from your experiences there. To that end, below are a few guides to working on the wards; they might not work for you exactly, but hopefully they can serve as a starting point o help you develop your own workflow for wards.


PRE-ROUNDING

Pre-rounding can often feel like a mad rush to get as much information together as you can and cobble together something of a plan. Having a systematic way to approach it can help make sure you get all the information you need in an efficient manner. Below is one way in which you might think to structure your pre-rounding process.

  1. Handoff/sign out

    • Check the written epic handoff quickly; though only do this if your team is one that uses the handoff to communicate interval events; you may be able to get a fair amount of this information from verbal sign-out from the night team


  1. Vitals/physiologic data

    • Start by checking to make sure You can also look at other physiologic data that might be pertinent; for cardiac cases that usually means I/O, weights (if you're diuresing); vent settings if a patient is vented (can be seen on the comprehensive flowsheet); fever curve


  1. MAR

    • Take a quick look through the MAR next, mostly want to see if they got PRNs, if they refused anything scheduled, and to check if anything central to therapy stopped/fell off (esp. antibiotics)


  1. Results

    • Look through labs, and then any imaging. You can also check the panel on the lower left hand side with 'new results'. Would also check things like POC glucose on the 'glucose tab' if that's something you're following here.


  1. Notes

    • Finally look at any notes, specifically the attestation from the attending on your note if you haven't seen that yet, any consult notes, and significant event notes. Sorting by service instead of by time can help make sure you catch all the consult notes.


  1. Examine patient

    • Check in with them re: symptoms, targeted ROS, and targeted exam. If you're able to catch the nurse to ask about specific interval events now is also a good time (e.g. BMs/output if you're concerned about that, issues with the vent/BiPAP/CPAP (or if they actually were on CPAP/BiPAP)).


  1. Tele (if relevant)

    • If you are on a telemetry unit, you can round out pre-rounding by checking tele for all my patients. Start with the alarm view, look at any specific alarms and print out ones that look concerning. Then go through general view to get a sense of the heart rate overnight.


WORKFLOW DURING THE DAY

One of the most overwhelming parts of working on the wards is knowing how to structure your day and manage your tasks. Again, there is no one right way to do this, and everyone needs to find a structure that works for them. One way to think about this is dividing tasks into those that need to be done before noon conference and those that can happen later in the day. Below is one such division that may work for you:

Before noon conference:

    • Consults placed

    • Tests ordered

    • Therapy changes (e.g. new meds, dose changes)

    • Any labs/data/tasks to be followed up from overnight


After noon conference:

    • Procedures

    • Discharges

    • Handoff/signout (and updated discharge summaries for patients staying)

    • Notes

Again, this is just one way to think of dividing your work; talk with your team and your senior about other ways you might think to prioritize your tasks.



TEACHING AND CONFERENCES

While on wards, you will have noon conference everyday at lunch (12-1pm). There is also typically 1 intern report and 1 resident report each week; these occur at 3 pm. The full conference schedule for a block is usually posted on the chief's office. The lectures can be opportunities for learning but can also interrupt the workflow for the day; you can check the schedule in the morning or ask your senior if there is a conference that day so that you can plan as needed.



SIGNOUTS/HANDOFFS

Transitions of care are often places where lapses in care can happen, and so particular attention should be paid at these times. Both the verbal and written hand-offs are important elements. The written handoff in Epic should include both an update on the days events as well as tasks and contingency plans for the night team. There are many ways to structure a verbal handoff; one of the most common is the I-PASS system:

  • I: illnesses severity (stable, watcher, unstable)

  • P: Patient summary (one liner, hospital course, general assessment and plan)

  • A: Action items (including ownership of tasks)

  • S: Situational awareness (provide contingency plans)

  • S: Synthesis by receiver (summarizes what's heard, ask questions to clarify)