There is a debate going on in the inpatient world among hospitalists, bed management and other hospital leaders and managers. It is one that emergency physicians should familiarize themselves with because it affects hospital-wide patient flow and thereby boarding in the emergency department (ED). It involves hospitalist medicine, which is now the largest admitting service at most hospitals and the service that the emergency physician interfaces with most often. The debate is whether hospitalists should work in geographic zones in the hospital. You may hear it discussed using a number of terms including geographic localization, geographic rounding, geographic cohorting, or simply geography. These terms refer to the placement of patients on a physician’s service into a defined area, typically a unit or a floor, as opposed to distributing them throughout the hospital.
In the late 1990s, geography was a promising strategy for hospitalist medicine.1 Geography allows the health care team (physician, APP, nurse, physical therapist, case manager) to work all together in proximity to their patients. It improves communication, improves productivity, removes wasted time spent in transit and improves length of stay by facilitating the discharge process.2 As servers in the hospitality industry discovered, it is much more efficient for waitstaff to have all their tables in one area. Most nurses, (whether working on an inpatient unit or in the emergency department), have assignments involving contiguous rooms. Hospitalists found similar advantages when working on one hospital unit or floor.
However, in the 2000s, after many hospital closures, hospital bed occupancy rates became higher and bed capacity was tight. Many hospitalist services gave up geographic localization and patients were now assigned to whatever staffed bed was available. At the same time, there was a growing concern in health care for the hand-off of patients. Consequently, patients were no longer re-distributed after admission to be cared for by a single physician staffing a unit. Hospitalists now had patients scattered all over the hospital, covering massive inpatient footprints. Insidiously, as they abandoned the concept of geography, they found themselves caring for patients on many different floors (often in many different towers). The walk between patients situated in the farthest points of the hospital might exceed 20 minutes!
Meanwhile, the rest of the care team (nurses and case managers) continued to work in a unit-based or floor-based model. The care team became fragmented, and communication faulty. Facts about a patient’s care and course that were small but consequential were not shared in a systematic manner. Traditional rounding with the entire care team was often abandoned. Today’s hospitalized patients are increasingly complex, and there are many necessary interfaces between care team members, subspecialists and families during the hospital stay. Robust and regular communication has become essential to optimize patient care. Thus, the fractured care team suffers from lapses in communication resulting in delays and dangers to patient care. Patients often experience discharge delays that are the result of these communication breakdowns, resulting in longer inpatient stays.