You'll cringe when you read this, but this a typical day on the ward

"Healthcare is broken" is common phrase, especially in Silicon Valley. Even with this understanding, most people here - especially the engineer who gets around by uber and has instacart deliver her groceries - don't believe it when we explain to them the simple problem we are trying to solve with Listrunner. 

So, though its long, we've summarized what actually happens on the ward on a typical day. You'll likely cringe at how ineffective and risky we are but this is the reality on the ward floor:  

A day on the ward typically starts with the medical student tasked with arriving first to get the patient list. This is done in one of three ways:

None of these options garuantee a current list. New admissions and late discharges are often not reflected in the EMR, making the list outdated even as soon as you hit the print button.

When the rest of the team assembles they try to make sense of what happened overnight from the chart or hear it third hand from a charge nurse. The team is lucky if one of their own team members was on call last night to give a quick brief before going home. Otherwise, the team is on their own.  

Next the med student or intern needs to chase down vitals and lab values all around the unit known as “pre-rounding”. If they are electronically available, they will physically copy down the numbers on to the list. This is part of the med student or intern’s role as “scut monkey”.

With copies of the updated list photocopied for everyone, rounds are ready to start. Although invariably a lab result is missing, or worse yet a patient. During ward rounds, the team assesses patients and makes plans for the day. Each member of the team will jot down notes and tasks for their patients to be done after rounds.

Orders are either entered directly into the chart, often by physically carrying the binders from room to room. Some places will have a means of accessing the chart and entering orders into EHR from the bedside meaning no more fights over the chart cart! Yes we still have carts to carry around charts.

With rounds complete, the team splits up. Some head to clinic or the operating room, others will stay on the ward to follow up on the care plan, and someone is assigned to new consults and admissions.

Those left on the ward carry out the care plan using the paper list and the notes and tasks they’ve scribbled down as a to do list. Additional orders are entered separately. Daily progress notes are written from the bullet points that are taken down from ward rounds. Everything that has been written on paper list must be re-entered into the chart or orders whether its paper or electronic. You can’t just photocopy the paper list into the chart, its all short form and needs to be properly documented in the chart and orders.

Throughout the day, as patients are discharged and care plans updated, the team will communicate via pager, phone, and text message. We’re not supposed to text, but everybody does it.

Throughout the day the chief or senior resident will try to stay abreast by calling on the team to regroup and run the list. Running the list means getting a interim update on the patients’ status. This usually ends up as a web of phone calls, pages and text messages. If you are lucky, you can entice the whole team together over coffee but there is always someone missing, usually stuck in the OR or with a consult, so you don’t have a complete picture.

Before the end of the day, the senior resident and on-call team will run the list again and compile a list of outstanding tasks and clinical points from the collective maze of the team’s lists generated over the course of the day on a freshly printed patient list.  This is then repeated for all the other teams the on-call team must cover.  This is a haphazard process relying on a degree of luck and a web of phones, pagers and text messages. If it happens at all.

On call, if something arises with a patient that’s not on your list, you hopefully have some story of them from handover. But usually its a complete mystery and the on call resident has to put together the clinical picture from the nurses and the chart.  At the same time, the resident is being paged by the emergency department to admit another patient or two.  These new patients will be added manually or a sticker to the back of the list or into their scrub pocket.

The next morning, the on call resident should find the teams he/she has been covering and handover. Again, this is haphazard and often updates are only discovered on rounds when reviewing the chart.

And the cycle repeats itself. 

Drs. Trevor Chan and Jeeshan Chowdhury