Both in the clinic and the wards, neurology is very much an interprofessional discipline. Nurses, physical therapists, occupational therapists, speech/language pathologists, neuro- and health psychologists, dieticians, respiratory therapists, social workers, and case managers all play crucial roles in our patients’ care. Importantly, optimal patient care depends not just on having members of these various disciplines independently performing their evaluations and treatments, but on actual collaboration among the team members; this is what is meant by the term “interprofessional”. The sine qua non of an interprofessional team is communication; in our residency program, interprofessional communications occur constantly throughout the work day, and formally occur at the following times:
- Morning interdisciplinary rounds—weekdays at 0900. The stroke and general neurology inpatient teams gather with the PT, OT, speech, swallow, social work, case management, etc. to discuss each patient on service with specific attention to their overall plan of care and anticipated discharge needs.
- Morning nursing-led care team visits—weekdays during morning team rounds for Stroke service patients only. For Stroke service patients (admitted > 24 hours), the charge nurse or the Stroke clinical nurse specialist will page the bedside nurse during team rounds. The nurse will introduce the medical team and participate with the daily discussion and bedside evaluation.
- Afternoon nursing-led care team visits—weekdays at 1330 (new Stroke patients only). For Stroke patients admitted in the previous 24 hours, the Stroke APP, the bedside nurse, and case management/social work will participate in the afternoon care team visit. Residents and faculty are welcome but not required to participate.
- Afternoon physician rounds—usually before, or if needed just after the 1600 signout to the night float resident, the stroke and general neurology residents touch base with the care team leader (charge nurse), pharmacist, and social worker. This helps ensure that all team members are on the same page about the patient’s current status and plan of care, that orders are clarified, and that discharges can be readied before the resident leaves for the day.
Roles and Responsibilities of the Rounding Team Members
- Provide the highest quality patient and family centered care
- Treat patients, families, colleagues, and staff with respect
- Take ownership of your patients
- Promptly complete necessary documentation. (The provider discharging the patient is responsible for completing the discharge summary).
- Documentation, including the documentation of the exam, should not be cut and pasted.
- Medications and past medical history should be elicited from the patient and documented in the H&P
- If there is OSH data, it should be reviewed.
- Most of our inpatients need non-neurologic examinations (e.g. cardiac, abdominal, etc.) in addition to a neurologic exam
- Personally review imaging studies
- Maintain/update the sign out list
- Maintain your role in the Provider Team function
- Participate in morning multidisciplinary rounds
- Check in with the D6/4 lead nurse daily: in the afternoon on weekdays and at some point on weekends
- Facilitate open lines of communication about patient assignments, days off, etc.
- Sign pager out when unavailable
- Leader of the team.
- Know all of the patients on the team.
- Work with the intern and APP to determine which provider is following which patients.
- Answer questions from the interns and APPs and if the answer isn’t known, discuss with the attending.
- Run the list with the team members at least daily
- Respond to stroke codes
- Attend didactic session, as able.
- Inform the team about admissions (ED, consult, and OSH)
- Sign out the service to short call
- Teach medical students
- Know the patients you are caring for.
- Attend didactic sessions, as able.
- Review discharge summaries and discharge orders with resident or APP
- Know the patients you are caring for and have some familiarity with all the patients on the team.
- Carry a patient load that can be safely managed.
- Cross cover other patients on the service when the resident is unavailable (e.g. stroke code, clinic, VA).
- Attend didactic sessions, if interested.
- If your service is slow, offer to help other services.
- Sign out to the appropriate resident at the end of your work day.
- Communicate days off and weekend coverage with the team
- If possible, only one inpatient APP should be off per day
- Work 40 hours per week
- Bill independently when there is no-to-minimal faculty input and bill as a shared visit when there is shared decision-making (substantive portion of the E/M visit is performed by the APP and physician on the same day).
Guidelines to help distribute work across services with the APPs
If the consult service is busy (more than 12 patients to chart check or see when both an APP and a resident are on; more than 6 patients to chart check or see when the consult APP is off):
- If the primary list has 8 or fewer patients, the APP should take 4 or fewer primary patients and be available to help on consults with at least 1-2+ patients.
- The patients will be on the same service the APP is on (i.e., if the APP is on general, he/she will see general consults. If on stroke, he/she will see stroke consults). The APP should not be expected to round with more than one attending if on a primary service.
- The distribution of patients should be arranged via secure text, secure email, or phone call between the resident and APP.
- The resident shall put “APP” by ANY patients that are APP appropriate before 0800 (this does not necessarily mean the APP will take ALL of those patients). The APP will change it to their name if they will care for that patient.
- If the APP does not feel a patient is appropriate, they should discuss this with the resident.
- If there is any concern someone is not contributing fairly (by APP or resident), please discuss directly with the person. If concerns continue, please escalate to the APP supervisor and/or residency program director.
Appropriate APP patients include those with:
- Standard GBS
- Stable myasthenia gravis
- Stable ICU patients
- Complicated patients with clear diagnosis and/or clear treatment plans
Inappropriate APP patients include those with:
- Active status epilepticus
- Prognostication/brain death exams
- Complicated stroke with unusual etiology and/or unusual treatment plans
- Neuromuscular patients, especially with unclear diagnosis
- Complicated patients with uncertain diagnosis and unclear treatment plan
Latest revision: 3-12-2021
Justin A. Sattin, MD