How I Structure My Workday Using COLDSAND

Its 7am and   I am an intern resident doctor on floors. There are ten patients on my list to start my day. Out of these 10, 3 are very sick and have multiple specialty services involved and will likely require interval labs and updates to their families. Out of the remaining seven, 3 patients will be discharged home. The other four are status quo and nothing much will be changing in their overall plan. Its starting to look like a busy day  filled with varying tasks such as rounding, notes, orders,  discussions with consultants and other members of my interdisciplinary team. Where do I even begin?!

Days like this are the norm  for an internist (and for some busier, high acuity hospitals, this may even be considered a "light day").  In order to traverse the demands of a rigorous workday, I had to develop a workflow that prioritizes the various tasks Ill be challenged to complete in a timely fashion.
I came across a mnemonic during residency named COLD SAND (as if your brain isn't already inundated with these crazy mnemonics already) that I found to be very helpful with establishing a framework for my work to be completed in an efficient and practical manner. Credit for this acronym I believe goes to Dustyn Williams with onlinemeded,  Even now, as an attending, I still use elements of cold sand as a template to my workflow. With this template in place, I am able to maintain focus and prioritize with the flexibility to make adjustments as I see fit. Now you may be asking, "what the hell is cold sand?"
COLD SAND stands for Consults, Orders, Labs, Discharges, Sign out, AM Labs, Notes and diet orders. Each of these components will be broken down below.

Consults:
When  a case requires expert opinion or procedures that are outside the scope of practice of an internist,  we call on our trusty consultants to help our patients get the care they need. Consultants are very busy individuals. Some specialty services have their own patients to round on, as well as answering consults from other primary services. With this in mind, consults that are initiated too late will be addressed the next day, which won't necessarily lead to poor outcomes, but could have the potential to prolong their hospital stay. Therefore, it is important for us to involve our specialists EARLY in the day to ensure  are able to receive expert input and necessary procedures in a timely fashion.  Let's say for example that you have a 48 year old woman coming in with an acute upper GI bleed with resulting anemia refractory to proton pump inhibitors. The sooner you are able to get gastroenterology involved for an upper endoscopy, the sooner her bleeding will be address, and the sooner she will be ale to get back to her life in the community.

Orders/Labs:
After you have contacted your consultants and received recommendations for their care, next are labs and orders.  Whether its a GI bleed as mentioned earlier needing interval Hemoglobin checks, or a newly intubated patient that just finished a chest x-ray to confirm placement, labs and orders hold great importance to our day to day patient care as physicians. To keep it simple, get your labs and orders out of the way after you've called your consultants or are waiting for them to call you back to save time.  

Discharges:
This goes without saying, but discharges need to occur early in the day to free up beds for the ER and direct admits.  This order works well because by now discharge recommendations if any have been conveyed by our specialists and any last minute orders have been implemented or followed up on.  Discharged however, should not come at the expense of delaying care for your sicker peeps.

Sign outs:
Writing a good quality sign out takes practice and time, especially early in residency when everything is new. I usually wrote up my sign outs after I finished my work for the day so that I was able to head home immediately after talking with the night float resident. However, on busier days, were my work would extend beyond sign out, I would draft my sign out first, relieve myself of the dreaded pager and complete the remainder of my work.

AM labs:
Unless you are ordering something that requires daily follow up, automated DAILY labs is a bad habit to pick up in residency. Taking a moment to decide what labs are necessary for the morning will aid in the efficiency of your prerounds and possibly spare your patient of unnecessary pokes.

Notes:
Nothing to add here besides notes are easier to complete when all of the work is done  as they give the reader a comprehensive overview of what occurred that day.

Diet Orders: This mainly includes NPO at midnight orders.
Aside from simply using this a schedule or template for work flow, this can also be used as a checklist during prerounds or when running the list with your floor team.

I hope this helps!