Hospitalist Co-Management of Surgical Patients
Hospitalists assume a role between hospital and community physicians and are increasingly commonplace in the leading academic hospitals in the United States. The Mayo and Cleveland Clinics and Harvard's Brigham and Beth Israel Hospitals, to name but a few, have already developed hospital medicine programs. Although no board certification in hospital medicine exists yet, there is a visible movement taking shape toward the formation of a recognized subspecialty, which some residency and fellowship programs have already implemented.
Hospital administrators are beginning to recognize hospitalists as an asset, because they manage the continuum of care of hospitalized medical patients with surgical problems and postoperative patients with medical problems. Interest is especially intensifying now, when most hospitals, which have traditionally relied on overworked in-house staff to bear these complex, time-consuming responsibilities, are facing the recent Accreditation Council for Graduate Medical Education (ACGME) regulations restricting residents' duty hours.
"The impact of the ACGME resident duty hours' restriction is really the straw that broke the camel's back and has really motivated people to push ahead with a surgical co-management model," says Sylvia C. W. McKean, MD, of the Brigham and Women's Faulkner Hospitalist Service, in Boston, Massachusetts, and Professor of Medicine at Harvard Medical School. "Five years ago there was less of an interest among surgical or orthopaedic department heads for a co-management model as there is now," she explained. When Dr. McKean approached the head of an orthopaedic department within a leading academic teaching hospital a few years ago with the idea of implanting an academic hospitalist co-management model, there was little interest other than possibly managing postoperative anticoagulation.
Given the history of surgical management in most hospitals, it is no surprise that there would be little interest in a co-management program within surgical departments. "Traditionally, surgeons have expected their trainees to have the skills to care for medical postoperative conditions, and at many tertiary care hospitals they call in a medical specialist when they feel like they can no longer take care of a problem," explains Alpesh Amin, MD, MBA, founder and executive director of the hospitalist program at the University of California Irvine Medical Center. Dr. Amin also serves as Vice Chair for Clinical Affairs and Quality in the Department of Medicine. He believes that we are at the "cutting edge" of developing concepts for co-management issues and that there is an emerging trend for use of hospitalists in hospitals.
"Before staring a program, it is important to take the time and the energy to address the culture levels first; we want to foster a culture of communication -- of collaboration and teamwork and patient safety and quality. If we don't agree, we have problems later on that can eventually lead to failure of a co-management program," warned Dr. Amin at a teleconference on the subject. He went on to advise, "Many of these changes need to start at the highest operational level of an organization with a common agreement by all of the stakeholders on a desired culture of care within the hospital. Everyone needs to be aware of what the core measures are that need to be achieved, such as deep vein thrombosis (DVT) prophylaxis and how to deal with delirium, seen postoperatively in many elderly patients."
Dr. McKean believes that many problems in quality of care are due to a lack of protocols on triaging once a patient enters a hospital. "There are currently no clear triage protocols, but there are a lot of variables based on individual preferences rather than on specific patient needs." She also emphasized a possible harmful outcome for patients from potential conflict between residents of different services. Depending on the specialty of the consulting physician, different strategies may exist regarding where to place a new patient and how to manage continued follow-up care, leading to a lack of standardized oversight of the patients' medical problems and a danger of them "falling through the cracks." A combination of standard procedures plus a designated hospitalist in charge of the cases could provide shorter hospitals stays and better quality of care for patients, possibly also resulting in a competitive advantage for the hospital. Marketing advantages are not to be overlooked, Dr. Amin commented.
Even given proper triaging, some patients who enter in low-intermediate risk category based on their comorbidity escalate to intermediate or high risk during their medical stay, sometimes with little oversight by an in-house physician. Given staffing limitations -- including limited weekend coverage -- a patient's safety may depend on one designated intern. In surgical departments, residents in training, who already have limited operating room (OR) time due to duty hour restrictions, are often pulled away from their learning experiences to deal with discharge issues or developing medical problems on the floor. A hospitalist in charge would have the time to deal with such emerging complications and so allow the surgical residents to deepen the quality of their training. Additionally, in the current hospital climate, physician assistants and nurse practitioners who are caring for complex patients while the surgeons are in the OR are at risk for burn-out and consequential errors, increasing the potential for medical-legal consequences.
Another arm of the current in-patient problem is the shortage of generalists in the hospital. Most primary care physicians have offices off-site so they are not really available to handle emerging medical emergencies.
Dr. McKean then brought up yet another incentive for hospitals to institute a specialized in-house co-management program. "We also have, in the year 2006, an emerging focus on quality of care reporting by hospitals, regulators, and the public as consumers." In Massachusetts, for example, there is now consideration of reporting morbidity and mortality data on individual surgeons. She also addressed the need for change due to the emerging shifts in patient population. "We are seeing a predominance of frail, elderly patients and patients with increasing medical comorbidities and surgical risks made possible by minimally invasive surgery." Citing a congestive heart failure patient as an example of problems posed by this situation, she posited that such a patient might be told to hold his or her diuretics by a surgical team performing a minimally invasive procedure only to be given volume expansion during the procedure due to blood loss, increasing the risk for later decompensation from the stress. The advent of widespread minimally invasive procedures promising less risk for the elderly has made these frail patients more at risk in many medical centers due to lack of oversight in the clinic following the procedures.
The following summarizes issues that are potentially addressed or improved by a co-management program:
Dr. Amin believes that a surgical co-management program may potentially help manpower issues, foster collaboration and teamwork, and hopefully reduce the silo mentality while potentially improving the quality of care.
Hospitalists assume a role between hospital and community physicians and are increasingly commonplace in the leading academic hospitals in the United States. The Mayo and Cleveland Clinics and Harvard's Brigham and Beth Israel Hospitals, to name but a few, have already developed hospital medicine programs. Although no board certification in hospital medicine exists yet, there is a visible movement taking shape toward the formation of a recognized subspecialty, which some residency and fellowship programs have already implemented.
Hospital administrators are beginning to recognize hospitalists as an asset, because they manage the continuum of care of hospitalized medical patients with surgical problems and postoperative patients with medical problems. Interest is especially intensifying now, when most hospitals, which have traditionally relied on overworked in-house staff to bear these complex, time-consuming responsibilities, are facing the recent Accreditation Council for Graduate Medical Education (ACGME) regulations restricting residents' duty hours.
"The impact of the ACGME resident duty hours' restriction is really the straw that broke the camel's back and has really motivated people to push ahead with a surgical co-management model," says Sylvia C. W. McKean, MD, of the Brigham and Women's Faulkner Hospitalist Service, in Boston, Massachusetts, and Professor of Medicine at Harvard Medical School. "Five years ago there was less of an interest among surgical or orthopaedic department heads for a co-management model as there is now," she explained. When Dr. McKean approached the head of an orthopaedic department within a leading academic teaching hospital a few years ago with the idea of implanting an academic hospitalist co-management model, there was little interest other than possibly managing postoperative anticoagulation.
Given the history of surgical management in most hospitals, it is no surprise that there would be little interest in a co-management program within surgical departments. "Traditionally, surgeons have expected their trainees to have the skills to care for medical postoperative conditions, and at many tertiary care hospitals they call in a medical specialist when they feel like they can no longer take care of a problem," explains Alpesh Amin, MD, MBA, founder and executive director of the hospitalist program at the University of California Irvine Medical Center. Dr. Amin also serves as Vice Chair for Clinical Affairs and Quality in the Department of Medicine. He believes that we are at the "cutting edge" of developing concepts for co-management issues and that there is an emerging trend for use of hospitalists in hospitals.
"Before staring a program, it is important to take the time and the energy to address the culture levels first; we want to foster a culture of communication -- of collaboration and teamwork and patient safety and quality. If we don't agree, we have problems later on that can eventually lead to failure of a co-management program," warned Dr. Amin at a teleconference on the subject. He went on to advise, "Many of these changes need to start at the highest operational level of an organization with a common agreement by all of the stakeholders on a desired culture of care within the hospital. Everyone needs to be aware of what the core measures are that need to be achieved, such as deep vein thrombosis (DVT) prophylaxis and how to deal with delirium, seen postoperatively in many elderly patients."
Dr. McKean believes that many problems in quality of care are due to a lack of protocols on triaging once a patient enters a hospital. "There are currently no clear triage protocols, but there are a lot of variables based on individual preferences rather than on specific patient needs." She also emphasized a possible harmful outcome for patients from potential conflict between residents of different services. Depending on the specialty of the consulting physician, different strategies may exist regarding where to place a new patient and how to manage continued follow-up care, leading to a lack of standardized oversight of the patients' medical problems and a danger of them "falling through the cracks." A combination of standard procedures plus a designated hospitalist in charge of the cases could provide shorter hospitals stays and better quality of care for patients, possibly also resulting in a competitive advantage for the hospital. Marketing advantages are not to be overlooked, Dr. Amin commented.
Even given proper triaging, some patients who enter in low-intermediate risk category based on their comorbidity escalate to intermediate or high risk during their medical stay, sometimes with little oversight by an in-house physician. Given staffing limitations -- including limited weekend coverage -- a patient's safety may depend on one designated intern. In surgical departments, residents in training, who already have limited operating room (OR) time due to duty hour restrictions, are often pulled away from their learning experiences to deal with discharge issues or developing medical problems on the floor. A hospitalist in charge would have the time to deal with such emerging complications and so allow the surgical residents to deepen the quality of their training. Additionally, in the current hospital climate, physician assistants and nurse practitioners who are caring for complex patients while the surgeons are in the OR are at risk for burn-out and consequential errors, increasing the potential for medical-legal consequences.
Another arm of the current in-patient problem is the shortage of generalists in the hospital. Most primary care physicians have offices off-site so they are not really available to handle emerging medical emergencies.
Dr. McKean then brought up yet another incentive for hospitals to institute a specialized in-house co-management program. "We also have, in the year 2006, an emerging focus on quality of care reporting by hospitals, regulators, and the public as consumers." In Massachusetts, for example, there is now consideration of reporting morbidity and mortality data on individual surgeons. She also addressed the need for change due to the emerging shifts in patient population. "We are seeing a predominance of frail, elderly patients and patients with increasing medical comorbidities and surgical risks made possible by minimally invasive surgery." Citing a congestive heart failure patient as an example of problems posed by this situation, she posited that such a patient might be told to hold his or her diuretics by a surgical team performing a minimally invasive procedure only to be given volume expansion during the procedure due to blood loss, increasing the risk for later decompensation from the stress. The advent of widespread minimally invasive procedures promising less risk for the elderly has made these frail patients more at risk in many medical centers due to lack of oversight in the clinic following the procedures.
The following summarizes issues that are potentially addressed or improved by a co-management program:
Patient experience and satisfaction
Satisfaction levels of attending physicians, residents, and nurses
Competitive advantages relative to outside institutions by attracting more patients to the hospital
Implementation of prevention protocols for complications, such as delirium and DVT
Reduction in average length of stay
Reduction in transfers to medical units, duplication of effort, and loss of communication between services
Opportunities for quality improvement research and best practices
Current staff limitation produced by ACGME restrictions
Shortage of generalists
Cross-departmental collaboration
Support of the emerging focus on quality-of-care reporting by hospitals, regulators, and the public
Response to an increasingly frail and elderly patient population
Opportunities for cross-teaching and developing team models of care
Resident training in consultative medicine and postoperative care
Time crunch of discharge, given limited availability of house staff to perform discharge duties
Dr. Amin believes that a surgical co-management program may potentially help manpower issues, foster collaboration and teamwork, and hopefully reduce the silo mentality while potentially improving the quality of care.
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