by SHM Benchmarks Committee; Project Leader: Patrick Cawley, MD; Coordinating Writer: Phyllis Hanlon
According to data from the American Hospital Association (1), in 1985, the United States had 5732 operational community hospitals; by 2002, the latest year for which figures are available, the number had decreased to 4927, a loss of approximately 14% (1). In that same timeframe, these hospitals lost approximately 18% of their beds, dropping from just over 1 million to 820,653 beds. This reduction in bed capacity has been accompanied by hospital cost-cutting efforts, staff downsizing, and elimination of services. Many explanations for these trends have been suggested, including changes in Medicare reimbursement and the growth of managed care organizations (MCOs).
However, as the current baby boom generation ages, rising inpatient demands are presenting hospitals with significant challenges. According to a 2001 report from Solucient (2), who maintains the nation’s largest health care database, the senior population—individuals age 65 and older—are projected to experience an 85% growth rate over the next two decades. Since this age group utilizes inpatient services 4.5 times more than younger populations, the number of admissions and beds to accommodate those cases will soar. By the year 2027, hospitals can anticipate a 46% rise in demand for acute inpatient beds as admissions escalate by approximately 13 million cases. Currently, the nation’s healthcare facilities admit 31 million cases; this number will jump to more than 44 million, representing a 41% growth from present admissions figures. For hospitals that maintain an 80% census rate, an additional 238,000 beds will be needed to meet demands (1).
Adding to this increase in demand and pressure on bed capacity, hospitals must address the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) passed by the US Congress in 1986 as part of the Consolidated Omnibus Reconciliation Act (COBRA). The law’s initial intent was to ensure patient access to emergency medical care and to prevent the practice of patient dumping, in which uninsured patients were transferred, solely for financial reasons, from private to public hospitals without consideration of their medical condition or stability for the transfer (3). EMTALA mandates that hospitals rank the severity of patients. Thus, tertiary referral centers are required to admit the sickest patients first. This directive presents a significant challenge to many healthcare facilities. High census rates prohibit the admission of elective surgical cases, which, although profitable, are considered second tier. Routine medical cases or complicated emergency surgical cases have the potential to adversely affect the institution’s financial performance.
In addition to the challenge of increased bed demands and EMTALA, hospitals also cite an increasingly smaller number of on-site community physicians. Longstanding trends from inpatient to outpatient care have prompted many community physicians to concentrate their efforts on serving the needs of office-based patients, limiting their accessibility to hospital cases.
To address these pressures, hospitals must execute innovative strategies that deliver efficient throughput and enhance revenue, while still preserving high-quality services. Since 1996, hospital medicine programs have demonstrated a positive impact on the healthcare facility’s ability to increase overall productivity and profitability and still maintain high quality Patients today present to the doctor sicker than in the past and require more careful and frequent outpatient care. Since hospitalists operate solely on an inpatient basis, their availability to efficiently admit and manage hospitalized patients enables delivery of quality care that expedites appropriate treatment and shortens length of stay.
According to the Society of Hospital Medicine (SHM), “Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Coined by Drs. Robert Wachter and Lee Goldman in 1996 (4), the term implies an additional point of emphasis. Part of a new paradigm in clinical care, the hospitalist enhances the processes of care surrounding patients and adopts an attitude of accountability for that care. In practice, hospitalists play two key roles.
Primarily, the hospitalist is a practicing clinician — managing throughput on a case-by-case, patient-by-patient basis. In addition, a hospitalist performs a non-clinical role as an “inpatient expert,” taking the lead in creating system changes and communicating those changes to other hospital personnel as well as to community physicians. As an inpatient expert, hospitalists are often asked to lead organization-wide throughput initiatives to identify and implement strategies to facilitate patient flow and efficiency. As dedicated members of multi-disciplinary in-house teams, the hospitalist is in a prime position to foster change and improve systems.
As suggested by Heffner (5), the process of admission, hospitalization, and discharge resembles a “bell-shaped curve.” To achieve effective throughput, hospitals must expedite patient care and also maintain careful oversight throughout a patient’s entire hospital stay. The hospitalist, as an integral part of a multidisciplinary team, coordinates care to promote a positive outcome and shorten length of stay. Drawing on strong leadership qualities, as well as on intimate knowledge of hospital procedures, layout design and infrastructure, and available community resources, the hospitalist plays a pivotal role in creating efficient throughput from admission to discharge.
At the front end of the bell-shaped curve, the hospitalist may be engaged by emergency department (ED) physicians to assist in ensuring smooth patient flow and, more important, identifies the “intensity of service” needed. Through the use of clinical criteria, such as lnterQual, the hospitalist, together with the ED physician, may be asked to quantitatively rate the patient’s illness for degree of severity.
Timely patient evaluation helps prevent a backlog of ED cases and enables more patients to be seen. Immediate attention to and initiation of appropriate therapy guarantees a better outcome while minimizing the potential risk for complications, which could possibly lead to longer inpatient stays.
Once a patient has been admitted to an inpatient unit, the hospitalist, together with a multidisciplinary team, facilitates care and determines the inpatient services that will optimize patient recovery through strong interdepartmental communications. Working together with admissions, medical records, nursing, laboratory and diagnostic services, information technology and other pertinent departments, the hospitalist maintains a pulse on all activity surrounding the patient and his care.
Judicious inpatient consultations and treatment decisions result in timely changes in therapy, potentially reducing the length of stay. The frequency with which the hospitalist sees the patient allows him to monitor any changes in condition and reduce possible decompensation, a practice known as vertical continuity (6). Such careful attention may reduce inpatient length of stay significantly. When aggressive management is mandated, the presence of the hospitalist enables initiation of effective therapy and results in quicker discharge and a reduction in potential readmission (7).
The surgeon and hospitalist are ideally suited to work together in managing a surgical patient. The hospitalist focuses on the peri-operative management of medical issues and risk reduction, which allows the surgeon to concentrate more on surgical indications and the surgery itself. The hospitalist’s role in the management of a surgical patient enables vertical continuity when the surgeon may be occupied in the operating room with another patient as documented by Huddleston’s Hospitalist Orthopedic Team (HOT) approach (8).
In many hospitals, particularly those that do not have intensivists, hospitalists are able to provide quality care to patients. Even in hospitals where intensivists manage ICU patients, hospitalists work together with the intensivist to ensure smoother transition into and out of the unit.
Timing is a critical issue with regard to discharge. Since the hospitalist operates solely in-house and in collaboration with a multidisciplinary team, he is able to round early in the day to discharge patients by mid- or late-morning, freeing a bed for a new patient. In some cases, the hospitalist, in anticipation of early discharge, may begin pre-planning the day prior to discharge, which further expedites the process. Early discharge applies to the ICU, step-down areas and general inpatient care areas, as well as to full discharge from the healthcare facility. Moving a patient from one of these areas enables other patients to fill those empty beds thus optimizing throughput.
Having managed the patient throughout his hospital stay, the hospitalist — again working together with a multidisciplinary team —can facilitate arrangements to send the patient home or to a rehabilitation or skilled nursing facility or alternative housing situation upon discharge, as well as coordinating post-discharge care, whether it be arranging for a visiting nursing or social services or communicating with the primary care physician regarding follow-up appointments. If additional outpatient care is prescribed, the hospitalist will work with the discharge planning staff to contact various community agencies to arrange services best suited to the patient’s needs. Efficient discharge makes possible the admission of other, more critically ill patients, potentially enhancing the hospital’s revenue stream.
Five specific stakeholders need to be examined to document the value-added by hospitalists. Anecdotal evidence, as well as documented studies, has demonstrated numerous returns—physical, social, psychological and financial—to stakeholders involved in the hospital process. With regard to throughput, the hospitalist provides benefits to each of the stakeholders listed in Table 1.
A dozen studies have been conducted that document the impact of hospital medicine programs on cost and clinical outcomes. Of these trials, nine found a significant decrease in the average length of stay (15%) as well as reductions in cost (9). Two other studies, one from an academic medical center and the other from a community teaching hospital, demonstrate similar reductions during a 2-year follow-up period. At the Western Penn Hospital, a 54% reduction in readmissions was reported with a 12% decrease in hospital costs, while the average LOS was 17% shorter. Additionally, an unpublished study from the University of California, San Francisco Medical Center revealed a consistent 10-15% decline in cost and length of stay between hospitalists and non-hospitalist teaching faculty. More important, those differences remained stable through 6 years of follow-up. In general, hospitals with hospitalist programs realized a 5-39% decrease in costs and a shortened average LOS of 7-25% (6).
According to Robert M. Wachter, author of the 2002 study, “If the average U.S. hospitalist cares for 600 inpatients each year and generates a 10% savings over the average medical inpatient cost of $8,000, the nation’s 4500 hospitalists save approximately $2.2 billion per year while potentially improving quality” (6).
In a study conducted by Douglas Gregory, Walter Baigelman, and Ira B. Wilson, hospitalists at Tufts-New England Medical Center in Boston, MA were found to substantially improve throughput with high baseline occupancy levels. Compared with a control group, the hospitalist group reduced LOS from 3.45 days to 2.19 days (p<.001). Additionally, the total cost of hospital admission decreased from $2,332 to $1,775 (p<.001) when hospitalists were involved. According to the study authors, improved throughput generated an incremental 266 patients per year with a related incremental hospital profitability of $1.3 million with the use of hospitalists (7).
As hospital administrators attempt to address the issue of expeditiously admitting, treating and discharging patients in these days of restricted budgets and increased demand, hospitalist programs are poised as an invaluable factor in the throughput process.
Dr. Cawley can be contacted at firstname.lastname@example.org.
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