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Generation Next

From: The Hospitalist, October 2010

Efficiency, lifestyle, and necessity lead medical specialists’ switch to HM model of inpatient care

by Gretchen Henkel

If imitation is the sincerest form of flattery, then hospitalists have a lot to crow about. For the same reasons that sparked the original hospital medicine movement, HM’s specialist colleagues are flocking to the HM model.

“I switched because your impact with consultation is limited,” says geriatrician-hospitalist Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile Acute Care for the Elderly Service (MACE) at Mount Sinai Hospital in New York City. As the former director of the Department of Geriatrics’ consult service, Dr. Farber adds, “I like being able to call the shots and direct the care.”

He’s not the only one. Neurologists, surgeons, and even dermatologists and otolaryngologists have been establishing inpatient services based on the HM model. While many of these programs first begin in the academic setting, where resident work-hour limits necessitate faculty coverage, community hospitals increasingly are turning to specialist hospitalists to address patient-safety and treatment-innovation issues.

According to a leading surgical hospitalist, more than 250 such programs exist throughout the country.

Shaun Frost, MD, FACP, SFHM, chair of SHM’s Membership Committee and SHM’s Emergency Medicine Task Force, an SHM board member, and regional medical director for Brentwood, Tenn.-based Cogent Healthcare, views the growth of specialty hospitalist programs as a positive development. “In many ways, [this trend] is confirmatory regarding the key reasons for creation of the hospital movement,” he says.

For example, mirroring the performance of adult inpatient hospitalist programs, pediatric hospitalist programs have now documented improved throughput, increased efficiency, and increased patient satisfaction, especially when such programs combine pediatric emergency department and pediatric inpatient coverage.1

“We’ve all been inspired by the success of the medical hospitalist model, and we want to acknowledge and credit them for being the trailblazers and pioneers who are leading the way,” adds John Maa, MD, FACS, assistant professor in the Department of Surgery, assistant chair of the Surgery Quality Improvement Program, and director of the Surgical Hospitalist Program at the University of California at San Francisco (UCSF). Dr. Maa and colleagues introduced the surgical hospitalist program at UCSF in July 2005.

David Likosky, MD, FHMIt used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed. It really helped to give birth to the neurohospitalist movement.
—David Likosky, MD, FHM, neurohospitalist, stroke program director, Evergreen Hospital Medical Center, Seattle

What’s Driving the Trend?

The impetus for adopting and adapting the HM model varies across medical specialties. For some, it was necessity; for others, it was a way to extend coverage or streamline the hospital stay; and for still others, it was a matter of personal choice.

“We couldn’t continue in the old paradigm and deliver safe care, because it was traditionally resident-dependent,” says Dr. Maa, explaining that the 80-hour resident workweek restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME) “annihilated” the old-school model.

The goal in organizing the Society of Dermatology Hospitalists (SDH), according to SDH cofounder Lindy P. Fox, MD, assistant professor of clinical dermatology and director of the hospital consultation service at UCSF, was to ensure 24/7 coverage by a dedicated group of dermatologists whose skill set is focused on inpatient care, and who, because of their involvement with the university hospital, are probably more comfortable with the nuances of inpatient dermatologic care than their outpatient-based colleagues. The SDH currently has 20 members representing about 15 academic programs.

Innovations in stroke treatment caused a “sea change” for the field of neurology, says David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Seattle. Dr. Likosky, who is board-certified in neurology and internal medicine, says the HM model allows neurohospitalists to enjoy a work-life balance.

“It used to be that neurologists didn’t have to get out of bed at night for most strokes. But with innovations in stroke treatments, that’s all changed,” Dr. Likosky says. “It really helped to give birth to the neurohospitalist movement.”

A recent survey on the current scope of neurohospitalists’ practice presented by Dr. Likosky and colleagues at the American Academy of Neurology found that 8% of those surveyed were full-time neurohospitalists. The number might seem small, but it might be a matter of perception. The same study showed 73% of neurologists surveyed listed inpatient neurology care as their primary practice focus.2

Another driver for the neurohospitalist movement was that it became unfeasible to staff inpatient neurology services with physicians who maintained offices “across town,” observes S. Andrew Josephson, MD, director of the neurohospitalist program and inpatient neurology at UCSF. “Stroke is just one example of a disease that has so many emergent therapies that hospitals decided they needed a neurologist on site to make those types of treatment decisions.”

At a quaternary-care center such as UCSF, the requirements for otolaryngology expertise have increased exponentially, says Andrew H. Murr, MD, FACS, vice-chair of the Department of Otolaryngology/Head and Neck Surgery at UCSF. “For instance, our hospital has a huge transplant volume. Often, patients are on immuno-compromising medications that create the specter of fungal sinusitis,” he says. “We also get called to the operating room or ICU when patients have breathing problems and require surgical airways or other complicated intubation schemes. All of these problems require a lot of time, effort, and special expertise.”

Since September of last year, Dr. Murr’s department has been using office space adjacent to the hospital as headquarters for a full-time otolaryngologist whose sole responsibility is to cover inpatient work. Increased complexity of otolaryngologic-related problems, increased ED commitment, and a simple matter of logistics prompted the move. The Department of Otolaryngology moved 10 minutes away from the hospital, so literally running across the street for an otolaryngology consult was no longer an option.

Today, the hospital duty is linked to the department’s call schedule. Dr. Murr anticipates the department soon will establish a full-time faculty position to create a hospitalist niche within the department.

Usefulness Affirmed

Dr. Farber
Dr. Farber

Good results already have been demonstrated for the hospitalist model in other specialties. In the first two years of the surgical hospitalist program at UCSF, response times for surgical consultations averaged less than 20 minutes; the average wait for patients with acute appendicitis to undergo surgery was cut in half; and the number of billable consults rose by almost 200%.3

Heidi Wald, MD, MSPH, FHM, a 2009 Health and Aging Policy Fellow, and two hospitalist colleagues studied the impact of hospitalist programs on acute-care geriatrics and found a paucity of geriatric-care approaches.4 “The employment of geriatrics-trained clinicians by hospitalist programs is one approach to supporting generalist-hospitalists and inclining group culture toward clinical geriatric concerns,” the authors wrote. “Programs that purposefully hired geriatricians and gerontology nurse-practitioners used them to staff geriatrics services.”

Dr. Wald, assistant professor of medicine in the division of Health Care Policy Research and a hospitalist at the University of Colorado Denver, says trends in patient demographics and patient-safety initiatives will drive the proliferation of more geriatrician-hospitalists and geriatrics-focused services in the future. “The median age of the hospital population is increasing,” she notes, “and there are not enough geriatricians to deal with every elderly patient.”

Mount Sinai’s Dr. Farber is in the process of submitting for publication two years’ worth of data about the MACE service at Mount Sinai, which will evaluate the effect of MACE on costs, length of stay, and rehospitalization rates.

Variations on a Theme

The dermatology HM model at UCSF more closely resembles a consultative practice model. UCSF’s dermatology hospitalists do not admit patients. Still, says SDH’s Dr. Fox, because of their conversance with inpatient care and round-the-clock availability, dermatology hospitalists are invaluable. They help colleagues “puzzle out” the causes of cutaneous manifestations of system disease, quickly initiate state of the art treatment for hospital-acquired skin conditions, and improve outcomes for hospitalized patients with skin diseases.

“We see our charge as being multifold,” Dr. Fox explains. “We provide continuity of care for patients who are frequently hospitalized; we keep up with the medical literature; we are comfortable with and know the nuances of hospital operations; and we provide education to residents, house staff, and colleagues.”

Advanced Training Fosters Hospitalist-Geriatric Partnerships

In 1998, when she finished her residency at the University of Pennsylvania Medical School in Philadelphia, Dr. Wald and three colleagues started the hospitalist program at their institution. She directed the program for three years before moving to Colorado with her husband.

Re-examination of her career goals prompted Dr. Wald to seek additional training. She chose geriatrics and became board-certified in that subspecialty. “Geriatrics was both clinically appealing and has a great patient-safety angle,” she says.

Dr. Wald’s advice to hospitalists who share her interest in geriatrics but do not have the time to complete a 12-month fellowship: Attend a mini-fellowship course on geriatrics. Many institutions offer such courses, including Mount Sinai and UCLA.

“Four of the hospitalists on our geriatric service have attended UCLA’s mini-course. In addition, SHM offers geriatrics-themed sessions in many of its CME offerings,” Dr. Wald says. “These efforts to ‘geriatricize’ hospitalists are a great and necessary approach to addressing the care needs of the aging inpatient population. There will never be enough geriatricians, so hospitalists are important partners in this work.”—GH

In Denver, the Acute Care for the Elderly (ACE) service operated by the internal-medicine hospitalist group has only informal ties to the Department of Medicine’s Geriatrics Division, Dr. Wald says. Although not a closed geriatric-care unit, the service concentrates elderly patients on one inpatient service and introduces the tenets of geriatric care—multidisciplinary approach, functional assessment, early discharge planning, mitigating the hazards of hospitalization, and patient and family-centered care—into a hospitalist milieu.

Surgical hospitalist models also vary by setting, and continue to evolve as surgeons examine processes to determine what works and what doesn’t. At UCSF, the original model relied on surgeons taking call for seven days running. “You probably couldn’t do that continuously for your career,” says Dr. Maa, who worked the seven-day call schedule for 3 1/2 years.

The program has been modified so that the surgical hospitalists now work three- or four-day stretches.

Another successful variation involves one surgeon taking all the daytime shifts, while others rotate in for the PM shifts and weekends.

A Win-Win for Hospitalists?

Does the proliferation of specialty hospitalists create competition for patients? That could be a possibility, says Dr. Frost, should other specialty hospitalists become interested in providing care for the “bread and butter” pathologies.

“For instance, if neurohospitalists were interested in evaluating and managing patients with TIAs (transient ischemic attacks), or cardiohospitalists were interested in managing patients with low-risk chest pain, then there could be some competition,” Dr. Frost says. Although possible, he senses it isn’t a likely scenario.

What’s more likely, according to neurohospitalist Dr. Likosky, is cross-fertilization between specialties, where hospitalists who interface with their specialty colleagues gain the benefit of on-site, in-service education. “Many hospitalists feel that they were not adequately trained in neurologic illnesses, and yet, by default, they have become the first-line providers of inpatient neurologic care nationally,” Dr. Likosky says. “The neurohospitalist model is a way of getting at that issue. I don’t think that we are in competition. I think we are welcome partners.”

Dr. Likosky and fellow neurohospitalists Dr. Josephson and W. David Freeman, MD, assistant professor in the department of neurology and critical care at the Mayo Clinic College of Medicine in Jacksonville, Fla., offered the first neurology precourse in April at HM10 in Washington, D.C., and more and more hospitalist meetings are including neurohospitalist courses on their schedules.

Increased education also is a benefit of Mount Sinai’s adaptation of the MACE concept, Dr. Farber says. Because the hospitalist-run MACE patients are located throughout the hospital, the team conducts nursing grand rounds to educate other hospital staff about geriatrics-centered HM principles.

John Maa, MD, FACSThis represents a transformation of the way an academic medical center is structured. We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority.
—John Maa, MD, FACS, assistant professor, Department of Surgery; assistant chair, Surgery Quality Improvement Program; director, Surgical Hospitalist Program, University of California at San Francisco

Economies of Scale

Dr. Fox, the dermatology hospitalist, is the first to admit that UCSF’s practice model probably works best in a large, tertiary-care, academic medical center. However, the potential exists for extension into rural settings with telemedicine models and trained physician assistants or nurse practitioners, she notes.

Dr. Farber agrees the HM model is adaptable to a variety of medical specialties; he foresees geriatric hospitalists working in community settings. “Even in smaller hospitals with fewer discharges, there will be a sizable subset of admissions of patients at risk for high utilization of resources,” he says. “Many of Medicare’s hospital-acquired conditions are geriatrics-related, such as catheter-associated urinary tract infections, central-line infections, and falls. The investment [in geriatrician-hospitalist teams] could be justified if you track the outcomes of these high-risk patients over time and see whether you’re reducing length of stay, direct costs, and readmissions.”

Dr. Likosky says the benefits of the neurohospitalist model closely mirror those of the HM model, and although volumes are lower, the benefits “remain significant even in relatively small hospitals.” His American Academy of Neurology (AAN) survey backs up this observation: Neurohospitalists were about evenly split between academic and private settings (49% and 51%, respectively). “Unlike dermatology, neurologic diagnoses are very common as either a primary or secondary reason for admission to the hospital,” Dr. Likosky says.

In the community setting, surgical hospitalist programs provide a new answer for ED call coverage, Dr. Maa says. Surgical practices often approach the medical center leadership to negotiate a stipend, then contribute salary support so that a new surgeon can be recruited to join the practice. This physician—usually a younger surgeon—then is hired in the role of a surgicalist so that timely patient care and surgeon availability can be ensured.

In rural settings, however, even this model might not be feasible, Dr. Maa says, because surgical practices could be comprised of only one or two surgeons. “We will have to think differently about telemedicine, telesurgery, and having ERs equipped with video monitors so that the ED physician can examine the patient while a surgeon, at a remote centralized area, can provide input,” he says.

Adoption of the hospitalist model by other specialties shows no sign of slowing down. That’s good news for HM and patient care, Dr. Maa says.

“This represents a transformation of the way an academic medical center is structured,” he adds. “We’ve traditionally prioritized research ahead of patient care, but this model is inverting that. It is patient-centered, making them the priority, and answers the question, ‘How can we reconfigure what we have to take better care of patients?’ And that’s why I think we’ll succeed.” TH

Gretchen Henkel is a freelance writer based in California.

References

  1. Krugman SD, Suggs A, Photowala HY, et al. Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit. Ped Emerg Car. 2007;23(1):33-37.
  2. Likosky D. Is it time for neurohospitalists? Neurology. 2009;72(9):859-860.
  3. Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
  4. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006;1(1):29-35.

Unique Factors Propel Proliferation of “ists” at Washington Hospital

By Gretchen Henkel

Unique Factors Propel Proliferation of “ists” at Washington Hospital

“Ists” are multiplying at Providence Regional Medical Center in Everett, Wash. (PRMCE), about 25 miles north of Seattle. The medical hospitalist team manages 90% of the hospital’s medical patients and comprises 34 FTEs, with nocturnists and a palliative-care service; other in-house services include general surgery hospitalists, critical-care hospitalists, orthopedic hospitalists, neurology hospitalists, pediatric hospitalists, and obstetrics hospitalists.

So many “ists” under one roof is unusual for a community-based medical center. One reason for the trend is a highly successful hospitalist program that’s caused other specialists to take notice of the increase in quality metrics and job satisfaction.

“For some reason, we were blessed with an early decision by the hospitalists to acculturate themselves with the hospital’s mission,” says Joanne C. Roberts, MD, FACP, chief of the division of medicine, hospice, and palliative medicine at PRMCE.

The medical hospitalists quickly instituted standardization, quality, and utilization measures, and tied their performance to incentives, says HM medical director Jefferey S. Winningham, MD. For example, every hospitalist is required to leave voicemails for referring physicians upon admittance and discharge of their patients. A 95% compliance rate—validated by surveys of referring physicians—yields bonuses for the HM team.

Quality scores have increased dramatically since 2003, when the hospitalist program took off. PRMCE chief medical officer Larry Schechter, MD, says that the hospitalists’ success has increased the willingness of other specialists to adopt the HM model for delivering inpatient care.

Another factor in the swift adoption of specialist hospitalists: Except for the intensivist service—recipient of the American Association of Critical-Care Nurses’ 2008-2009 Beacon Award for Care Excellence—most of PRMCE’s programs are staffed with physician members of Everett Clinic, a large multispecialty group. “The secret of this community is the large medical groups,” Dr. Roberts says. “Everybody plays well together, especially at the senior leadership level.”

Fewer administrators means nimble decision-making, Dr. Schechter notes. Hospitalists’ internal teamwork is continuously reinforced through bimonthly team meetings; with hospital administrators in steering committee meetings, the hospitalist program has “set a high bar and brought the community together,” Dr. Winningham says.

As PRMCE grows—a new, 12-story tower is set to open in 2011—the hospital is poised to attain its mission of becoming a regional referral center. “To deliver quality at the lowest cost is a really serious enterprise,” Dr. Roberts says, “so getting the hospitalists engaged in that value proposition has been challenging but delightfully fun.”


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