In 1994, Jack Rosenbloom was admitted to an Indiana hospital after suffering a serious heart attack. While in the critical care unit (CCU) of the healthcare facility, he experienced a major relapse, prompting a “code blue” situation. Although the floor nurse called for assistance instantaneously a physician did not arrive in CCU until 1 hour later — too late to save Jack Rosenbloom. Convinced that the immediate presence of a physician could have spared her husband’s life and surprised that round-the-clock, on-site coverage was not required in a hospital setting, Myra Rosenbloom decided to pursue Federal legislation that would mandate such a policy and ensure the safety of all patients in the future. The result was the drafting of The Physician Availability Act, which directs any hospital with at least 100 beds to have a minimum of one physician on duty at all times to exclusively serve non-emergency room patients. In June 2003, Pete Visclosky (D-Indiana) introduced H.R. 2389 to the U.S. House of Representatives; it has since been referred to the Energy and Commerce Committee’s subcommittee on health.
Although it is not clear if or when HR. 2389 might become law, the bill is emblematic of the pressure hospitals are experiencing to provide round-the-clock physician coverage. Hospital administrators are keenly aware of the importance of creating and implementing protective and preventive measures to ensure the best possible quality care and safety for all inpatients. Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, emphasizes that patients expect to see a doctor, regardless of the hour or day. “If there is no doctor to treat the patient, it’s like going to a major league baseball game and seeing minor league players,” he says. More important, Inlander notes that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is considering the addition of requirements similar to the ones specified in the pending Physician Availability Act (1).
Today, most hospitals use traditional physician on-call systems to provide overnight coverage. These systems are not always effective or efficient for patients, physicians, nursing staff, and other hospital departments. Delay of care may jeopardize a patient’s medical well-being. Nurses become frustrated trying unsuccessfully to locate on-call physicians in a timely fashion in the case of a medical emergency. On-call physicians cannot enjoy a normal lifestyle and may suffer from overwork. The emergency room may experience a backlog of patients waiting for admission until the doctor arrives in the morning, creating logjams for other hospital departments.
Direct and Indirect Value
Hospitalists can alleviate these issues and add direct value to a healthcare facility through the implementation of a 24/7 program. Their positive impact affects patients, first and foremost, as well as various hospital departments and staff, hospital recruitment efforts, and the healthcare facility’s fiscal status.
Emergency Department (ED)
As an on-site fully trained physician, the hospitalist is available to conduct emergency room evaluations and enable the timely admission of patients. By tending to ED cases immediately, the hospitalist can prevent unnecessary delays and ensure efficiency in this department. Also, this prompt action prevents the need for “bridging orders,” whereby an ED physician writes temporary orders until the patient can be seen and admitted in the morning by the primary care physician (PCP). The absence of lag time between an emergent situation and the on-site presence of a physician might mean the difference between short-term treatment/rapid discharge and a lengthy hospital stay.
Depending on medical staff bylaws, some hospitals routinely handle late night and early morning admissions over the telephone. In a traditional on-call system, the attending physician may provide orders over the phone to admit a patient following a discussion with the ED physician. Formal evaluation of the patient would not take place until the following morning at rounds or later in the evening after office hours. This practice may result in delays in patient management and often increases the duration of hospitalization.