Sign-offs, change of service, handoffs, inter-shift communications. Whatever the euphemism used, these occurrences symbolize the stigmata of disruption in the continuity of care for the hospitalized patient. The medical literature is saturated with studies pointing to the universal fact that disruption in the continuity of care leads to medical errors, and this ultimately contributes to compromise in patient care and safety. The New England Journal of Medicine article demonstrating that mortality rates are higher on the weekends than on weekdays is just a hint of the negative consequences that result from the disruption of the continuity of care in hospital medicine.1
Disruptions in continuity of care have been viewed as a necessary evil by the medical community. There is an ever-present diametric pull between physician hourly workload and continuity of care. Is the full potential of the hospitalist model undermined by the disruption in continuity of care? As hospitalists, we are fully aware of the inherent benefits of being in-house in terms of delivering efficiency and quality of care. Unfortunately, the weakness inherent in the hospitalist model has been the fragmented delivery of care it provides—a problem that is primarily due to the multiple changes in physician care that set it apart from the continuity of care that a primary care physician model can deliver. In the traditional primary care physician model, a patient is under the care of the primary care physician during hospitalization, with 24/7 pager coverage and occasional weekend sign-ons and sign-offs.
Decatur (Ill.) Memorial Hospital (DMH) is a 350-bed hospital; our facility serves a community of 100,000 and acts as a tertiary center for the smaller medical facilities in the collar counties. All specialty services are represented, including invasive cardiology, interventional radiology, neuro-interventional radiology, cardiothoracic surgery, and neurosurgery. Currently DMH Hospitalist Services has four physicians (with the addition of two more hospitalists planned for July 2007), two physician assistants, and an office manager. DMH Hospitalist Services utilizes a one-week-on/one-week-off system. Because Decatur has no traffic congestion, all hospitalists live 10 to 15 minutes from the hospital by car.
We in Hospitalist Services advocate a paradigm shift: Continuity-of-care disruptions should be minimized by eliminating the process entirely. We didn’t want to improve the sign-off process; instead, we eliminated it. We don’t use the traditional hospitalist model of shift work. Rather we have affected a marriage of the primary care physician model and the hospitalist model, utilizing the advantages of both models in a hybrid system.
In our model, we have eliminated the daily sign-off and sign-on process altogether. The only time there is a sign-off and sign-on is on a weekly basis, when the new service starts its weekly shift on Monday mornings. Instead of the 14 handoffs required in a week for a nocturnist shift model, there is only one physician sign-off and sign-on per patient per week. Because the number of handoffs has been reduced from 14 to one per week, the change of service sign-outs on Monday are performed face to face and at a deliberate pace, with sign-out averages of 15 patients sometimes taking a full hour or more. This luxurious pace is not possible with multiple handoffs per day.
For the patient admitted and discharged between Mondays, there is no disruption in continuity of care in terms of physicians. The hospitalist who accepts the patient on Monday morning will be on pager call for the patient until the next Monday morning when he or she signs off for the week—or until the patient is discharged, whichever comes first.
Responsibilities for new admissions and consults are divided into a 24-hour period, with the physician on call performing all the admissions and consults. During the next 24-hour period, the same hospitalist does not have any admission responsibilities. All new admissions are evaluated in real time by the admitting hospitalists; admissions between midnight and 7 a.m., however, can be evaluated in the morning at the discretion of the hospitalist in conjunction with the emergency department physician, who may write temporary holding orders. All critically ill patients are evaluated in real time.
We have found that there are some key advantages to our model. First, there is true continuity of care. As mentioned earlier, the admitting hospitalist will be the attending physician until the patient is discharged or until the following Monday morning when the relieving hospitalist accepts the patient.
Second, when the hospitalist is paged after hours, patient familiarity aids in the appropriate and efficient management of the patient, with reduction in unnecessary laboratory orders, redundant tests, and overcautious ICU transfers. “When our nurses call the hospitalist about their patients, especially in the evening and night shifts, the nurses are not wasting time and effort educating an on-call physician about the patient, but instead can focus on the acute medical issues at hand, knowing that the hospitalist intimately knows the patient’s background and current medical status,” says Chris Pope, RN, director of the Medical Nursing Unit at Decatur Memorial Hospital. “This gives confidence to our nursing staff that their interactions with the hospitalists will result in appropriate care delivered to the patient.”
Third, the hospitalist has a natural incentive to optimize patient care, knowing that a lackadaisical approach to patient care cannot be pawned to another physician at a later shift: The hospitalist has true ownership and attending status for the patient. I believe that the manner in which a hospitalist program’s infrastructure is set up plays a critical role in the hospitalists’ behavior. Just as collective farms in the communist system were far less efficient and more poorly run than privately owned farms in a capitalist system, hospitalist programs that have more of a collective approach to patient management may offer less motivation for the hospitalist.
Fourth, our relationships and ability to communicate with the patients and their families are strengthened because the confusion about exactly who is the hospitalist in charge of patient care has been eliminated with the removal of nocturnists and weekend coverage. We have found this to be one of the most rewarding aspects of this system because communication is the bedrock of any doctor-patient relationship and is especially important for the hospitalist, who must quickly develop a rapport with the patient. This success is reflected in the fact that our hospitalists have earned among them 20 Decatur Memorial Hospital Exceptional Service Recognition Awards from our patients in the last two years.
Fifth, the nurses and the primary care physician have a clear understanding of which hospitalist/attending is responsible for patient care. The nursing staff was initially shocked that there was no cross coverage, even on weekends and nights; the primary care physician, though, knows exactly which hospitalist is taking care of his or her patient, even after hours. In thinking about my time spent working at a major teaching hospital (a powerfully negative experience, by the way) I found there that, most of the time, I couldn’t get a clear answer from the internal medicine residents who were taking care of my patient. If I rounded early, the service had not picked up the patient from night float; and if I rounded in the afternoon, the service had signed out to the night float, and the night float had no medical knowledge of the patient. I made a personal commitment that this would not happen at DMH.
Sixth, we believe that the ultimate sign-out, the sign-out to the primary care physician on discharge of a patient, is just as critical as any in-house sign-out process. The Hospitalist Services at Decatur Memorial Hospital utilizes General Electric’s Centricity EMR, an electronic medical record system. With modification of the program, we perform our histories, physicals, and discharge summaries electronically.
We have modified the software so the discharge summary serves a triple purpose: The summary serves as a discharge instruction for the patient, including medication reconciliation with electronic prescription printout, as well as instructions for diet, follow-up care, and ancillary services. Secondly, the discharge summary is electronically sent to the medical records department to fulfill the discharge summary requirements of the hospitalization. Finally, the discharge summary is electronically mailed to primary care physicians who have Centricity EMR and is faxed to those who do not. All of these goals are achieved prior to patient discharge. And, as an additional courtesy, all primary care physicians receive a phone call in order to add a human element.
The success of DMH’s Hospitalist Services is directly attributable to the continuity of care that our schedule provides. The hospitalist model was a new concept among the medical staff at Decatur Memorial Hospital. It was met with skepticism among our primary care physicians, mostly because of the strong relationships the physicians had developed with their patients. With the continuity of care provided by our model, however, we were able to market the Hospitalist Services with great success.
“The continuity of care was something my group was very concerned about when we decided to utilize the services of our local hospitalists,” says Michael Wall, MD, FAAFP, who is part of a DMH call group consisting of six family practice physicians. “Prior to our move to the hospitalist model, we would normally cover our own patients throughout the week and sign out to the on-call physician in our group for weekend coverage. Those sign-outs were very detailed and specific, including the nuances involved in [the] care of our ‘special’ patients.
“When we began using the hospitalists, Dr. Yu assured us that the same high quality service that our patients have come to expect from us would continue, including [in] the area of continuity of care,” he explains. “Since our transition, both the physicians and patients have been pleased with the high level of service delivered by our hospitalists. The Hospitalist Services has truly kept their promise to us on all the issues we were most concerned about. Our patients are happy, and our group physicians are happy. It has been a win-win arrangement for everyone.”
According to James Neviackas, MD, who was head of nephrology at DMH before being recruited as a hospitalist in Hospitalist Services, “Actually, the patients in our service receive better continuity of care than the primary care model, since there are no changes of service, even on the weeknights or weekends.”
The obvious major disadvantage of the DMH model is the fact that the hospitalist is on continuous pager call for seven days. But it has been our experience that the incentive to “tuck in the patient” to minimize after-hours pages continuously challenges each hospitalist to optimize medical care for the patient. This is especially true for the critically ill patient, because DMH is a regional tertiary center, and our Hospitalist Services act as accepting physicians for regional transfers to our institution.
We have been successfully recruiting physicians as we expand our services, and our model has not been a source of candidate qualm, even among physicians coming out of residency. What has helped tremendously in the acceptance of our model has been the fact that three out of our four hospitalists have been in a solo practice environment and are used to the concept of continuity of care; they do not see it as a burden but as a duty.
Our service views itself as practice partners with the primary care physicians we provide service to and feel that we are part of their group, not just hospital consultants. “I don’t feel like a hospitalist at all but [instead like] an internist following his own patients through hospitalization,” says Larry Holder, MD, FACP, who was in a solo internal medicine practice before joining the Hospitalist Services. “The schedule gives me the chance to bond with my patients and give them the optimal care that they deserve. Patients and their families frequently ask anxiously if I’m going to be there tomorrow or if there are emergencies [will I] be around. And to be able to say, ‘I’ll be here if you need me,’ gives patients and their families a sense of reassurance and instant bonding with the physician. At the end of the day, our profession is about healing the patient in a compassionate manner and not just about length of stay and cost reductions.”
Using a hospitalist model with multiple disruptions in continuity of care is analogous to having a Formula One race car but only being able to drive in rush hour traffic. The true potential of a hospitalist is constantly hindered when there is disruption in continuity of care. We should not be asking ourselves how to reduce the negative consequences of the sign-off process but, rather, how we can eliminate the process altogether. TH
Dr. Yu is medical director, Hospitalist Services, Decatur (Ill.) Memorial Hospital.
- Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001 Aug 30;345(9):663-668. Erratum in: N Engl J Med 2001 Nov 22;345(21):1580.