When hospitalists stepped into Parkland Hospital (Dallas) a few months ago, they knew they were taking up a new challenge. Initially, they were known as the doctors without a team in a place where everyone was used to seeing no fewer than six to eight physicians rounding in a group.
Soon our hospitalists realized that a lot of teaching and awareness was needed among the nursing and support staff of the hospital to get them ready for this new breed of physicians.
A Case of Nerves
After four years of administrative planning and developing, the hospitalist program finally started in July 2006. Parkland started a hospitalist program due to the new restrictions on resident work hours and the number of patients a resident can admit. There used to be a considerable delay in the admission process causing patients to wait in our emergency department (ED) for hours until an admitting team could see them. This led to higher patient load in the ED. This load not only affected our patient care adversely, but it also caused considerable financial loss to the hospital because we couldn’t bill for admission until the patients were assigned a bed.
Our hospitalists help ease this overcrowding because they don’t work under these restrictions and can increase the ED throughput of the patients. Parkland also instituted a hospital medicine program to decrease length of stay.
Initially there was a lot of excitement, nervousness, and anxiety about the program. When I say nervousness and anxiety, it was primarily related to the nursing and administrative staff’s skepticism about how they would deal with full-time attending physicians. They wondered whether hospitalists would be easily approachable or not. How would they compare with medical residents?
Fortunately, during the next few months, this anxiety gave way to a new trust between the nurses and the hospitalists as the nurses realized that their concerns were answered promptly. Nursing staff also enjoyed a new benefit: the ability to communicate directly with the attending physicians and, in the process, the potential to play a greater role in the medical management of their patients.
Initially we hired eight hospitalists (actually we started with two because the others were in the process of getting credentialed). We handled the workload in the beginning by limiting the number of admissions each day for each hospitalist until everyone was on board. One hospitalist was already a Parkland doc; the rest were hired from outside.
Like many new hospital medicine programs, Parkland’s hospitalists were venturing into a place where the nursing staff’s involvement in patient care was different from that of their private counterparts.
Background: Parkland Hospital is the main teaching site for the University of Texas Southwestern Medical School and Residency Training Program. The residents and medical students are involved to a great extent in patient care. They assume most patient care responsibilities, including placing PPDs (tuberculosis skin tests), caring for wounds, taking arterial blood gases (ABGs), and removing peripherally inserted central catheter (PICC) lines—to name just a few.
As a result of the residents’ involvement, our nursing staff took a back seat in these aspects of care. But once our hospitalists entered the picture they didn’t have the support of medical students or residents. Therefore, to increase the hospitalists’ efficiency in seeing more patients, the onus of doing those procedures fell on the shoulders of the nursing and paramedic staff. Educating the nursing and paramedical staff to help them regain autonomy and play a great role in patient care was a new challenge for the hospitalists.
We achieved this goal by holding a series of meetings in which physicians, including hospitalists and administrators, worked continuously on these concerns. Also, more operational issues were identified. Among them:
- Giving telephonic verbal orders to nurses for medications, laboratory studies, and radiology procedures, which was not the case with residents;
- Easing restrictions on the use of different medicines that usually require approval of attending faculty for the resident teams; and
- Setting up new dictation lines for our hospitalists (residents have to write their own patient histories and physical assessments).
We resolved to ensure that the program would run like any other private hospitalist program.
Modifications and Scheduling
Other services, including pharmacy, wound care, medical records, and pathology, were also approached by the hospitalists—including the medical director and chief of general internal medicine. The pharmacy was approached to ease restrictions on the medicine prescribed by hospitalists (as opposed to rules for residents, who have to work under different restrictions because they are training.)
Wound-care nurses were asked to implement their orders after telephone approval by the hospitalists (again, this is not the case with resident services). The Medical Records Department created a separate way to handle incomplete medical records for hospitalists—one that takes into account their week-on/week-off schedule. All these requests are now in different phases of approval and implementation.
Overall Parkland has responded well to these changes by appointing senior leadership to fast-track several of these recommendations. Many more policies are under review to complete the transformation from a resident-run model to one that is run by hospitalists.
Like any other new program, the hospitalist program at Parkland went through the growing pains of choosing the right kind of schedule to meet the expectations of the hospital as well as the professional expectations of its doctors. As mentioned above, we currently employ eight hospitalists. Four hospitalists work a week of 12- to 13-hour shifts; they are then off the following week. At that time the other four hospitalists take over for their counterparts. We cover nights using nocturnists.
When the program was not fully staffed there were fewer teams, depending on the number of hospitalists on shift. After the first two hospitalists were hired, we added one team to bring the total number of teams to four. Our teams worked the week-on/week-off schedule. During our initial start-up, the odd-numbered hospitalist who didn’t have a partner to work in week-on/week-off mode worked Monday through Friday each week with weekends covered by one of the main teams.
One of the most important considerations in a hospitalist’s job is the need for flexibility in working hours as compared with the schedule used in a traditional internal medicine practice. At Parkland, hospitalists see 10 to 12 patients in a week. During their week off from patient duties, they are free from all clinical duties and can handle administrative duties, conduct research projects, and accomplish any other tasks awaiting their attention.
Dual Launch Benefits Both Hospitals
At the same time the Parkland Hospital Medicine Program was launched, the Southwestern University also started a hospitalist program at St. Paul University Hospital, Dallas. The Department of Medicine of the University of Texas Southwestern oversees both the programs. All hospitalists are hired by Southwestern University and are part of the Department of General Internal medicine.
The common leadership of both of these programs in the Department of Medicine led to the implementation of a variety of policies derived from the best practices of the two groups. The interaction between these programs has been fruitful. The exchange of physicians credentialed at both hospitals has also reduced the staffing problems that tend to occur due to vacations, holidays, and illness.
Working toward the Future
As we settle down, fully staffed with eight hospitalists, we have started participating in the hospital’s administration by joining various committees. Our hospitalists participate on the pathology clinical advisory committee, the antibiotic committee, the medical reconciliation committee, and the utilization review committee.
Every day brings new challenges and continuous hard work. To make a successful program, it is not only important to grow out of the teething problems, but also to provide exceptional care so that the idea of a hospitalist program is well thought of by the hospital administration. Two of our teething issues included:
- General acceptance of our hospitalists as attending physicians by nursing, support staff, and the other physicians—not as trainees interacting with residents for patient care; and
- Recognition of the distinction between residents who traditionally work under several restrictions as a part of their training as compared with hospitalists who have already undergone training in their field.
Naturally, the hospital wants improvements in both short-term and long-term quality of care. The advantages the hospitalists provide include rendering consistent quality of care, developing new clinical pathways to provide efficient care, and ensuring greater continuity of care.
Regarding specific expectations, for example, SHM advocates 10 to 12 patient encounters per day as adequate. And so we expect our hospitalists to see that number of patients. Other expectations we have:
- That our hospitalists be involved in research projects on patient safety and quality of care; and
- That our hospitalists be involved in developing clinical pathways.
The future of the hospitalist program at Parkland Hospital is bright. As part of the university’s teaching faculty, our hospitalists will be progressively more involved in resident and medical student teaching. As a result, as time goes on, the schedule will have to change in order to provide both continuity of patient care and continuity in the teaching service. While our schedule now works well, we expect to get involved in a resident teaching service to a greater extent, as well as medical consult service and perioperative consult and care. These additional responsibilities may change our schedule.
The hospitalists are actively involved in developing an inpatient curriculum for the residents, along with a new set of standard orders suited to hospitalist practice. Other areas the hospitalists will become more involved in include pre- and perioperative consultations and co-management of surgical and orthopedic patients. We are also working on special hospital projects, focusing on patient safety and hospital efficiency.
The hospitalists at the University of Texas Southwestern put in nothing less than their best efforts. After all, “High achievement always takes place in a framework of high expectation” (Jack Kinder, motivational author). TH
Dr. Mohan is the medical director of the hospital medicine program at Parkland Hospital, Dallas.