I enjoy hearing about the value hospitalists provide our healthcare system. These stories come from peer-reviewed research, magazine articles, local newspapers, and even the occasional blog. When I talk to hospitalists from around the country, they are often eager to tell of their success and how they made it happen.
Not as often, I also hear about problems that may be a result of the hospitalist model. I think any successful practice, and our field as a whole, must remain open to the weaknesses in the hospitalist model and work continuously to address them. Issues like disruptions in care and poor communication between hospitalists and outpatient providers get a reasonable amount of attention and seem to be on most groups’ radar screens. But there are some potential problems I don’t hear discussed often, and I’m not aware of any significant research that has been published or presented to analyze them. I’ll review two such potential problems here.
Are hospitalists sometimes the cause of a bottleneck in the emergency department (ED)? Hospitalist practice is nearly always credited with improving throughput at a hospital, including in the ED. But many hospitalist practices could impede throughput by delaying patients from leaving the ED when there are multiple simultaneous admissions. Consider the following scenarios:
The pre-hospitalist era: It is 7:30 p.m. and the ED has four patients ready for hand-off to an admitting doctor. There are several primary care groups at the hospital, and each has a doctor on call. Of the four patients needing admission, two go to Dr. Emerson from group A, one goes to Dr. Lake from group B, and one to Dr. Palmer from group C. Because the on-call doctor for these groups is home, he/she provides admitting orders by phone and may or may not see the patient that night. Of course, waiting until the next day to see the patient can be risky. In many cases the ED would have admitting orders on all four patients quickly, say within 30 minutes, and can send the patients up to the floor as soon as the bed is ready.
The hospitalist era: Things can happen differently when hospitalists are at this hospital. All daytime hospitalists are typically signed out to a single night hospitalist (nocturnist) at 7:30 p.m. when the ED has four patients to admit. This solo nocturnist might show up almost immediately after being notified about the admissions by the ED doctor and promptly start seeing the first of the four admissions. But it might take him/her three or four hours or more to finish admitting all four patients. By that time there are probably additional admissions waiting. The ED might end up keeping each patient much longer than in the first scenario.
The difference in these two scenarios is the availability of several doctors to admit patients simultaneously in the pre-hospitalist era. These doctors may be replaced by a single hospitalist who admits patients one at a time.
A clear benefit of the hospitalist system described in this example is that patients are seen in person by the hospitalist at the time of admission, rather than admitted over the phone by the primary care physician (PCP) and perhaps not seen in person by the PCP until the next day. Yet this may come at a cost of creating a bottleneck that didn’t exist in the pre-hospitalist era.