“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.
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.