Patient Care

Establish Rules of Engagement before Covering Ortho Inpatients


 

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

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  • Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
  • Medicine does the admission and medication reconciliation (“med rec”) at discharge;
  • There is shared discussion on the need for transfusion; and
  • There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

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