Margherita Mascolo, MD

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.