Affiliations
Division of Hospital Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Denver, Colorado
Given name(s)
Nancy
Family name
Maller
Degrees
MD

Curbside vs Formal Consultation

Article Type
Changed
Mon, 05/22/2017 - 18:04
Display Headline
Prospective comparison of curbside versus formal consultations

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).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

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.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

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.

Acknowledgements

Disclosure: Nothing to report.

Files
References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
Article PDF
Issue
Journal of Hospital Medicine - 8(1)
Publications
Page Number
31-35
Sections
Files
Files
Article PDF
Article PDF

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).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

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.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

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.

Acknowledgements

Disclosure: Nothing to report.

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).

Characteristics of Curbside Consultations (N = 47)
 Curbside Consultations, N (%)
 47 (100)
  • Consultations could be listed in more than one category; accordingly, the totals exceed 100%.

Requesting service 
Psychiatry21 (45)
Emergency Department9 (19)
Obstetrics/Gynecology5 (11)
Neurology4 (8)
Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology)8 (17)
Requesting provider 
Resident25 (53)
Intern8 (17)
Attending9 (19)
Other5 (11)
Consultative issue* 
Diagnosis10 (21)
Treatment29 (62)
Evaluation20 (43)
Discharge13 (28)
Lab interpretation4 (9)
Medical concern* 
Cardiac27 (57)
Endocrine17 (36)
Infectious disease9 (19)
Pulmonary8 (17)
Gastroenterology6 (13)
Fluid and electrolyte6 (13)
Others23 (49)

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.

Curbside Consultation Assessment
 Curbside Consultations, N (%)
 TotalAccurate and CompleteInaccurate or Incomplete
47 (100)23 (49)24 (51)
  • P < 0.001

  • P < 0.0001.

Advice in formal consultation differed from advice in curbside consultation26 (55)7 (30)19 (79)*
Formal consultation changed management28 (60)6 (26)22 (92)
Minor change18 (64)6 (100)12 (55)
Major change10 (36)0 (0)10 (45)
Curbside consultation insufficient18 (38)2 (9)16 (67)

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.

Acknowledgements

Disclosure: Nothing to report.

References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
References
  1. Myers JP.Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797802.
  2. Keating NL,Zaslavsky AM,Ayanian JZ.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900904.
  3. Kuo D,Gifford DR,Stein MD.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905909.
  4. Grace C,Alston WK,Ramundo M,Polish L,Kirkpatrick B,Huston C.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651655.
  5. Manian FA,Janssen DA.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145147.
  6. Weinberg AD,Ullian L,Richards WD,Cooper P.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174180.
  7. Manian FA,McKinsey DS.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303307.
  8. Findling JW,Shaker JL,Brickner RC,Riordan PR,Aron DC.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328331.
  9. Pearson SD,Moreno R,Trnka Y.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435438.
  10. Muntz HG.“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456459.
  11. Leblebicioglu H,Akbulut A,Ulusoy S, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724726.
  12. Golub RM.Curbside consultations and the viaduct effect.JAMA.1998;280:929930.
  13. Borowsky SJ.What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497498.
  14. Cartmill M,White BD.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453455.
  15. Olick RS,Bergus GR.Malpractice liability for informal consultations.Fam Med.2003;35:476481.
  16. Bergus GR,Randall CS,Sinift SD,Rosenthal DM.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541547.
Issue
Journal of Hospital Medicine - 8(1)
Issue
Journal of Hospital Medicine - 8(1)
Page Number
31-35
Page Number
31-35
Publications
Publications
Article Type
Display Headline
Prospective comparison of curbside versus formal consultations
Display Headline
Prospective comparison of curbside versus formal consultations
Sections
Article Source

Copyright © 2012 Society of Hospital Medicine

Disallow All Ads
Correspondence Location
Denver Health, 777 Bannock, MC 4000, Denver, CO 80204‐4507
Content Gating
No Gating (article Unlocked/Free)
Alternative CME
Article PDF Media
Media Files

Evolving Practice of Hospital Medicine

Article Type
Changed
Mon, 01/02/2017 - 19:34
Display Headline
Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

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

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions
  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

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

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

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.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

Files
References
  1. SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
  2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
  3. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:15.
  4. Pines JM, Hollander JE, Baxt WG, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510516.
  5. Chaflin DB, Trzeciak S, Likourezos A, Baumann DB, Dellinger RP; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:14771483.
  6. Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
  7. Vasilevskis E, Knebel M, Wachter RM, Auerback AD. California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528534.
  8. Wachter R, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514517.
  9. Auerbach A, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:10791085.
  10. Lindenauer P, Pantilat S, Katz P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  11. Wachter R, Katz P, Showstack J, et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:15601565.
  12. Wachter R, Katz P. The hospitalist movement 5 years later. JAMA. 2002;287:487494.
  13. Auerback AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859865.
  14. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561568.
  15. Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):25892600.
  16. Peterson MA. Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248254.
  17. Kuo Y, Goodwin J. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152159.
  18. Lurie J, Miller D, Lindenauer P, et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441445.
  19. Whinney C, Michota F. Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394397.
  20. Pistoria MH, Amin AN, Dressler DD, et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):130.
  21. Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796801.
  22. Roy A, Heckman MG, Roy V, et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):2831.
  23. Batsis JA. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219225.
  24. Huddleston JM, Long KH, Naessens JM, et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):2838.
  25. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
  26. Simon TD, Eilert R, Dickinson LM, et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:2329.
  27. Siegal E. Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398402.
  28. Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
  29. American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
  30. Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:18691874.
  31. Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247254.
  32. Jaffer A, Michota E. Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
  33. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529533.
  34. Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
  35. Lucas BP, Kumapley R, Mba B, et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276284.
  36. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):14771480.
  37. Scheinder M. Hospitalists can cut ED overcrowding. ACEP News. 2010.
  38. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2E5.
  39. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:129.
  40. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:3566.
  41. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87103.
  42. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:10851091.
  43. Doherty RJ, Barish RA, Groleau G. The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:10471052.
  44. Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:8898.
  45. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:18.
  46. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:2533.
  47. Goodacre S, Nicholl J, Dixon S, et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
  48. Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):5558.
  49. Myers JS, Bellini LM, Rohrback J, et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432435.
  50. Bayley MD, Schwarts JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110117.
  51. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186192.
  52. Darves B. Taking charge of observation units. Today's Hospitalist. July 2007.
  53. Fatovich DM, Nagree Y, Spirvulis P. Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351354.
  54. Nicholl J, West J, Goodacre S, Tuner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665668.
  55. Hoot N, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126136.
  56. Howell E, Bessman E, Kravat S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804810.
  57. Chadaga S, Mancini D, Mehler PS, et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):1718.
  58. Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591596.
  59. Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
  60. Magallanes M. The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:1316.
  61. Darves B. A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
  62. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:167.
  63. Cherlin E, Morris V, Morris J, Johnson‐Hurzeler R, Sullivan GM, Bradley EH. Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357365.
  64. Auerbach A. End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669675.
  65. Lindenauer PK, Pantilat SZ, Katz PP, Watcher RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  66. Muir JC, Arnold RM. Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S14S.
  67. Hertz B. Giving hospitalists their space. ACP Hospitalist. February 2008.
  68. Gesensway D. Having problems findings your patients? Today's Hospitalists. June 2010.
  69. O'Leary KJ, Wayne DB, Landler MP, et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):12231227.
  70. Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
  71. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):19871993.
  72. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):2934.
  73. Hinami K, Whelan CT, Konetzka RT, Meltzer DO. Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401404.
Article PDF
Issue
Journal of Hospital Medicine - 7(8)
Publications
Page Number
649-654
Sections
Files
Files
Article PDF
Article PDF

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

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions
  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

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

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

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.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

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

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions
  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

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

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

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.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

References
  1. SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
  2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
  3. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:15.
  4. Pines JM, Hollander JE, Baxt WG, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510516.
  5. Chaflin DB, Trzeciak S, Likourezos A, Baumann DB, Dellinger RP; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:14771483.
  6. Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
  7. Vasilevskis E, Knebel M, Wachter RM, Auerback AD. California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528534.
  8. Wachter R, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514517.
  9. Auerbach A, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:10791085.
  10. Lindenauer P, Pantilat S, Katz P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  11. Wachter R, Katz P, Showstack J, et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:15601565.
  12. Wachter R, Katz P. The hospitalist movement 5 years later. JAMA. 2002;287:487494.
  13. Auerback AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859865.
  14. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561568.
  15. Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):25892600.
  16. Peterson MA. Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248254.
  17. Kuo Y, Goodwin J. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152159.
  18. Lurie J, Miller D, Lindenauer P, et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441445.
  19. Whinney C, Michota F. Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394397.
  20. Pistoria MH, Amin AN, Dressler DD, et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):130.
  21. Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796801.
  22. Roy A, Heckman MG, Roy V, et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):2831.
  23. Batsis JA. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219225.
  24. Huddleston JM, Long KH, Naessens JM, et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):2838.
  25. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
  26. Simon TD, Eilert R, Dickinson LM, et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:2329.
  27. Siegal E. Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398402.
  28. Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
  29. American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
  30. Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:18691874.
  31. Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247254.
  32. Jaffer A, Michota E. Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
  33. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529533.
  34. Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
  35. Lucas BP, Kumapley R, Mba B, et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276284.
  36. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):14771480.
  37. Scheinder M. Hospitalists can cut ED overcrowding. ACEP News. 2010.
  38. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2E5.
  39. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:129.
  40. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:3566.
  41. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87103.
  42. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:10851091.
  43. Doherty RJ, Barish RA, Groleau G. The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:10471052.
  44. Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:8898.
  45. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:18.
  46. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:2533.
  47. Goodacre S, Nicholl J, Dixon S, et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
  48. Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):5558.
  49. Myers JS, Bellini LM, Rohrback J, et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432435.
  50. Bayley MD, Schwarts JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110117.
  51. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186192.
  52. Darves B. Taking charge of observation units. Today's Hospitalist. July 2007.
  53. Fatovich DM, Nagree Y, Spirvulis P. Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351354.
  54. Nicholl J, West J, Goodacre S, Tuner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665668.
  55. Hoot N, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126136.
  56. Howell E, Bessman E, Kravat S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804810.
  57. Chadaga S, Mancini D, Mehler PS, et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):1718.
  58. Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591596.
  59. Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
  60. Magallanes M. The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:1316.
  61. Darves B. A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
  62. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:167.
  63. Cherlin E, Morris V, Morris J, Johnson‐Hurzeler R, Sullivan GM, Bradley EH. Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357365.
  64. Auerbach A. End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669675.
  65. Lindenauer PK, Pantilat SZ, Katz PP, Watcher RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  66. Muir JC, Arnold RM. Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S14S.
  67. Hertz B. Giving hospitalists their space. ACP Hospitalist. February 2008.
  68. Gesensway D. Having problems findings your patients? Today's Hospitalists. June 2010.
  69. O'Leary KJ, Wayne DB, Landler MP, et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):12231227.
  70. Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
  71. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):19871993.
  72. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):2934.
  73. Hinami K, Whelan CT, Konetzka RT, Meltzer DO. Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401404.
References
  1. SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
  2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
  3. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:15.
  4. Pines JM, Hollander JE, Baxt WG, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510516.
  5. Chaflin DB, Trzeciak S, Likourezos A, Baumann DB, Dellinger RP; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:14771483.
  6. Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
  7. Vasilevskis E, Knebel M, Wachter RM, Auerback AD. California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528534.
  8. Wachter R, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514517.
  9. Auerbach A, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:10791085.
  10. Lindenauer P, Pantilat S, Katz P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  11. Wachter R, Katz P, Showstack J, et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:15601565.
  12. Wachter R, Katz P. The hospitalist movement 5 years later. JAMA. 2002;287:487494.
  13. Auerback AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859865.
  14. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561568.
  15. Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):25892600.
  16. Peterson MA. Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248254.
  17. Kuo Y, Goodwin J. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152159.
  18. Lurie J, Miller D, Lindenauer P, et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441445.
  19. Whinney C, Michota F. Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394397.
  20. Pistoria MH, Amin AN, Dressler DD, et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):130.
  21. Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796801.
  22. Roy A, Heckman MG, Roy V, et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):2831.
  23. Batsis JA. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219225.
  24. Huddleston JM, Long KH, Naessens JM, et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):2838.
  25. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
  26. Simon TD, Eilert R, Dickinson LM, et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:2329.
  27. Siegal E. Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398402.
  28. Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
  29. American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
  30. Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:18691874.
  31. Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247254.
  32. Jaffer A, Michota E. Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
  33. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529533.
  34. Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
  35. Lucas BP, Kumapley R, Mba B, et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276284.
  36. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):14771480.
  37. Scheinder M. Hospitalists can cut ED overcrowding. ACEP News. 2010.
  38. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2E5.
  39. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:129.
  40. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:3566.
  41. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87103.
  42. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:10851091.
  43. Doherty RJ, Barish RA, Groleau G. The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:10471052.
  44. Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:8898.
  45. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:18.
  46. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:2533.
  47. Goodacre S, Nicholl J, Dixon S, et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
  48. Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):5558.
  49. Myers JS, Bellini LM, Rohrback J, et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432435.
  50. Bayley MD, Schwarts JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110117.
  51. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186192.
  52. Darves B. Taking charge of observation units. Today's Hospitalist. July 2007.
  53. Fatovich DM, Nagree Y, Spirvulis P. Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351354.
  54. Nicholl J, West J, Goodacre S, Tuner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665668.
  55. Hoot N, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126136.
  56. Howell E, Bessman E, Kravat S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804810.
  57. Chadaga S, Mancini D, Mehler PS, et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):1718.
  58. Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591596.
  59. Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
  60. Magallanes M. The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:1316.
  61. Darves B. A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
  62. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:167.
  63. Cherlin E, Morris V, Morris J, Johnson‐Hurzeler R, Sullivan GM, Bradley EH. Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357365.
  64. Auerbach A. End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669675.
  65. Lindenauer PK, Pantilat SZ, Katz PP, Watcher RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343349.
  66. Muir JC, Arnold RM. Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S14S.
  67. Hertz B. Giving hospitalists their space. ACP Hospitalist. February 2008.
  68. Gesensway D. Having problems findings your patients? Today's Hospitalists. June 2010.
  69. O'Leary KJ, Wayne DB, Landler MP, et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):12231227.
  70. Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
  71. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):19871993.
  72. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):2934.
  73. Hinami K, Whelan CT, Konetzka RT, Meltzer DO. Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401404.
Issue
Journal of Hospital Medicine - 7(8)
Issue
Journal of Hospital Medicine - 7(8)
Page Number
649-654
Page Number
649-654
Publications
Publications
Article Type
Display Headline
Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies
Display Headline
Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies
Sections
Article Source
Copyright © 2012 Society of Hospital Medicine
Disallow All Ads
Correspondence Location
Department of Hospital Medicine, Denver Health Medical Center, 777 Bannock, MC 4000, Denver, CO 80204‐4507
Content Gating
Gated (full article locked unless allowed per User)
Gating Strategy
First Peek Free
Article PDF Media
Media Files