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Emergency departments discover hospitalists are a secret weapon
While you’re waiting for three physicians to return your calls about their patients in your ED, you anxiously watch the clock and realize that if they don’t call before leaving the office, they aren’t likely to call until tomorrow. Don’t you have enough to worry about without trying to track down dozens of physicians all the time?
Some hospitals have decided ED managers can be more efficient — and patients will benefit — if in-house physicians can handle much of the daily care of patients in the ED and beyond. Hospitalists increasingly are coming to the rescue, and ED managers welcome them with open arms.
Unlike most other physicians, hospitalists can care for a wide range of patients within the hospital and continue with a patient for long periods. By being available around the clock, hospitalists are able to attend to a patient’s changing condition as it occurs, proponents say, rather than having care delayed until the primary care physician can arrive.
Hospitalists complement the practice of emergency physicians by focusing timely attention on admitted patients, says James J. Augustine, MD, FACEP, vice chair of clinical operations in the department of emergency medicine at Emory University in Atlanta, and director of clinical operations at EMP, a physicians group based in Canton, OH. He says the use of hospitalists is growing across the country and promises substantial benefits to EDs in particular.
"Hospitalists benefit the patient by rapidly directing the work-up and treatment, the same goals as emergency physicians," he says. "Efficient movement of patients through evaluation and treatment and back to the outpatient setting will make the hospitalist group successful, just like the ED group."
One of the most tangible benefits to EDs is that the hospitalist presence in the hospital keeps the ED physicians or managers from making long series of calls to community-based physicians, the same physicians who are so busy making their outpatient offices work efficiently, Augustine says. The hospitalist then arranges appropriate consults and works quickly to begin arrangements for dismissal of the patient.
"The ED physicians and the hospitalist group often use a very collaborative approach to the design and implementation of care protocols," he notes. "These protocols encourage time and cost-efficient work-up and treatment, and lower the length of stay for many inpatients. Collaborative inpatient management is also good risk management practice for both groups."
Hospitalists also can improve patient satisfaction by speeding patient management, he says.
Help standardize inpatient care
Providers are adopting the hospitalist model at a rapid pace, and EDs can be a primary beneficiary, says Ron Greeno, MD, chief medical officer and senior vice president of physician services at Irvine, CA-based Cogent Healthcare, one of several companies that provide hospitalist services across the country. The system of hospitalists is very different from the traditional model of primary care physicians coming to the hospital to care for individual patients.
"Every hospital I’ve ever worked in has had the goal of trying to standardize care given by physicians within the walls of the hospital," Greeno says. "The first big obstacle is the sheer numbers. With 400 physicians giving care, and most only spending small parts of the day in the hospital, they’re much more concerned with their private practice than your hospital goals. The second obstacle is the way physicians are paid."
The typical payment system for physicians provides "a reverse incentive" for speedy care, because they are paid more money when the patient stays in the hospital longer and more treatment is provided, he explains. That is a direct conflict with hospitals, which are paid a flat rate based on diagnosis, motivating their clinicians to get the patients out as quickly as possible.
ED reaps benefits of hospitalist program
The recent arrival of hospitalists has been a boon to Brookhaven Memorial Hospital Medical Center in East Patchogue, NY, says Paolo Coppola, MD, ED director.
"The Cogent [Healthcare] hospitalists have made a significant difference in the efficiency of the emergency department in our hospital," he says. "The emergency physicians no longer have to wait for the doctor on call to come in to admit a patient after or before their office hours or in the middle of the night. This was very taxing for the doctors and inconvenient for everyone, especially the patients who had to wait to be seen."
Coppola says Brookhaven adopted hospitalists about a year ago, and predictably, there was some resistance from physicians who felt threatened by the new system. But it didn’t take long for them to realize that hospitalists take a lot of pressure off other physicians, usually in the form of uninsured patients and others who aren’t highly reimbursed.
Once the hospitalists admit the patients, patients begin their program of care under the hospitalist team, and the emergency physicians can turn their attention to the new patients presenting in the ED, Coppola says. About 20% of patients coming through his ED go to the hospitalist service, which has four hospitalists on staff.
"The hospitalist physicians really have become valuable members of our team," he adds. "They have been a huge help with improving the flow of the patient in the ED, definitely."
Hospitalists more available to ED
One reason for the improved patient flow in the ED is that it is easier for ED staff to get to know one group of hospitalists rather than 120 physicians on call, Coppola says. Thus, they work more cohesively and quickly as a team, he says. Another reason is that hospitalists are much more available because they are not dividing their time between hospital rounds, office hours, and other demands.
"Every minute counts. If you’re waiting 20 minutes for a doctor to return your page, multiplied by 15 admissions that day, that’s a lot of time wasted," he says. "With hospitalists, I can call him up, and he actually picks up the phone."
The lead hospitalist at Brookhaven, Sayeed Syed, MD, FACP, FRCP, says the use of hospitalists has helped the facility shorten length of stay and increase bed turnover. No specific figures for the improvements are available yet because the program is just 1 year old.
"The hospitalists help reduce length of stay for inpatients, and that in turn helps the ED move patients out faster," he says. "The patients who are staying in the ED for two days waiting for a bed can get moved out much faster. And we are available all day here, so we can change the patient’s condition whenever it is appropriate. We can downgrade a patient to a regular unit at 3 a.m. instead of waiting for another doctor’s rounds the next morning, and that opens up that intensive care bed."
Syed says ED managers usually are some of the strongest supporters of hospitalist programs because they see the benefits so directly. But how do you go about getting hospitalists in your facility? Well, don’t think you can do it on your own. Adopting a hospitalist program is a major endeavor for any hospital, and you’re going to need the support of the medical staff to make it happen.
"An ED manager coming up with this idea isn’t going to be persuasive enough to make it happen, but the medical staff can have a lot of influence if you get them on your side," Coppola says.
"Plant that bug in the ear of the medical staff, and show them how much they can benefit because they’re not going to called in the middle of the night as much and they’re going to have more time for office hours. Once they get excited about it, the idea can move forward," he adds.
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