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Universal admitters: hospitalists' new identity?
Hospitalists make peace with a new paradigm

Keywords: Hospitalists' new paradigm: admitting just about everyone


by Paula S. Katz



Published in the June 2013 issue of Today's Hospitalist

IT STARTED SIX YEARS AGO when short-handed orthopedic surgeons asked the hospitalist service at Gwinnett Medical Center in suburban Atlanta to handle some of their patients admitted for hip fracture. Once word spread of how efficient it was to have a hospitalist as the admitter of record— starting pain management and discharge planning sooner—it didn't take long for other specialists to get on board. Today, the hospitalists are the hospital's default admitters, deferring only on elective orthopedics, major trauma, pediatrics and certain pregnant patients.

Taking more admissions has led to rapid changes
"Going into meetings with the idea that we're going to protect our turf won't work."

–Brian Bossard, MD
Inpatient Physician Associates

for the group: The average daily census jumped from 45 in 2006 to between 190 and 200, while the number of hospitalists in the hospital-employed service tripled from 10 to 30. The hospitalists' expanded role is also reshaping their identity from traditional medical admitters to universal ones, something Bedri Yusuf, MD, associate medical director of the hospitalist program, predicts will occur in his group within five years.

"The ED's happy because patients are leaving quicker," Dr. Yusuf says, "and patients are happy because they're not stopped in the ED. Specialists don't have to stress out from their office, and administrators like the lower cost per case and length of stay. It's a win-win."

Some say the move toward universal admitting was a given, starting the day hospital medicine admitted its first patient. But the trend has picked up steam as hospitals look to meet new quality metrics and maximize income. And hospitalists have proven what they bring to the table: better medication reconciliation, improved documentation to boost case mix index and reimbursement, and enhanced patient satisfaction.

Yet there are challenges, from accommodating individual specialists to coordinating with the ED. Plus, some hospitalists fear that they're moving out of their clinical comfort zone with an ever-burgeoning patient load.

Others contend that the path toward universal admitter feels like a step back toward resident status. Still, analysts say, it's time for hospitalists to make peace with the idea that their admitting role may be changing for good.

"There's a risk in being everything to everybody," admits Brian Bossard, MD, director of Inpatient Physician Associates, with 25 hospitalists working with Bryan Health in Lincoln, Neb. "But our mindset can and should be taking care of a larger percentage of patients in the hospital."

An easy sell
Unlike the initial resistance hospitalists met when taking over admissions for primary care physicians, taking on specialists' admissions hasn't been a hard sell.

Specialists used to hospitalist coverage at night, for instance, can easily segue into more, says Timothy Osonma, MD, medical director for the practice at Southwest Texas Methodist Hospital in San Antonio, part of IPC The Hospitalist Company, a national group practice company.

"Specialists are comfortable with us taking admissions at night," Dr. Osonma notes, "so why not during the day?"

Then there's the issue of money. "It can save hospitals up to $2,000 a night to pay specialists to take call," explains Kimberly A. Bell, MD, the Seattle-based regional medical director for EmCare Hospital Medicine, West division. "Hospitalists also relieve the tension between surgeons over managing call during coverage gaps."

Given increasingly complicated inpatients, Dr. Bell adds, it also makes sense to take the stress off specialists. Consider, for example, a 75-year-old patient on three medications with high blood pressure and diabetes who breaks a hip. "The hospitalist may think this patient is stable, what's the big deal?" she notes. "But specialists might say, 'Managing these problems and prescriptions is not my thing.' And they're right."

And with the pressures of health care reform, hospitals hope to see a positive impact on readmissions. The patient with a broken hip admitted by an orthopedic surgeon may go home and fall again, says Dr. Yusuf. But when hospitalists admit that patient, they evaluate the reason behind the fall, coordinate care with rehab, and assess family needs to prevent another fall and another admission.

"You break that cycle," Dr. Yusuf says.

At the 15-bed Gifford Medical Center in Randolph, Vt., taking on specialist admissions is key to retaining those specialists, says Martin C. Johns, MD, medical director of the hospitalist division. Hospitalists there admit for urologic surgery because the urologist is onsite only one or two days a week.

Another factor driving hospitalists toward more admissions: Subspecialists are frustrated with electronic medical records. It makes sense to hand off the computer work associated with being the admitting physician to hospitalists, who log in much more screen time.

Making it work
But taking on more admissions won't work unless hospitalists have a solid relationship with specialists, something that can take years to build, says Dr. Bossard. He recommends having group leaders and ED representatives meet face-to-face to establish criteria, responsibilities and objectives upfront.

"That's the time to hammer out details such as emergent consults," he says. "That recognizes that in the heat of the moment, everything can fall apart." After that, he says, continual and informal interaction sustains the relationships, and thus the process.

Service arrangements also vary by hospital size and culture. "It's easier to take on admissions at a small, community-based hospital because we know each other by name and call each other directly," says Albert Langou, MD, interim chief and medical director of hospital medicine for the 16-physician Eastern Connecticut Health Network, which is based in Manchester, Conn. "I used to work at a larger hospital, and it can be an issue if there are 1,000 beds and dozens of doctors you don't know." More specialists are asking Dr. Langou and his colleagues to admit pulmonary, cardiology and hematology/oncology patients.

Felix Aguirre, MD, vice president of medical affairs for IPC The Hospitalist Company, recommends hammering out admitting algorithms. "An informal process can work for small places with only three or four specialties," Dr. Aguirre says. "But with bigger facilities, you need something more formal. Admitting algorithms say, 'This is what we expect,' and help you avoid turf wars and misunderstandings."

When putting together algorithms, Dr. Aguirre adds, it's important to leave room for case-by-case outliers. While hospitalists might easily admit GI patients with anemia and a hemoglobin of 12, for example, they would expect the ED to be able to call in the specialist if the hemoglobin was five.

While he works in a small hospital, Dr. Johns at Gifford Medical Center worked with specialists to create order sets and standardized protocols. Knee replacement patients, for instance, typically get 14 days of Lovenox while hip-replacement patients usually receive 28 days of Coumadin. That upfront work, he says, "helps those admitting avoid the time-consuming process of managing each situation separately."

At Gwinnett, hospitalist leaders first met with the ED to establish a system to handle new admissions, and they now meet monthly to discuss patient flow. When new specialists come on board, the ED calls them when they have an admission to ask if they want the hospitalist to take it. Otherwise, when patients are admitted for specialists, the ED gives those specialists a courtesy call, letting them know how soon a patient needs to be seen. If the ED doctor is not sure how quickly a consult may be needed, the admitting hospitalist makes that call.

Need for flexibility
Some patients may be outside your comfort zone because of support. If there's a patient with an acute MI but no one to take that patient to the cath lab, for instance, EmCare hospitalists won't admit that patient, Dr. Bell explains. It's another condition to be worked out in advance.

And hospitalists agree that they need the ability to make on-the-spot admission decisions. At Gwinnett, if a patient has a nose bleed that the hospitalists can't stop, they will admit the patient only if they know a specialist will be available immediately.

"We would insist to the ED that we are happy to admit the patient, but the ENT should be willing to see him," Dr. Yusuf says. In such cases, the ENT packs the bleed, calls the OR and documents that he or she is the physician on record.

And hospitalists who worry that they may have trouble getting specialists to live up to the letter of service agreements may want to submit those to a governing body in the hospital, such as the medical executive committee, to be approved, says G. Bruce Waldon, MD, director of the hospitalist division for the Northwest Health System in Bentonville, Ark.
In previous positions, Dr. Waldon says he's seen situations in which specialists have pulled out of an agreement or "reinterpret" it if they didn't want to care for a particular patient.

"If they have to answer to a board of their peers, it makes it more difficult for them to be noncompliant," he says. "Hospitalists cannot be expected to put themselves at increased liability because of a surgeon not showing up or not being available."

Growing staff
When it comes to increased liability, hospitalists say they consider that risk in making a case for expanding staff. If practice size doesn't grow along with caseloads, experts agree that quality of care will suffer and physician burnout will escalate.

"If you open the door wide, you get tons of patients and then hospitalist resentment," says Dr. Yusuf. "When we hit a threshold of asking for a lot of back-up, it automatically triggers hiring."

Gwinnett, which aims for an average daily patient load of 18, uses the criteria of needing back-up more than half the time for three months to ask for more staffing. "If you're paying somebody a premium to do work every day for three months, it's cheaper to hire two people," Dr. Yusuf explains. "I'll also lose hospitalists to burnout if I don't."

Dr. Bell cautions that hospitalists shouldn't expect pay increases to accompany the added caseload unless their contract is structured accordingly. RVU-based incentives for extra work may kick in at certain hospitals, she notes.

Hospitalist satisfaction
Then there's the issue of keeping hospitalists happy. If, say, an orthopedic patient with underlying diabetes and high blood pressure comes to the ED for an orthopedic reason, hospitalists might ask why they should admit a patient with no medical conditions, says Dr. Yusuf. "The hospitalist might feel like a resident, and there's no prestige in that."

That became a problem for Dr. Waldon who, in 2007, worked at a hospital with a universal admitter model. He and his colleagues found themselves admitting 20-year olds with acute appendicitis. With such patients, he says, hospitalists felt they brought no value to anyone except the surgeon who, despite being paid call pay, was expecting someone else to admit the patient.

"I never mind being involved if I can bring value to patients' care," says Dr. Waldon. At the same time, he adds, the definition of hospitalists' "value" is now very different than it was six years ago.

"We do many things better than other specialists in terms of performance and care coordination," he says. While he never sees hospitalists moving toward admitting, say, trauma patients, "We need to embrace the value that we bring and figure out how to judiciously take on more admissions."

A new paradigm
For Dr. Yusuf, the best way he's found to combat hospitalists' concerns about being placed in a subservient role is to become more involved in medical staff leadership. That way, he says, hospitalists will always be dealing with specialists as their peers.

And instead of resisting change, sources say, hospitalists need to acknowledge that there's a new paradigm. "Figure out how to provide value to who's writing the check," says EmCare's Dr. Bell. "That may be keeping surgeons happy because they bring revenue to the hospital. That helps the bottom line, which allows them to pay you."

She grants that the trend may rub some hospitalists the wrong way. "But the reality is that this is a business," Dr. Bell says. "The hospital is a customer and we have to work to meet its needs."

In the end, says IPC's Dr. Aguirre, "there will be some degree of universal admitter everywhere, and we need to plan for it." Take one service on as a pilot, he recommends. Then "plan over a year or three which specialties to incorporate, if they're available and how to get them on board."

At Gwinnett, having hospitalists take on new admissions led to launching a separate palliative care program. In seeing more patients with readmission issues like COPD and heart failure, hospitalists realized there were no doctors to do palliative care and took the initiative. Six hospitalists now work in that service.

That's the type of innovation possible, says Dr. Bossard, as hospitalists expand their scope of influence.

"The greatest difficulty for hospitalist groups is not recognizing the value in being on the front lines of caring for the majority of patients," Dr. Bossard says. "Going into meetings with the idea that we're going to try to protect our turf and reduce the number of patients we carry by establishing rules to protect us won't work."

Paula Katz is a freelance health care writer based in Vernon Hills, Ill.
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