Key takeaways:
- ENT hospitalists are a small but growing group nationwide
- What conditions ENT hospitalists treat in-house
- How having a dedicated ENT in the hospital benefits patient care
- The improved efficiency with treatment and procedures that ENT hospitalists deliver
THERE’S ANOTHER ADDITION to the constellation of specialties that have taken the hospitalist model and made it their own. In a small but growing number of academic centers, in-house otolaryngologists are taking on a new moniker: ENT hospitalist.
Meet Ran “Annie” Wang, MD, an otolaryngologist now in her second year as the sole ENT hospitalist at Houston Methodist Hospital in Houston. Today’s Hospitalist spoke with Dr. Wang about how she helped create her own position and how both patients and the hospital benefit from her dedicated inpatient practice.
How her position came about
Dr. Wang realized that Houston Methodist would benefit from having an ENT hospitalist during her ENT rotation there as a resident. She then pitched that position to the chair of otolaryngology.
“I was impressed by the sheer volume of consults,” Dr. Wang recalls, noting that having three ENT inpatient consults a day is a “very light day” for the service. “Given the number of patients we were following and the complexity of hospitalized patients, it seemed clear we could benefit from a dedicated ENT inpatient surgeon.”
When Dr. Wang made that pitch, she learned that leadership had been considering just such a position but had not made much progress with it. (More than 10 years ago, one pioneering ENT at the University of California, San Francisco, became a prominent advocate of the model.) Over the course of a year, Dr. Wang worked with the department to create the ENT hospitalist service line and then accepted the job she helped create.
A new model of care
The Houston Methodist ENT hospitalist line is one of only a few in academic centers across the country. In some programs, an ENT hospitalist works with APPs, while others—including Dr. Wang’s—center the service around consult care with resident physicians. While the nationwide sample is small, it’s growing, Dr. Wang says.
The benefits of an in-house ENT
“People see the advantage of shifting the care model so that instead of collectively distributing consults among different ENT surgeons, you have only one overseeing the majority of inpatient and emergency room consults,” Dr. Wang says. With a dedicated ENT hospitalist, Dr. Wang’s ENT partners can focus on their scheduled outpatient surgeries and procedures. She does, however, call on those colleagues when inpatients are so complex that they need further subspecialty care.
“Having one person—or a few people—focus in one specific setting leads to more predictability and consistency.”
Ran “Annie” Wang, MD
Houston Methodist Hospital
On the inpatient side, “having one person—or a few people—focus in one specific setting leads to more predictability and consistency for the units and the teams consulting our service,” she points out. In addition to reliable and prompt inpatient care, that consistency makes a difference in patient coordination, inpatient surgery scheduling, faster turnaround for ER and inpatient consults, and more comprehensive post-discharge follow-up for hospitalized patients.
That consistency also extends to the OR where, Dr. Wang says, she serves as a consistent point of reference for all the different anesthesia and nursing team members in the specialized ORs. “The whole hospital,” she says, “has been very, very happy with the results.”
Schedule and the diagnoses she treats
Dr. Wang works 6 a.m.-3 p.m. Monday through Friday. For four of those days, she does inpatient consults and procedures. During the week, she also blocks out a half-day for outpatient follow-ups and procedures, many with patients discharged from the hospital. She also sets aside a half day each week for operating block time.
According to Dr. Wang, procedures make up about half of her inpatient work.
“I see a lot of tracheostomies and laryngology, with about half of my inpatient consults having something to do with the airway, voice or swallowing,” she says. On the rhinology side, “there are nosebleeds, invasive sinusitis, and sometimes sinonasal masses or lesions found on imaging.” Dr. Wang also treats skin and soft tissue masses and infections requiring incision and drainage. Ear-related consults include TMJ-related pain, middle-ear fluid, ear infections and mastoiditis.
“A lot of these consults are the same as bread-and-butter outpatient ENT consults,” Dr. Wang notes. “But in the hospital, they’re applied to a special subset of patients.”
She has also done emergency intubations and surgical airways as part of her role. “Having that sort of prompt response is, I think, invaluable to the hospital.”
Outcomes and metrics
Dr. Wang points out that, since her service line began, the hospital’s length of stay index has consistently stayed below 1.
She has also taken on quality improvement responsibilities for her department and the hospital. She is working on finding operative quantitative outcomes to measure the impact of an ENT hospital medicine service on such metrics as length of stay, readmissions and in-house complication rates.
Those quantitative data have been hard to parse out with conventional measures, particularly when trying to account for patient complexity. One metric she began tracking early on stands out: In the year before she started the service, 66% of tracheotomies were performed within two working days. That percentage jumped to 97% within the year after she started.
On the qualitative side, Dr. Wang mentions this example: She works with one GI physician who consistently does bedside PEG tube insertions for ICU patients. To decrease the cumulative anesthesia exposure for ICU patients undergoing two procedures, she reached out to the GI service to develop a system to coordinate those procedures at the same time on patients for whom both service lines were consulted.
“Everyone—patients, families, all the service lines involved—have been very happy with those outcomes. There is less cumulative anesthesia time for the patient.”
And when rounding with residents, she can do procedures at the bedside and review the care plan at the same time, so everybody is up to date. “We do not have to wait for a junior resident to discuss with their senior, because I am seeing consults with them. It makes for a better patient experience and allows for one-on-one teaching with resident physicians.
Dr. Wang has also converted many outpatient procedures to inpatient ones for patients who can’t safely leave the hospital or for those projected to be hospitalized for months, so an outpatient ENT evaluation/procedure would be impractical.
“I see the biggest impact on my inpatient vocal cord injection patients,” she says, noting that some patients have vocal cord paralysis after heart/lung surgery or from another cause. Such patients may need to stay in the ICU for weeks to months.
Living with a soft/weak voice limits communication and causes patients to speak less, a very frustrating experience.
“I do vocal cord injections the same way in the hospital as I do in clinic, and it can immediately strengthen the patient’s voice and ability to cough, leading them to speak and feel better,” Dr. Wang says. “It’s a seemingly little thing that can really change a patient’s morale.” As other physicians realize the benefits of having such procedures done in-house, “they’ve been consulting us more and more, and that’s been growing my practice.”
Barriers to starting such a service line
One key barrier is consult volume; another, says Dr. Wang is recruitment. “We have so little data across all specialties about the impact of such a position, particularly in a field that’s typically focused on outpatient,” she says. “This type of position would have to align with a physician’s interest and their vision for their future practice.”
At this point, Dr. Wang says she has no plans to switch to doing only outpatient ENT care. Fortunately, in terms of ENTs, “we need more people everywhere.”
As for what she bills, “billing and value requires a multi-tier analysis,” Dr. Wang notes. “For the simplest numbers, I have made back my salary in collections from consultations and procedures within my first year of practice. My collections also factor in my outpatient clinic encounters and procedures, so those may skew the numbers a little bit.”
The next factor to consider is if the hospital has incurred increased costs in supplies and equipment with her inpatient care. That would have to be balanced against how much time and money she saves the hospital by treating complex patients and coordinating both their care in the hospital and their transition to outpatient follow-up.
“Sometimes, follow-up may be the biggest barrier to my patients’ care,” says Dr. Wang, “because I notice a difference between healthy enough to leave the acute care hospital and able to easily return to clinic for follow up.” Accounting for that, she adds, “is sometimes the difference between a full transition to outpatient and a readmission.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
