Richard Quinn

Hospitalist-led, active-bed management can save hospitals millions of dollars a year by reducing ambulance diversions and trimming emergency department (ED) throughput times, according to a single-institution study.

The study in Annals of Internal Medicine (2008;149(11):804-810) found twice-daily bed management rounds in the ICU and regular visits to the ED to assess flow reduced ED throughput by 98 minutes. It also cut the number of ambulance diversions for overcrowding by 6% and reduced diversions caused by a lack of ICU beds by 27%. The study compared data from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period).

Lead author Eric Howell, MD, a hospitalist with Collaborative Inpatient Medical Service at Johns Hopkins Bayview Medical Center in Baltimore, estimated ambulance diversions cost hospitals $1,000 to $8,000 an hour. His study found a decrease of more than 2,000 hours in ambulance diversions, which could translate into $16 million in annual savings

"You've got to have the money up front," Dr. Howell says, acknowledging startup costs for a new or expanded hospitalist program. "You can't do it on the cheap. It falls apart."

Smaller hospitalist groups without the staffing for a full-time program could run a 12-hour, daytime version, or a trial run during specific hours.

"It's not an easy thing to do," he says, "but it adds tremendous value to a hospitalist group."

Hospitalist-led, active-bed management can save hospitals millions of dollars a year by reducing ambulance diversions and trimming emergency department (ED) throughput times, according to a single-institution study.

The study in Annals of Internal Medicine (2008;149(11):804-810) found twice-daily bed management rounds in the ICU and regular visits to the ED to assess flow reduced ED throughput by 98 minutes. It also cut the number of ambulance diversions for overcrowding by 6% and reduced diversions caused by a lack of ICU beds by 27%. The study compared data from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period).

Lead author Eric Howell, MD, a hospitalist with Collaborative Inpatient Medical Service at Johns Hopkins Bayview Medical Center in Baltimore, estimated ambulance diversions cost hospitals $1,000 to $8,000 an hour. His study found a decrease of more than 2,000 hours in ambulance diversions, which could translate into $16 million in annual savings

"You've got to have the money up front," Dr. Howell says, acknowledging startup costs for a new or expanded hospitalist program. "You can't do it on the cheap. It falls apart."

Smaller hospitalist groups without the staffing for a full-time program could run a 12-hour, daytime version, or a trial run during specific hours.

"It's not an easy thing to do," he says, "but it adds tremendous value to a hospitalist group."

Hospitalist-led, active-bed management can save hospitals millions of dollars a year by reducing ambulance diversions and trimming emergency department (ED) throughput times, according to a single-institution study.

The study in Annals of Internal Medicine (2008;149(11):804-810) found twice-daily bed management rounds in the ICU and regular visits to the ED to assess flow reduced ED throughput by 98 minutes. It also cut the number of ambulance diversions for overcrowding by 6% and reduced diversions caused by a lack of ICU beds by 27%. The study compared data from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period).

Lead author Eric Howell, MD, a hospitalist with Collaborative Inpatient Medical Service at Johns Hopkins Bayview Medical Center in Baltimore, estimated ambulance diversions cost hospitals $1,000 to $8,000 an hour. His study found a decrease of more than 2,000 hours in ambulance diversions, which could translate into $16 million in annual savings

"You've got to have the money up front," Dr. Howell says, acknowledging startup costs for a new or expanded hospitalist program. "You can't do it on the cheap. It falls apart."

Smaller hospitalist groups without the staffing for a full-time program could run a 12-hour, daytime version, or a trial run during specific hours.

"It's not an easy thing to do," he says, "but it adds tremendous value to a hospitalist group."

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

Jaxon Hernandes, MD, a hospitalist with Apogee Physicians at Clara Maass Medical Center in Belleville, N.J., believes he and his colleagues are positioned perfectly to help properly diagnose asthma, a timely opinion given new Canadian research suggesting the bronchial condition routinely is over-diagnosed.

The study in the Canadian Medical Association Journal (2008;179(11):1121-1131) found up to 30% of adults diagnosed with asthma had no evidence of the condition. It included 496 people from eight Canadian cities who reported a diagnosis of asthma from their physician. The researchers' goal was to determine whether obese people were more likely to be misdiagnosed with asthma, but researchers found the issue was just as prevalent in people of normal weight.

Henderson notes hospitalists rarely make initial diagnoses when a patient is first encountered in the hospital, but once they are admitted, a hospitalist can order peak-flow-rate and spirometric tests. Clinical guidelines recommend using a spirometer to objectively measure long volume and airway flow.

"The hospitalist is in a position where he can get the pulmonologist to do what he needs to do," Dr. Hernandes says. "He can force a diagnosis being made."

Dr. Hernandes adds hospitalists have an onus to order the tests because doctors "may be under-diagnosing the primary issue with a patient or over-diagnosing and psychologically scarring them."

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

The recent suspension of a New York City doctor who failed to report a gunshot wound suffered by a football star is an opportunity for hospitalists to revisit their own reporting requirements, the president of SHM's NYC chapter says.

Josyann Abisaab, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, was suspended after treating New York Giants wide receiver Plaxico Burress on Nov. 29. Less than a year after catching the winning touchdown pass in the Giants' Super Bowl victory, Burress, who told police he accidentally shot himself in the thigh at a NYC nightclub, has been suspended by the league and charged with criminal possession of a gun.

"I was not aware that something like this needed a report to the police," says Bradley Flansbaum, DO, MPH, chief of hospitalist services at Lenox Hill Hospital in Manhattan and president of SHM’s NYC chapter. "It opened up space in my brain. If I were confronted with this, when would I know when to and when not to call the police?"

Complicating matters is the fact hospitalists may have to report issues to more than just law enforcement; depending on diagnoses and patient histories, doctors may have to notify state and federal health agencies or social service departments. Rules vary by state, so Dr. Flansbaum says hospitalists would do well to brush up on their requirements and liabilities.

"I may not know the rules," Dr. Flansbaum said, "but I certainly would speak to the right people here and ask them: 'What are my obligations? How do I protect myself and the patient?' " He recommends hospitalists verify local requirements with their hospital administration.

As critical care workforce shortages continue, and as Medicare enrollment swells—a number slated to increase an estimated 50% by 2030—hospitalists are increasingly filling in the gaps in their institutions’ intensive care units.1-2 In SHM’s 2005-06 survey, “The Authoritative Source on the State of the Hospital Medicine Movement,” for example, 75% of participants reported caring for patients in the ICU.3

The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-35% The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-25% shortfall of needed critical care physicians (also called “intensivists”) by 2030. Are hospitalists a viable option to fill the void created by the shortage of intensivists? What is the practice scope of hospitalists in the ICU? Which models work for effective co-management of ICUs and can hospitalists help to deliver round-the-clock coverage in the ICU that the Leapfrog Group safety standards have stipulated should be provided by intensivists?4 According to academic and community-based hospitalists and intensivists, much depends on local demographics and each hospital’s ICU model.

Two Models

Michael A. Gropper, MD, PhD, believes hospitalists are well suited to help manage patients in the critical care unit. At the University of California, San Francisco (UCSF), where Gropper is a professor, vice chair of the Department of Anesthesia and Perioperative Care, and the Medical Center’s director of critical care medicine, the ICU uses a co-management system.

This high-intensity model mandates an intensivist consultation for every patient. In addition, the intensivists conduct procedures, such as ventilator management, placement of central lines, and sedation. The hospital medicine service then handles patient medical management. Hospitalists write orders for antibiotics, nutrition, and fluid management. Splitting the patient management with their hospitalist colleagues allows the intensivists to care for more patients than in a completely “closed” ICU. (In “closed” systems, only intensivists are authorized to care for ICU patients.)

For this model to be effective, however, participating hospitalists should have experience and feel comfortable working in the ICU. “I don’t think you would want to pluck the average hospitalist and throw him into the ICU,” cautions Dr. Gropper. “But a hospitalist who started to consistently spend some time in the ICU would be very good. In collaboration with an intensivist, I think it’s a model that allows high-quality patient care.”

Inpatient Physician Associates, a privately owned hospital medicine group in Lincoln, Neb., headed by Brian Bossard, MD, found a slightly different way to collaborate with a group of intensivists to deliver high-quality care at the city’s two community hospitals, BryanLGH Medical Center and St. Elizabeth Regional Medical Center. Dr. Bossard and Bill Johnson, MD, a pulmonologist certified in intensive care, and director of the ICU at both hospitals, crafted an open ICU model. Although intensivists conduct multidisciplinary rounds at Bryan and St. Elizabeth, consults are not mandatory. Hospitalists provide 24/7 coverage, often placing central lines and doing other procedures. Intensivists are available for consultations and more complicated critical care procedures, such as chest tube placement, Swan-Ganz catheters, and difficult ventilator management.

This system evolved out of necessity; the hospitalist program predated the intensivist program at BryanLGH. “When I started the group, we needed docs who were comfortable in the ICU,” explains Dr. Bossard. With the open ICU model, that requirement still applies today.

When recruiting new hospitalists, Dr. Bossard looks for those who function well in the ICU environment, understand evidence-based practice, and have an aptitude for learning procedures. He also seeks out doctors comfortable with cognitive critical care.

The system seems to work.

“There are many patients who are admitted and discharged from the ICU who don’t require an intensivist’s care,” Dr. Bossard says. Hospitalists in his group cooperatively manage most patients, with intensivist consultation.

“We have a very good collaborative approach here,” says Dr. Johnson, adding that it’s difficult to have a closed ICU at a community hospital because of intensivist shortages and resistance from primary care physicians who want access to their patients. The key to the success of the program in Lincoln is that all physicians know their limits. “We don’t force ICU consults upon anybody,” Dr. Johnson says. “But I think the hospitalists do recognize when it benefits them to have the intensivist involved.”

The proof is in the proverbial pudding. Since the co-managed ICU program began in 2006 in Lincoln, the ICU mortality rate has dropped 50%, and there have been no ventilator-acquired pneumonias or central line-related infections for two years.

Ideals Versus Reality

The Leapfrog Group identified around-the-clock coverage of surgical and medical intensive care units by intensivists as one of its three safety standards.5 “In an ideal world,” says Bradley A. Sharpe, MD, associate division chief in the Division of Hospital Medicine at UCSF, “every critically ill patient would be seen, managed, or co-managed by a critical care specialist.”

David A. Hoffmann, DO, agrees certain standards in the ICU should exist, but says community hospitals will never be able to reproduce the academic model. “They don’t have the labor from residencies,” says Dr. Hoffman, medical director of Hospitalists of Franklin County, an HM group at Chambersburg Hospital, a community hospital in Chambersburg, Pa.

He says his hospitalists fill a crucial gap that intensivists can’t: “We’re the only doctors who are here in the hospital 24 hours a day—besides the ER doctors.”

Dr. Hoffman believes it’s more important to focus on outcomes than to adhere to strict Leapfrog standards. His HM group, comprised of half family medicine-trained, half internal medicine-trained hospitalists, emphasizes teamwork, evidence-based protocols, and bonuses tied to quality outcomes and patient satisfaction.

In many smaller community hospitals, HM groups must do what works to simply provide coverage. Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in Cortland, N.Y, who also works as a hospitalist, says, “The people who are here around the clock are the hospitalists, so they also do the ICU management.” Last summer an intensivist who joined his hospitalist team provided ICU coverage five days a week.

Dr. Rohr believes hospitalists must acquire skills in mechanical ventilation and placement of central lines, and have high-level knowledge of infectious disease. For most ICU patients, however, this type of care is “basically internal medicine pushed to extremes,” he says.

Advantages and Disadvantages of Shared Responsibility

Under a co-managed ICU model, hospitalists can offer benefits beyond their direct time on the unit, says Hugo Quinny Cheng, MD, associate clinical professor in the Division of Hospital Medicine at the University of California at San Francisco. Dr. Cheng says his colleagues can provide more continuous care to patients because they rotate less frequently than do intensivists. In addition, hospitalists may have a broader view of hospital-wide systems and often can maximize ancillary services, such as physical therapy or nutrition, when it’s most appropriate for the patient, Dr. Sharpe adds.

One possible downside to a co-managed ICU, however, is confusion about responsibility. “In a critical care setting, ambiguity can lead to bad outcomes,” says Dr. Sharpe. To avoid this, make all ICU policies and procedures collaborative and involve all providers, including ancillary staff, in the process. “The clearer those guidelines and boundaries are, the easier it is for everyone,” he emphasizes.

For the most part, offering ICU rotations is a useful recruiting, hiring, and retention tool.

“Many hospitalists enjoy critical care and enjoy the opportunity to take care of very ill patients as part of their day-to-day practice, as long as they’re not in over their heads,” Dr. Sharpe says.

Preparation for the Future

Physicians have differing ideas about how intensivist-hospitalist relations will look in the future and what role hospitalists should play in the ICU. R. Neal Axon, MD, assistant professor in the departments of internal medicine and pediatrics at the Medical University of South Carolina in Charleston and a Team Hospitalist member, has worked in both academic and community settings. In the former, a pulmonary critical care specialist with a team of fellows, residents, and students ran the high-intensity ICU. In a local hospital where he worked as an attending, “there was no critical care team, per se. The hospitalists were the critical care team,” he says. “The difference in the care setting was pretty dramatic.”

Dr. Axon believes it might be a better long-term solution (in light of continuing critical care workforce shortages) to pursue formation of a fellowship program that combines advanced training in hospital medicine and critical care medicine.

Robert M. Wachter, MD, professor and chief of the Division of Hospital Medicine, associate chairman of the Department of Medicine, and Lynne and Marc Benioff Endowed Chair in Hospital Medicine at the University of California at San Francisco, and author of the “Wachter’s World” blog (www.the-hospitalist.org) says it’s a matter of whether hospitalists have enough intensive care training to work in the ICU.

“My own bias is that they’re probably close enough that they don’t need an extra year of training, but they’re not quite there,” he says.

As a result, UCSF’s HM division developed these strategies to augment hospitalists’ ICU skills:

• A hospitalist mini-college: a small group, hands-on experience, with one full day in the ICU, added to its annual CME course in October (www.ucsfcme. com/2009/MDM09P01A.pdf); and
• The creation of a critical care/hos-pital medicine fellowship that will launch in 2009.

By improving their ICU skills, hospitalists can form collaborative partnerships with their intensivist colleagues—both on the unit and in the critical care committees. This team approach can help their hospitals achieve the attributes of successful intensive care units.

“We have to acknowledge there’s no magic in being a hospitalist or a critical care specialist,” Dr. Axon says. “Individual decisions for individual patients, and the ways in which we all work together to systematize care, are the real differences that affect outcomes.” TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA December, 2006;284(21):2762-2770.
2. White J. Uses and abuses of long-term Medicare cost estimates. Health Aff (Millwood). 1999;18:63-79.
3. The Society of Hospital Medicine 2005-2006 Survey: The Authoritative Source on the State of the Hospital Medicine Movement.
4. Mello MM, Studdert DM, and Brennan TA. The Leapfrog Standards: Ready to jump from marketplace to courtroom? Health Aff 2003;22(2):46-59.
5. Leapfrog Group, The Leapfrog Group Fact Sheet, May 2002. Available at www.leapfroggroup.org/FactSheets/LF_FactSheet.pdf. Last accessed May 28, 2008.

As critical care workforce shortages continue, and as Medicare enrollment swells—a number slated to increase an estimated 50% by 2030—hospitalists are increasingly filling in the gaps in their institutions’ intensive care units.1-2 In SHM’s 2005-06 survey, “The Authoritative Source on the State of the Hospital Medicine Movement,” for example, 75% of participants reported caring for patients in the ICU.3

The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-35% The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-25% shortfall of needed critical care physicians (also called “intensivists”) by 2030. Are hospitalists a viable option to fill the void created by the shortage of intensivists? What is the practice scope of hospitalists in the ICU? Which models work for effective co-management of ICUs and can hospitalists help to deliver round-the-clock coverage in the ICU that the Leapfrog Group safety standards have stipulated should be provided by intensivists?4 According to academic and community-based hospitalists and intensivists, much depends on local demographics and each hospital’s ICU model.

Two Models

Michael A. Gropper, MD, PhD, believes hospitalists are well suited to help manage patients in the critical care unit. At the University of California, San Francisco (UCSF), where Gropper is a professor, vice chair of the Department of Anesthesia and Perioperative Care, and the Medical Center’s director of critical care medicine, the ICU uses a co-management system.

This high-intensity model mandates an intensivist consultation for every patient. In addition, the intensivists conduct procedures, such as ventilator management, placement of central lines, and sedation. The hospital medicine service then handles patient medical management. Hospitalists write orders for antibiotics, nutrition, and fluid management. Splitting the patient management with their hospitalist colleagues allows the intensivists to care for more patients than in a completely “closed” ICU. (In “closed” systems, only intensivists are authorized to care for ICU patients.)

For this model to be effective, however, participating hospitalists should have experience and feel comfortable working in the ICU. “I don’t think you would want to pluck the average hospitalist and throw him into the ICU,” cautions Dr. Gropper. “But a hospitalist who started to consistently spend some time in the ICU would be very good. In collaboration with an intensivist, I think it’s a model that allows high-quality patient care.”

Inpatient Physician Associates, a privately owned hospital medicine group in Lincoln, Neb., headed by Brian Bossard, MD, found a slightly different way to collaborate with a group of intensivists to deliver high-quality care at the city’s two community hospitals, BryanLGH Medical Center and St. Elizabeth Regional Medical Center. Dr. Bossard and Bill Johnson, MD, a pulmonologist certified in intensive care, and director of the ICU at both hospitals, crafted an open ICU model. Although intensivists conduct multidisciplinary rounds at Bryan and St. Elizabeth, consults are not mandatory. Hospitalists provide 24/7 coverage, often placing central lines and doing other procedures. Intensivists are available for consultations and more complicated critical care procedures, such as chest tube placement, Swan-Ganz catheters, and difficult ventilator management.

This system evolved out of necessity; the hospitalist program predated the intensivist program at BryanLGH. “When I started the group, we needed docs who were comfortable in the ICU,” explains Dr. Bossard. With the open ICU model, that requirement still applies today.

When recruiting new hospitalists, Dr. Bossard looks for those who function well in the ICU environment, understand evidence-based practice, and have an aptitude for learning procedures. He also seeks out doctors comfortable with cognitive critical care.

The system seems to work.

“There are many patients who are admitted and discharged from the ICU who don’t require an intensivist’s care,” Dr. Bossard says. Hospitalists in his group cooperatively manage most patients, with intensivist consultation.

“We have a very good collaborative approach here,” says Dr. Johnson, adding that it’s difficult to have a closed ICU at a community hospital because of intensivist shortages and resistance from primary care physicians who want access to their patients. The key to the success of the program in Lincoln is that all physicians know their limits. “We don’t force ICU consults upon anybody,” Dr. Johnson says. “But I think the hospitalists do recognize when it benefits them to have the intensivist involved.”

The proof is in the proverbial pudding. Since the co-managed ICU program began in 2006 in Lincoln, the ICU mortality rate has dropped 50%, and there have been no ventilator-acquired pneumonias or central line-related infections for two years.

Ideals Versus Reality

The Leapfrog Group identified around-the-clock coverage of surgical and medical intensive care units by intensivists as one of its three safety standards.5 “In an ideal world,” says Bradley A. Sharpe, MD, associate division chief in the Division of Hospital Medicine at UCSF, “every critically ill patient would be seen, managed, or co-managed by a critical care specialist.”

David A. Hoffmann, DO, agrees certain standards in the ICU should exist, but says community hospitals will never be able to reproduce the academic model. “They don’t have the labor from residencies,” says Dr. Hoffman, medical director of Hospitalists of Franklin County, an HM group at Chambersburg Hospital, a community hospital in Chambersburg, Pa.

He says his hospitalists fill a crucial gap that intensivists can’t: “We’re the only doctors who are here in the hospital 24 hours a day—besides the ER doctors.”

Dr. Hoffman believes it’s more important to focus on outcomes than to adhere to strict Leapfrog standards. His HM group, comprised of half family medicine-trained, half internal medicine-trained hospitalists, emphasizes teamwork, evidence-based protocols, and bonuses tied to quality outcomes and patient satisfaction.

In many smaller community hospitals, HM groups must do what works to simply provide coverage. Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in Cortland, N.Y, who also works as a hospitalist, says, “The people who are here around the clock are the hospitalists, so they also do the ICU management.” Last summer an intensivist who joined his hospitalist team provided ICU coverage five days a week.

Dr. Rohr believes hospitalists must acquire skills in mechanical ventilation and placement of central lines, and have high-level knowledge of infectious disease. For most ICU patients, however, this type of care is “basically internal medicine pushed to extremes,” he says.

Advantages and Disadvantages of Shared Responsibility

Under a co-managed ICU model, hospitalists can offer benefits beyond their direct time on the unit, says Hugo Quinny Cheng, MD, associate clinical professor in the Division of Hospital Medicine at the University of California at San Francisco. Dr. Cheng says his colleagues can provide more continuous care to patients because they rotate less frequently than do intensivists. In addition, hospitalists may have a broader view of hospital-wide systems and often can maximize ancillary services, such as physical therapy or nutrition, when it’s most appropriate for the patient, Dr. Sharpe adds.

One possible downside to a co-managed ICU, however, is confusion about responsibility. “In a critical care setting, ambiguity can lead to bad outcomes,” says Dr. Sharpe. To avoid this, make all ICU policies and procedures collaborative and involve all providers, including ancillary staff, in the process. “The clearer those guidelines and boundaries are, the easier it is for everyone,” he emphasizes.

For the most part, offering ICU rotations is a useful recruiting, hiring, and retention tool.

“Many hospitalists enjoy critical care and enjoy the opportunity to take care of very ill patients as part of their day-to-day practice, as long as they’re not in over their heads,” Dr. Sharpe says.

Preparation for the Future

Physicians have differing ideas about how intensivist-hospitalist relations will look in the future and what role hospitalists should play in the ICU. R. Neal Axon, MD, assistant professor in the departments of internal medicine and pediatrics at the Medical University of South Carolina in Charleston and a Team Hospitalist member, has worked in both academic and community settings. In the former, a pulmonary critical care specialist with a team of fellows, residents, and students ran the high-intensity ICU. In a local hospital where he worked as an attending, “there was no critical care team, per se. The hospitalists were the critical care team,” he says. “The difference in the care setting was pretty dramatic.”

Dr. Axon believes it might be a better long-term solution (in light of continuing critical care workforce shortages) to pursue formation of a fellowship program that combines advanced training in hospital medicine and critical care medicine.

Robert M. Wachter, MD, professor and chief of the Division of Hospital Medicine, associate chairman of the Department of Medicine, and Lynne and Marc Benioff Endowed Chair in Hospital Medicine at the University of California at San Francisco, and author of the “Wachter’s World” blog (www.the-hospitalist.org) says it’s a matter of whether hospitalists have enough intensive care training to work in the ICU.

“My own bias is that they’re probably close enough that they don’t need an extra year of training, but they’re not quite there,” he says.

As a result, UCSF’s HM division developed these strategies to augment hospitalists’ ICU skills:

• A hospitalist mini-college: a small group, hands-on experience, with one full day in the ICU, added to its annual CME course in October (www.ucsfcme. com/2009/MDM09P01A.pdf); and
• The creation of a critical care/hos-pital medicine fellowship that will launch in 2009.

By improving their ICU skills, hospitalists can form collaborative partnerships with their intensivist colleagues—both on the unit and in the critical care committees. This team approach can help their hospitals achieve the attributes of successful intensive care units.

“We have to acknowledge there’s no magic in being a hospitalist or a critical care specialist,” Dr. Axon says. “Individual decisions for individual patients, and the ways in which we all work together to systematize care, are the real differences that affect outcomes.” TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA December, 2006;284(21):2762-2770.
2. White J. Uses and abuses of long-term Medicare cost estimates. Health Aff (Millwood). 1999;18:63-79.
3. The Society of Hospital Medicine 2005-2006 Survey: The Authoritative Source on the State of the Hospital Medicine Movement.
4. Mello MM, Studdert DM, and Brennan TA. The Leapfrog Standards: Ready to jump from marketplace to courtroom? Health Aff 2003;22(2):46-59.
5. Leapfrog Group, The Leapfrog Group Fact Sheet, May 2002. Available at www.leapfroggroup.org/FactSheets/LF_FactSheet.pdf. Last accessed May 28, 2008.

As critical care workforce shortages continue, and as Medicare enrollment swells—a number slated to increase an estimated 50% by 2030—hospitalists are increasingly filling in the gaps in their institutions’ intensive care units.1-2 In SHM’s 2005-06 survey, “The Authoritative Source on the State of the Hospital Medicine Movement,” for example, 75% of participants reported caring for patients in the ICU.3

The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-35% The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) has predicted a 22-25% shortfall of needed critical care physicians (also called “intensivists”) by 2030. Are hospitalists a viable option to fill the void created by the shortage of intensivists? What is the practice scope of hospitalists in the ICU? Which models work for effective co-management of ICUs and can hospitalists help to deliver round-the-clock coverage in the ICU that the Leapfrog Group safety standards have stipulated should be provided by intensivists?4 According to academic and community-based hospitalists and intensivists, much depends on local demographics and each hospital’s ICU model.

Two Models

Michael A. Gropper, MD, PhD, believes hospitalists are well suited to help manage patients in the critical care unit. At the University of California, San Francisco (UCSF), where Gropper is a professor, vice chair of the Department of Anesthesia and Perioperative Care, and the Medical Center’s director of critical care medicine, the ICU uses a co-management system.

This high-intensity model mandates an intensivist consultation for every patient. In addition, the intensivists conduct procedures, such as ventilator management, placement of central lines, and sedation. The hospital medicine service then handles patient medical management. Hospitalists write orders for antibiotics, nutrition, and fluid management. Splitting the patient management with their hospitalist colleagues allows the intensivists to care for more patients than in a completely “closed” ICU. (In “closed” systems, only intensivists are authorized to care for ICU patients.)

For this model to be effective, however, participating hospitalists should have experience and feel comfortable working in the ICU. “I don’t think you would want to pluck the average hospitalist and throw him into the ICU,” cautions Dr. Gropper. “But a hospitalist who started to consistently spend some time in the ICU would be very good. In collaboration with an intensivist, I think it’s a model that allows high-quality patient care.”

Inpatient Physician Associates, a privately owned hospital medicine group in Lincoln, Neb., headed by Brian Bossard, MD, found a slightly different way to collaborate with a group of intensivists to deliver high-quality care at the city’s two community hospitals, BryanLGH Medical Center and St. Elizabeth Regional Medical Center. Dr. Bossard and Bill Johnson, MD, a pulmonologist certified in intensive care, and director of the ICU at both hospitals, crafted an open ICU model. Although intensivists conduct multidisciplinary rounds at Bryan and St. Elizabeth, consults are not mandatory. Hospitalists provide 24/7 coverage, often placing central lines and doing other procedures. Intensivists are available for consultations and more complicated critical care procedures, such as chest tube placement, Swan-Ganz catheters, and difficult ventilator management.

This system evolved out of necessity; the hospitalist program predated the intensivist program at BryanLGH. “When I started the group, we needed docs who were comfortable in the ICU,” explains Dr. Bossard. With the open ICU model, that requirement still applies today.

When recruiting new hospitalists, Dr. Bossard looks for those who function well in the ICU environment, understand evidence-based practice, and have an aptitude for learning procedures. He also seeks out doctors comfortable with cognitive critical care.

The system seems to work.

“There are many patients who are admitted and discharged from the ICU who don’t require an intensivist’s care,” Dr. Bossard says. Hospitalists in his group cooperatively manage most patients, with intensivist consultation.

“We have a very good collaborative approach here,” says Dr. Johnson, adding that it’s difficult to have a closed ICU at a community hospital because of intensivist shortages and resistance from primary care physicians who want access to their patients. The key to the success of the program in Lincoln is that all physicians know their limits. “We don’t force ICU consults upon anybody,” Dr. Johnson says. “But I think the hospitalists do recognize when it benefits them to have the intensivist involved.”

The proof is in the proverbial pudding. Since the co-managed ICU program began in 2006 in Lincoln, the ICU mortality rate has dropped 50%, and there have been no ventilator-acquired pneumonias or central line-related infections for two years.

Ideals Versus Reality

The Leapfrog Group identified around-the-clock coverage of surgical and medical intensive care units by intensivists as one of its three safety standards.5 “In an ideal world,” says Bradley A. Sharpe, MD, associate division chief in the Division of Hospital Medicine at UCSF, “every critically ill patient would be seen, managed, or co-managed by a critical care specialist.”

David A. Hoffmann, DO, agrees certain standards in the ICU should exist, but says community hospitals will never be able to reproduce the academic model. “They don’t have the labor from residencies,” says Dr. Hoffman, medical director of Hospitalists of Franklin County, an HM group at Chambersburg Hospital, a community hospital in Chambersburg, Pa.

He says his hospitalists fill a crucial gap that intensivists can’t: “We’re the only doctors who are here in the hospital 24 hours a day—besides the ER doctors.”

Dr. Hoffman believes it’s more important to focus on outcomes than to adhere to strict Leapfrog standards. His HM group, comprised of half family medicine-trained, half internal medicine-trained hospitalists, emphasizes teamwork, evidence-based protocols, and bonuses tied to quality outcomes and patient satisfaction.

In many smaller community hospitals, HM groups must do what works to simply provide coverage. Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in Cortland, N.Y, who also works as a hospitalist, says, “The people who are here around the clock are the hospitalists, so they also do the ICU management.” Last summer an intensivist who joined his hospitalist team provided ICU coverage five days a week.

Dr. Rohr believes hospitalists must acquire skills in mechanical ventilation and placement of central lines, and have high-level knowledge of infectious disease. For most ICU patients, however, this type of care is “basically internal medicine pushed to extremes,” he says.

Advantages and Disadvantages of Shared Responsibility

Under a co-managed ICU model, hospitalists can offer benefits beyond their direct time on the unit, says Hugo Quinny Cheng, MD, associate clinical professor in the Division of Hospital Medicine at the University of California at San Francisco. Dr. Cheng says his colleagues can provide more continuous care to patients because they rotate less frequently than do intensivists. In addition, hospitalists may have a broader view of hospital-wide systems and often can maximize ancillary services, such as physical therapy or nutrition, when it’s most appropriate for the patient, Dr. Sharpe adds.

One possible downside to a co-managed ICU, however, is confusion about responsibility. “In a critical care setting, ambiguity can lead to bad outcomes,” says Dr. Sharpe. To avoid this, make all ICU policies and procedures collaborative and involve all providers, including ancillary staff, in the process. “The clearer those guidelines and boundaries are, the easier it is for everyone,” he emphasizes.

For the most part, offering ICU rotations is a useful recruiting, hiring, and retention tool.

“Many hospitalists enjoy critical care and enjoy the opportunity to take care of very ill patients as part of their day-to-day practice, as long as they’re not in over their heads,” Dr. Sharpe says.

Preparation for the Future

Physicians have differing ideas about how intensivist-hospitalist relations will look in the future and what role hospitalists should play in the ICU. R. Neal Axon, MD, assistant professor in the departments of internal medicine and pediatrics at the Medical University of South Carolina in Charleston and a Team Hospitalist member, has worked in both academic and community settings. In the former, a pulmonary critical care specialist with a team of fellows, residents, and students ran the high-intensity ICU. In a local hospital where he worked as an attending, “there was no critical care team, per se. The hospitalists were the critical care team,” he says. “The difference in the care setting was pretty dramatic.”

Dr. Axon believes it might be a better long-term solution (in light of continuing critical care workforce shortages) to pursue formation of a fellowship program that combines advanced training in hospital medicine and critical care medicine.

Robert M. Wachter, MD, professor and chief of the Division of Hospital Medicine, associate chairman of the Department of Medicine, and Lynne and Marc Benioff Endowed Chair in Hospital Medicine at the University of California at San Francisco, and author of the “Wachter’s World” blog (www.the-hospitalist.org) says it’s a matter of whether hospitalists have enough intensive care training to work in the ICU.

“My own bias is that they’re probably close enough that they don’t need an extra year of training, but they’re not quite there,” he says.

As a result, UCSF’s HM division developed these strategies to augment hospitalists’ ICU skills:

• A hospitalist mini-college: a small group, hands-on experience, with one full day in the ICU, added to its annual CME course in October (www.ucsfcme. com/2009/MDM09P01A.pdf); and
• The creation of a critical care/hos-pital medicine fellowship that will launch in 2009.

By improving their ICU skills, hospitalists can form collaborative partnerships with their intensivist colleagues—both on the unit and in the critical care committees. This team approach can help their hospitals achieve the attributes of successful intensive care units.

“We have to acknowledge there’s no magic in being a hospitalist or a critical care specialist,” Dr. Axon says. “Individual decisions for individual patients, and the ways in which we all work together to systematize care, are the real differences that affect outcomes.” TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA December, 2006;284(21):2762-2770.
2. White J. Uses and abuses of long-term Medicare cost estimates. Health Aff (Millwood). 1999;18:63-79.
3. The Society of Hospital Medicine 2005-2006 Survey: The Authoritative Source on the State of the Hospital Medicine Movement.
4. Mello MM, Studdert DM, and Brennan TA. The Leapfrog Standards: Ready to jump from marketplace to courtroom? Health Aff 2003;22(2):46-59.
5. Leapfrog Group, The Leapfrog Group Fact Sheet, May 2002. Available at www.leapfroggroup.org/FactSheets/LF_FactSheet.pdf. Last accessed May 28, 2008.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.