Acute medicine in the United Kingdom: first-hand perspectives on a parallel evolution of inpatient medical care

Survey of Inpatient Consultations with General Internal Medicine Physicians in a Tertiary Hospital: A Retrospective Observational Study

Purpose

The general internal medicine (GIM) department can be an effective diagnostic coordinator for undiagnosed outpatients. We investigated the contribution of GIM consultations to the diagnosis of patients admitted to specialty departments in hospitals in Japan that have not yet adopted a hospitalist system.

Patients and Methods

This single-center, retrospective observational study was conducted at a university hospital in Japan. GIM consultations from other departments on inpatients aged ≥20 years, from April 2016 to March 2021, were included. Data were extracted from electronic medical records, and consultation purposes were categorized into diagnosis, treatment, and diagnosis and treatment. The primary outcome was new diagnosis during hospitalization for patients with consultation purpose of diagnosis or diagnosis and treatment. The secondary outcomes were the purposes of consultation with the Diagnostic and Generalist Medicine department.

Results

In total, 342 patients were included in the analysis. The purpose of the consultations was diagnosis for 253 patients (74%), treatment for 60 (17.5%), and diagnosis and treatment for 29 patients (8.5%). In 282 consultations for diagnosis and diagnosis and treatment, 179 new diagnoses were established for 162 patients (57.5%, 95% confidence interval [CI], 51.5-63.3).

Conclusion

The GIM department can function as a diagnostic consultant for inpatients with diagnostic problems admitted to other specialty departments in hospitals where hospitalist or other similar systems are not adopted.

Association of hospital admission service structure with early transfer to critical care, hospital readmission, and length of stay

BACKGROUND

Hospital medical groups use various staffing models that may systematically affect care continuity during the admission process.

OBJECTIVE

To compare the effect of 2 hospitalist admission service models ("general" and "admitter-rounder") on patient disposition and length of stay.

DESIGN

Retrospective observational cohort study with difference-in-difference analysis.

SETTING

Large tertiary academic medical center in the United States.

PARTICIPANTS

Patients (n = 19,270) admitted from the emergency department to hospital medicine and medicine teaching services from July 2010 to June 2013.

INTERVENTIONS

Admissions to hospital medicine staffed by 2 different service models, compared to teaching service admissions.

MEASUREMENTS

Incidence of transfer to critical care within the first 24 hours of hospitalization, hospital and emergency department length of stay, and hospital readmission rates ≤30 days postdischarge.

RESULTS

The change of hospitalist services to an admitter-rounder model was associated with no significant change in transfer to critical care or hospital length of stay compared to the teaching service (difference-in-difference P = 0.32 and P = 0.87, respectively). The admitter-rounder model was associated with decreased readmissions compared to the teaching service on difference-in-difference analysis (odds ratio difference: -0.21, P = 0.01). Adoption of the hospitalist admitter-rounder model was associated with an increased emergency department length of stay compared to the teaching service (difference of +0.49 hours, P < 0.001).

CONCLUSIONS

Rates of transfer to intensive care and overall hospital length of stay between the hospitalist admission models did not differ significantly. The hospitalist admitter-rounder admission service structure was associated with extended emergency department length of stay and a decrease in readmissions. Journal of Hospital Medicine 2016;11:669-674. © 2016 Society of Hospital Medicine.

Hospital consultations and jurisdiction over patients: consequences for the medical profession

Advances in biomedical technologies and the increased specialisation of the medical profession have made collaborations among specialty physicians integral to care delivery. As physicians increasingly must share patients, how does this shape the jurisdiction that physicians hold? The sociological literature has extensively documented inter-professional jurisdictional claims and conflicts to maintain the professional power of physicians in relation to allied occupational groups. However, less is known of intra-professional avoidance and resolution of conflict over jurisdiction. This case study considers how jurisdictions are shared, maintained and challenged in a single profession. Drawing from ethnographic and interview data collected from September 2010 to October 2012 on the internal medicine service of a teaching hospital in the USA, I demonstrate the variation in jurisdictional conflicts that emerge between internal medicine and other specialties during the consultation process. Ignoring shared jurisdictions and refusing to accept jurisdiction of patients generate disputes among the principal medical and specialist teams. These disputes ensue due to blurred boundaries dividing the various specialties. To avoid conflicts, internal medicine physicians adopt strategies behind the scenes to facilitate smooth consultations.