California hospital leaders' views of hospitalists: meeting needs of the present and future

Utilization of an Internal Medicine Triaging Resident in the Emergency Department Reduces Preventable Admissions and Improves Trainee Experiences

OBJECTIVE

Increasing patient care requirements and suboptimal communication between emergency department (ED) and Internal Medicine (IM) services may lead to inefficient hospital utilization, lapses in transitions of care, and reduced trainee satisfaction in the inpatient setting. Furthermore, a lack of triaging roles for IM trainees has been a common limitation in graduate medical education. We aimed to demonstrate that the addition of an IM triaging resident (TR) in the ED may represent an innovative solution to these problems.

METHODS

A single-center pilot study was performed. An IM trainee served as the TR at a tertiary Veterans Affairs hospital for 2 weeks. The TR evaluated medical patients in a parallel manner with ED physicians and assisted in the initial management, disposition, and transitions of care under the supervision of an IM attending physician. Hospital utilization and patient safety were tracked using electronic records, and trainee satisfaction was measured using daily surveys administered to IM resident teams.

RESULTS

Of the 62 cases evaluated by the TR for medical admission, 26 (42%) represented preventable admissions; 12 (46%) of those patients were discharged from the ED, representing a 19% overall reduction. There were statistically significant improvements in trainee experiences relating to patient flow (P < 0.01) and initial patient management (P < 0.02), and our intervention did not have a negative impact on ED performance metrics or patient safety.

CONCLUSIONS

Expansion of this model in select integrated health systems may improve graduate medical education and healthcare system performance. Future iterations of this study can aim to improve transitions of care between ambulatory and inpatient providers and limit the overuse of antimicrobial agents, radiography, and consultative services.

Characteristics of the ideal hospitalist inpatient care program: perceptions of Canadian health system leaders

Background

Despite the growing prevalence of hospitalist programs in Canada, it is not clear what program features are deemed desirable by administrative and medical leaders who oversee them. We aimed to understand perceptions of a wide range of healthcare administrators and frontline providers about the implementation and necessary characteristics of a hospitalist service.

Methods

We conducted semi-structured interviews with a range of administrators, medical leaders and frontline providers across three hospital sites operated by an integrated health system in British Columbia, Canada.

Results

Most interviewees identified the hospitalist model as the ideal inpatient care service line, but identified a number of challenges. Interviewees identified the necessary features of an ideal hospitalist service to include considerations for program design, care and non-clinical processes, and alignment between workload and physician staffing. They also identified continuity of care as an important challenge, and underlined the importance of communication as an important enabler of implementation of a new hospitalist service.

Conclusions

Most hospital administrators and frontline providers in our study believed the hospitalist model resulted in improvements in clinical processes and work environment.

Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers

From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.

Triaging Inpatient Admissions: an Opportunity for Resident Education

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.

The association of hospital characteristics and quality improvement activities in inpatient medical services

BACKGROUND

Quality of U.S. health care has been the focus of increasing attention, with deficiencies in patient care well recognized and documented. However, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs.

OBJECTIVE

To identify 1) the extent of QIAs in Veterans Administration (VA) inpatient medical services; and 2) factors associated with widespread adoption of QIAs, in particular use of hospitalists, non-physician providers, and extent of goal alignment between the inpatient service and senior managers on commitment to quality.

DESIGN

Cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COM) at all 124 VA acute care hospitals. We conducted hierarchical regression, regressing QIA use on facility contextual variables, followed by use of hospitalists, non-physician providers, and goal alignment/quality commitment.

MAIN MEASURES

Outcome measures pertained to use of a set of 27 QIAs and to three dimensions--infrastructure, prevention, and information gathering--that were identified by factor analysis among the 27 QIAs overall.

KEY RESULTS

Survey response rate was 90 % (111/124). Goal alignment/quality commitment was associated with more widespread use of all four QIA categories [infrastructure (b = 0.42; p < 0.001); prevention (b = 0.24; p < 0.001); information gathering (b = 0.28; p = <0.001); and overall QIA (b = 0.31; p < 0.001)], as was greater use of hospitalists [infrastructure (b = 0.55; p = 0.03); prevention (b = 0.61; p < 0.001); information gathering (b = 0.75; p = 0.01); and overall QIAs (b = 0.61; p < 0.001)]; higher occupancy rate was associated with greater infrastructure QIAs (b = 1.05, p = 0.02). Non-physician provider use, hospital size, university affiliation, and geographic region were not associated with QIAs.

CONCLUSION

As hospitals respond to changes in healthcare (e.g., pay for performance, accountable care organizations), this study suggests that practices such as use of hospitalists and leadership focus on goal alignment/quality commitment may lead to greater implementation of QIAs.

The Hospital Medicine Reengineering Network (HOMERuN): a learning organization focused on improving hospital care

Converting the health care delivery system into a learning organization is a key strategy for improving health outcomes. Although the collaborative learning organization approach has been successful in neonatal intensive care units and disease-specific collaboratives, there are few examples in general medicine and none in adult medicine that have leveraged the role of hospitalists nationally across multiple institutions to implement improvements. The authors describe the rationale for and early work of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011 that seeks to measure, benchmark, and improve the efficiency, quality, and outcomes of care in the hospital and afterwards. Robust and timely evaluation, with learning and refinement of approaches across institutions, should accelerate improvement efforts. The authors review HOMERuN's collaborative model, which focuses on a community-based participatory approach modified to include hospital-based staff as well as the larger community. HOMERuN's initial project is described, focusing on care transition measurement using perspectives from the patient, caregiver, and providers. Next steps and sustainability of the organization are discussed, including benchmarking, collaboration, and effective dissemination of best practices to stakeholders.

Neurohospitalists: perceived need and training requirements in academic neurology

BACKGROUND AND PURPOSE

We sought to determine the current practices and plans for departmental hiring of neurohospitalists at academic medical centers and to identify the core features of a neurohospitalist training program.

METHODS

We surveyed department chairs or residency program directors at 123 Accreditation Council for Graduate Medical Education (ACGME)-accredited US adult neurology training programs.

RESULTS

Sixty-three(51% response rate) responded, 76% of whom were program directors. In all, 24 (38%) academic neurology departments reported employing neurohospitalists, and an additional 10 departments have plans to hire neurohospitalists in the next year. In all, 4 academic neurology departments have created a neurohospitalist training program, and 10 have plans to create a training program within the next 2 years. Hospitals were the most frequent source of funding for established and planned programs (93% of those reporting). Most (n = 39; 65%) respondents felt that neurohospitalist neurology should be an ACGME-accredited fellowship. The highest priority neurohospitalist training elements among respondents included stroke, epilepsy, and consult neurology as well as patient safety and cost-effective inpatient care. The most important procedural skills for a neurohospitalist, as identified by respondents, include performance of brain death evaluations, lumbar punctures, and electroencephalogram interpretation.

CONCLUSIONS

Neurohospitalists have emerged as subspecialists within neurology, growing both in number and in scope of responsibilities in practice. Neurohospitalists are in demand among academic departments, with many departments developing their existing presence or establishing a new presence in the field. A neurohospitalist training program may encompass training in stroke, epilepsy, and consult neurology with additional focus on patient safety and cost-effective care.

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.

Hospitalist utilization and hospital performance on 6 publicly reported patient outcomes

BACKGROUND

The increase in hospitalist-provided inpatient care may be accompanied by an expectation of improvement on patient outcomes. To date, the association between utilization of hospitalists and the publicly reported patient outcomes is unknown.

OBJECTIVE

Assess the relationship between hospitalist utilization and performance on 6 publicly reported patient outcomes.

DESIGN

Cross-sectional study.

PARTICIPANTS

Representatives of 598 hospitals in the United States with direct knowledge of inpatient service models.

INTERVENTION

Survey of hospital personnel with knowledge of hospitalist use and hospitalist programs.

MEASUREMENTS

Six publicly reported quality outcome measures across 3 medical conditions: acute myocardial infarction (AMI), congestive heart failure (HF), and pneumonia. Using multivariable regression models, we assessed the relationship between presence of hospitalists and performance on each outcome measure; we further assessed the relationship between the percentage of patients admitted by hospitalists and each outcome measure.

RESULTS

Of 598 respondents, 429 (72%) reported the use of hospitalist services. In the comparison of hospitals with and without hospitalists, there was no statistically significant difference on any of the mortality or readmissions measures with the exception of the risk-stratified readmission rate for heart failure. For hospitals that used hospitalists, there was no significant change in any of the outcome measures with increasing percentage of patients admitted by hospitalists.

CONCLUSIONS

The presence of hospitalists is not an independent predictor of performance on publicly reported mortality and readmissions measures for AMI, HF, or pneumonia. It is likely that broader system or organizational interventions are required to improve performance on patient outcomes.