By Joanne Conroy, MD
I had the opportunity recently to shadow Matt Lawler, MD, on the Hospitalist Service here at Lahey Hospital & Medical Center (LHMC) in Burlington, MA. After that experience, I have a much better appreciation for what hospitalists do, and how important their work is—not only to patient care but to the efficiency of the organization. They are under incredible pressure and need extra support from their specialist colleagues.
We changed our staffing model at LHMC last year, but are struggling to fill 15 open MD positions and five AP positions. We are trying to level the load of inpatients across our services so our hospitalists are not overwhelmed: The goal is to average 15 patients for an MD and seven for a PA. Researchers at Christiana Health have correlated hospitalist workload with both quality and efficiency outcomes, as they reported in JAMA Internal Medicine. When hospitalists ran censuses of more than 15 patients, costs per case went up by $262 each additional patient.
When I was leading another hospital, we had a private practice that ran the largest hospitalist group; they managed more than 65 patients a day with only two MDs and two PAs. Every patient got cardiology, pulmonary, and ID consults (usually from the same small group of private specialists); their length of stay was a full day longer than the teaching service; and I received more complaints from patients about them than about any other group! We don’t want to practice that way at LHMC. Unfortunately, our hospitalist/PA teams have had 25-plus patients at times. On weekends, holidays, and short-staffed weeks, some private hospitalists were responsible for 18-22 patients on their own.
Matt Lawler has been at LHMC for more than two years, after completing his internal medicine residency at Tufts. During the week I shadowed him, Matt had a maximum of 17 patients and the hospitalist/PA teams had 25. Matt scopes out his patient list (patients are assigned by TRAC) when he first arrives at work. He tries to deal first with the new admissions to his panel and then assess where everyone else is in their diagnosis, treatment, and discharge process. On busy days, he leaves at 8:00 or 8:30 pm and finishes his charting at home.
Workups: One of Matt’s new patients had a pretty comprehensive workup in the ED (including a psych consult and a GI consult) prior to admission to the floor. However, Matt learned a lot more information (that was not in EPIC) from the patient and from the care manager. He spent 30 minutes gathering information from several sources so he could figure out what he needed to do to accelerate the process.
The ED staff is also working under significant pressure: Volume is up over 4 percent this year with no increase in staffing. They don’t always have the time to do a comprehensive workup. Often the default is to admit to hospital medicine for the workup.
Patient Expectations: Matt was very clear in setting expectations for patients about when they should expect to go home. His challenge was when we had not measurably addressed the admitting complaint, such as the case of the woman with right leg pain that prevented her from walking, who also had multiple co-morbidities. Even so, Matt told her that the rest of the evaluation could and should be continued on an outpatient basis. She was thrilled to go home.
Appropriateness of Admission: At LHMC, we work with an extremely difficult patient population to discharge safely from the ED. Often, the safest choice in the ED is to admit. However, this creates an increased burden on inpatient services: The majority of the admissions have a heavy social component in addition to medical issues, and are admitted to the hospitalist service.
There were a number of patients admitted for symptoms that likely could have been addressed on an outpatient basis. As Matt and I dug into the charts, there was usually a criterion for admission, such as the gentleman with symptomatic anemia who had multiple co-morbidities and was receiving his first RBC transfusion; or the woman with dysphagia who had a history of anorexia but also a documented 20-pound weight loss. As we move to risk contracts, we will need to think differently about how and where to safely care for these patients.
Patient Satisfaction: Matt gave every new patient his card, examined every patient and was uniformly thoughtful, kind, respectful, and a great listener.
Staff Support: The case managers (CMs) are the air traffic controllers and very supportive of the hospitalists. They are constantly trying to determine how to discharge and safely land patients. They do much more care coordination on the units than I expected. When we are short-staffed with CMs, we can have major challenges to timely coordination of care and discharge.
Our patient population is difficult to place for several reasons: Elderly and demented patients require significantly more time to coordinate discharge. CMs are critical to connecting with families and patients earlier in the hospitalization. This helps to ensure that family involvement in the discharge process starts before we look for rehab and skilled nursing facility placement, cutting down on delays in discharge. Putting hospitalists in pods, where they would be more closely located to their patients geographically, would allow them to work more closely with CMs throughout the admission.
Barriers to Care: Consultant communication has always been, and continues to be, one of our biggest barriers to efficient and effective care.
- We need resident/fellow recommendations to be aligned with those of attendings!
- Notes need to be entered in a timely manner, and at least a call or text be placed to the hospitalist if they have seen the patient and made recommendations. Not doing so just delays care.
- Some—but not all–of the consulting teams are responsive. Matt said the GI department could not be any better as consultants. They are responsive and have great follow-through.
- Procedural departments (EP, cath lab, IR, neuro IR) need to contact hospitalists after performing procedures. This can delay post-procedure care and interfere with communication about next steps.
- Some of the patients presented very difficult placements, needing geriatric psych or post-acute facilities that will take people requiring expensive medications.
Environment: Gown and gloves were always available outside the rooms. Hand sanitizers were conveniently located. The hallways are very pretty crowded and we are buffing the floors in the middle of the day, creating lots of noise!
Surprises: Over 50 percent of Matt’s patients had some behavioral health issue.
Opportunities: At LHMC, we have recently expanded the ED and transitioned the CDU to an observation unit. As a result, we need to retool many of our internal processes.
- We need to start working now on how we will triage out of the ED to the right service.
- We need to figure out how to easily involve specialty attendings in the decisions to “admit to medicine” to ensure safe and efficient delivery of care. (There was a trauma patient with an enlarging mediastinal hematoma who was admitted to medicine. Several hours later, the patient was transferred to the SICU under the trauma service, after much time and effort from the hospitalist team.)
- We need to create co-management models for some more of the subspecialty services. Orthopedics has been a success story.
- We need to shift uncomplicated EP and interventional cardiology patients back to those services.
Resolutions to tackle in 2017.
–Joanne Conroy, MD, is CEO of Lahey Hospital & Medical Center in Burlington, Massachusetts. She blogs at http://joanneconroymd.com/ and is on Twitter @joanneconroymd.