Published in the October 2005 issue of Today’s Hospitalist
Hospitalists know that they can’t be all things to all people, and that despite the seemingly endless requests for help from all quarters of the hospital, they sometimes need to say “No.”
Every so often, however, an opportunity comes along that you can’t pass up. These requests will not only help your hospital meet its mission, but will give you a valuable chance to secure your place in the fabric of the hospital. The trick is to spot these opportunities and make the most of them.
A good example of a hospitalist group that has done both can be found at Inpatient Care Service in Corvallis, Ore. The six-physician hospitalist service, which works at Good Samaritan Regional Medical Center, has found that saying yes to certain initiatives has earned it high marks with hospital administrators, emergency medicine physicians and subspecialists.
Keeping high-risk patients
While the hospitalist program has provided around-the-clock coverage since its inception three years ago, the group has seen its mission grown considerably. The group today supports a wide range of services, from working with the ED to co-managing orthopedic surgery patients and responding to the ever-growing base of community-based physicians and subspecialists who want the group to admit or manage their hospitalized patients.
“We don’t admit for elective orthopedic surgery cases and we don’t deal with trauma,” says Cliff Hall, MD, director of the hospitalist program, “but we handle just about everything else.”
But perhaps one of the most important ways the hospitalist group has increased its stature in the hospital is through its role overseeing the transfer of patients to Good Samaritan from other facilities in Samaritan Health Services, which owns five hospitals in Oregon’s Willamette Valley.
In the past, patients deemed either too ill or too high risk for Good Sam’s facilities were often transferred to urban centers in Portland or Eugene. When administrators started searching for a way to keep those patients in the system, the hospitalists spotted an opportunity to get involved.
“We wanted those referrals,” Dr. Hall says, “and we were in a position to receive more of those patients.” He estimates that approximately 20 percent of the group’s work involves managing and medically evaluating those transfer patients.
To manage transfers from the hospital system to Good Samaritan, Dr. Hall’s group works with a dedicated on-site transfer coordinator to help facilitate admissions and workups for the hospital’s subspecialists.
The coordinated system enables physicians from outlying facilities or community-based practices to call a single toll-free number to request a transfer. That reduces the hassle factor and obviates the problematic issue of ensuring the patient will be appropriately “received” on arrival.
Hospitalists, who already manage approximately 65 percent of admissions at the 188-bed facility, commit to evaluating and managing patients as appropriate, helping lighten subspecialists’ load. And the transfer coordinator and emergency department ensure the subspecialty or surgical coverage will be in place when it’s needed.
The highly organized approach reduces unnecessary work and the time-wasting phone calls that frequently plague the efforts of ED staff to track down a subspecialist who is willing to take a case in the middle of the night. It has also helped the hospital system keep many of the patients it used to refer outside the system.
In a sense, Dr. Hall explains, the hospitalists operate as a pressure valve for the entire operation.
“It’s good for the hospital because [the transfer service] makes it easier for outlying facilities or doctor’s offices to get their patients in,” he says. “But that regionalization put pressure on the subspecialists. So we’re there to help keep the subspecialists functioning well and reasonably happy. It’s working out well.”
Dr. Hall adds that the program has grown with continuing input. Initially, for example, the ED staff was planning to assume the overall coordination of regional transfers, but it quickly became clear that that wouldn’t work because the emergency department can be quickly overwhelmed by spikes in patient volume.
That’s when the hospitalists were brought into the picture to assist with evaluations and subspecialist coordination. The dedicated transfer coordinator position was gradually developed as all parties realized that the ED receptionist couldn’t manage the load alone “especially when trauma cases or multiple accident patients hit the unit. That “umbrella” coordination proved to be the glue that held the concept together.
Dr. Hall is careful to note that the program’s evolution hasn’t been entirely problem-free. The No. 1 issue, as he sees it, is ensuring complete communication with the subspecialists, especially surgeons, who will take the cases from the hospitalists after patients have been evaluated.
He notes that it’s not sufficient for one of the hospital’s coordinators to call the orthopedic surgeon on call and get a verbal commitment that the physician will repair a hip fracture, for example. The hospital won’t take the transfer unless one of Good Sam’s emergency physicians or a hospitalist has spoken directly to the subspecialist who will handle the case.
“Even though there’s a transfer coordinator, you still need to have that physician-to-physician communication about the transfers,” Dr. Hall says. “If it’s clearly a medical case, the ER doctor will talk to us. And if it’s a surgical case, we want to know that the surgeon is in fact aware of the patient and knows that patient will be in surgery the next morning. I cannot emphasize enough how important that is.”
That direct communication helps ensure, for example, that the OR has the patient on the schedule and the surgeon isn’t surprised at 7 a.m. with a call from the hospital stating that the patient prepped for surgery “and has been NPO for several hours. Things like that happen if you don’t have your lines of communication set in advance,” Dr. Hall says.
While the system has needed some tweaking here and there, Dr. Hall says the results more than speak for themselves.
“I think this sort of service is a good business opportunity for hospitalist groups working in areas where hospitals are consolidating or merging,” Dr. Hall continues. “I think it’s also a way to improve care overall.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.