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Admitting dialysis patients
For many hospitalists, nephrologists are model comanagers
by Deborah Gesensway



Published in the March 2012 issue of Today's Hospitalist

FOR HOSPITALISTS already being asked to admit nearly every hospitalized patient, adding dialysis patients might seem like the last straw. It certainly did for Jalila Cunningham, MD, and many of her hospitalist colleagues at Hamilton Medical Center in Dalton, Ga. With a per-hospitalist patient census that can push as high as 25 or 30 on a busy day, the physicians were close to the breaking point when the local nephrology group came knocking last fall.

But in the months since the medical director agreed to that request, the hospitalists realized that the
"As hospitalists, we tend to be more big-picture thinkers than many subspecialists."

–O. Scott Lauter, MD
Lancaster General Hospital

fear was much worse than the reality. Not only have the numbers of additional patients been manageable—maybe one or two a week—but nephrology patients have rarely been hospitalized simply for dialysis problems.

Instead, Dr. Cunningham says, these patients tend to have multiple medical comorbidities that hospitalists have the skills to address. And patients are also likely to benefit from hospitalists' attention to discharge planning and their relationships with case managers and social workers.

Even better, Dr. Cunningham notes that comanaging nephrology patients has turned out to be the example of how comanagement is supposed to work. In her experience, nephrologists not only want to be called about their patients in the middle of the night, but they are more than willing to help manage these often complicated patients.

If a doctor is covering upwards of 25 or 30 patients, it takes a lot of pressure off to know that someone else has his or her eye on the patient too," Dr. Cunningham explains. "The nephrologists are good consultants. They cover electrolyte abnormalities and fluids and they will be all over anything that has to do with the kidneys. That frees us up to take care of the pneumonia when we've admitted someone on dialysis."

A couple of months ago, Dr. Cunningham admits, she was feeling she was about to be "dumped on." That's no longer the case—at least not with nephrology patients.

The last holdouts
Around the country, hospitalist groups are reporting that nephrologists—who have been slow to ask hospitalists to admit their patients—have at long last joined the tide of specialists turning to hospitalists for help.
Sometimes, as at Dr. Cunningham's 282-bed hospital, a staffing shortage is behind that request. (A local nephrology group had lost one of its midlevels.) But in other cases, the move to admitting nephrology patients is due to the natural evolution of hospital medicine. That was the case at Via Christi St. Francis Hospital in Wichita, Kan., where anyone who comes to the emergency department now is almost automatically referred to the hospitalist service.

"The ER physician calls us because the ER physician always calls us," says Bobbie Loeffler, MD, a hospitalist there. "We are the simple answer." Dr. Loeffler acknowledges that she's not sure how that admission policy evolved, whether the nephrologists instructed the ED to call the hospitalist service or if "the ED has just gotten so used to calling us that they don't call anyone else anymore, or how much of it is the administration saying, 'Use the hospitalist, use the hospitalist, use the hospitalist!' It could be any of those reasons."

Like Dr. Cunningham, she also says that admitting dialysis patients has not been a problem for St. Francis' 18 hospitalists. "I don't think there is a sense of being dumped on," Dr. Loeffler says. "We work in conjunction with each other, and generally the patients are sick enough and complicated enough that there are so many issues—on top of a dialysis problem—that having us on board is not a bad idea."

It's not, she explains, "like dealing with pregnant patients or neurosurgical issues. This is routine medicine stuff: infections, volume-overloaded patients, diabetic patients, electrolytes. These are issues internists are trained to deal with."

Staffing challenges
In central Pennsylvania, David Hoffmann, DO, medical director of the Summit Hospitalist Group with 16 physicians and five midlevels, also looks back at his numbers and concludes unequivocally that nephrology has become a much more important part of his group than ever before. In 2011, he says, about 80% of the dialysis patients hospitalized at Chambersburg Hospital in Chambersburg Pa., were admitted by hospitalists. In 2010, it was about 50%, and three years ago, it was 30%.

Dr. Hoffmann thinks the trend has primarily been positive. The admitting hospitalists have a good working relationship with the consulting nephrologists, and they all help stretch the limited supply of specialists available in their rural area. But taking on these patients, Dr. Hoffmann notes, has had its challenges.

The main issue, he says, has been staffing. For the hospitalists, the problem is not just admitting dialysis patients but admitting for nearly all the other specialists and subspecialists.

"In community hospital settings like ours where we don't have enough specialty care, the hospitalists are touching almost every case," Dr. Hoffmann says. "Our group values the specialists as a limited resource, and we see it as our job to try to extend and expand their reach, but the biggest struggle is staffing enough hospitalists to manage all these patients."

Dr. Hoffmann adds that in the 17 years he's been practicing in the hospital, "I've never seen volumes like this. We are approaching volumes where people are seeing 25 to 30 patients some days." Even though the group hired six new providers in the last year, Dr. Hoffmann now finds himself in the position of "having to go back to administration and say, 'Every specialist now is using us.' " In addition, many of these new patients—and those on dialysis that nephrologists used to admit come specifically to mind— present with a lot of chronic illness and a high risk of readmission, particularly if attention is limited.

Putting new policies in place
A second challenge, Dr. Hoffmann says, has been the need to negotiate new department and hospital policies to make sure specialists behave as good consultants.

One innovation is a process for ordering a "stat consult." When a hospitalist orders a "stat consult" for a patient, the subspecialist has to be at the patient's bedside in one hour. A normal consult gives the consulting physician 24 hours to see the patient.

"If it's a dialysis patient, I can call the nephrologist and say, 'I know that it's 3 in the morning and you think it can wait until morning. But I want to let you know that I'm not comfortable with that, so I'm putting in a stat consult and I'll expect you at the bedside within 60 minutes,' " Dr. Hoffmann explains.

He has never had a problem with unresponsiveness or pushback. "They realize the value we bring," Dr. Hoffmann says. "We have made it clear that if they want us to admit these patients, these are the expectations."
Yet another challenge hospitalist groups face is guarding against the potential of interjecting an extra, perhaps unnecessary doctor into a patient's care. The issue arises when people need hospitalization for a reason relating only to their dialysis, such as a straightforward hyperkalemia, a problem with the arteriovenous (AV) fistula or a missed dialysis.

"If someone just needs to be dialyzed, you don't want to add another layer of provider who doesn't need to be involved," points out hospitalist O. Scott Lauter, MD, at Lancaster General Hospital in Lancaster, Pa. The former hospitalist director, Dr. Lauter last month became that hospital's department chair of internal medicine.

Setting limits
While it happened gradually, Dr. Lauter says he realized last fall that the nephrologists at his hospital had "evolved from 'We are PCPs for dialysis patients' and admitting all dialysis patients to telling the emergency department to 'admit to hospital medicine and consult nephrology.' " That's when he surveyed some other hospitalist programs and learned his situation was far from unique.

At the same time, Dr. Lauter questioned whether the new arrangement went too far. As a result, the hospitalist and nephrology group leaders began meeting to discuss which patients were best admitted to which service.

Now that those conversations have been completed, Dr. Lauter says, "If the patient comes to the emergency room, the hospitalist will be called, and we will consult with the nephrologist in a person-to-person discussion." For patients with a pure dialysis problem or dialysis-access problem, "we will discuss if nephrology will admit. Otherwise, we will always admit."

The goal is to make it easier for the ED to make just one phone call. "It is all about communication and collegial relationships," Dr. Lauter points out. "We've also agreed on general guidelines for notifying or involving the nephrologists for office patients they are following, patients with advanced chronic kidney disease, direct admissions from their office and transplant patients."

In Central Ohio, Laurie Bankston, MD, a hospitalist with Sound Physicians at Springfield Regional Medical Center, says that in her view, hospitalist involvement can serve dialysis patients well for several reasons.

Because the typical dialysis patient is taking about 12 medications, Dr. Bankston explains, "the medication reconciliation process is complicated." At the same time, patients' chronic condition leads many to have complex social needs, ranging from transportation to counseling for depression. She notes that it's the hospitalist programs that typically have good relationships with social workers and case managers to help address such issues. And controlling length of stay for many renal patients means starting discharge planning on admission—something hospitalists have taken the lead on in many institutions.

John Rooney, MD, hospitalist medical director at Banner Gateway Medical Center in Gilbert, Ariz., agrees. "We find that as far as patient throughput is concerned, we are able to get them in and get them out quicker" than if patients were on a subspecialty service, he notes. The hospitalists at his hospital are "pretty much the admitters for everybody," including dialysis patients. "We are here, and it's a saying around here that discharge planning begins when you hit the bed."

Starting end-of-life discussions
Dr. Bankston points to another advantage of hospitalist admission: Because end-stage renal disease is commonly accompanied by cardiovascular disease, hospitalists often play an important role as an intermediary between consulting nephrologists and cardiologists. "Sometimes, the job of the hospitalist is making sure that the nephrologist and the cardiologist are talking to each other when they adjust all the diuretics," she says.

"Initially, our reaction whenever a specialty decides that we should be admitting their patients is that we feel we are being dumped on," Dr. Bankston adds. "But I do think we have something to add for these patients."

Not only do patients have multi-organ problems and psychosocial issues related to their chronic illness, but "frequently, you do hit that end-of-life time," she points out. "I think it's easier for those of us who have more of a global perspective on things to have those discussions and to coordinate discharge planning for them. That's what's we bring to the table."

As an example, consider the patient that Dr. Lauter in Lancaster characterizes as "one of the most personally rewarding patient encounters" he has had during his medical career. It involved a recent dialysis patient on his service, one the local nephrology group would have admitted just a few years ago.

That patient was an 81-year-old woman with end-stage renal disease, critical aortic stenosis, heart failure and chronic GI bleeding who was being readmitted to the hospital every two to four weeks for worsening anemia, weakness and hypotension. She was in a general downward spiral and, as a hospitalist, Dr. Lauter was able to take care of her acute medical needs. But he also could talk to her about care planning and her thoughts and wishes.

"She gave it a lot of thought, and several days after admission, she decided to take the palliative care route, to stop dialysis and go into hospice for end-of-life care," says Dr. Lauter. "I think that as hospitalists, we tend to be more big-picture thinkers than many subspecialists. We are able to look beyond the acute episode."

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.




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