Published in the May 2009 issue of Today’s Hospitalist
IT’S AN ISSUE that hospitalists everywhere face: Calls from the ED to help move patients with borderline chest pain either out the door or into a bed. And if the patients’ uncertain status isn’t unnerving enough, the ED needs a decision as quickly as possible.
To handle those calls, a Chicago hospitalist group created a new service that not only gives the ED a hand, but gets patients in and out of testing much more quickly. Since 2003, the hospitalists at Stroger Cook County Hospital in Chicago have taken over exercise treadmill testing (ETT) for patients presumed to be at low risk for a near-term major cardiovascular event.
These patients used to be tested by cardiologists, who couldn’t provide same-day testing for low-risk patients. As a result, patients often waited a long time for a test that can help dictate disposition and discharge status.
The new service also helps the hospitalists who staff the short-stay unit figure out where patients should go next. And treadmill testing helps smooth out workflow issues that crop up when this group of academic hospitalists is “off service.” Between 10% and 30% of hospitalists’ work hours each year are not spent providing direct patient care, although physicians are still on the clock. Some hospitalists do bedside procedures when they are off service while others have administrative duties for the hospital or teach.
“We started the service because we were trying to figure out what to do with the hospitalists when they were ‘off wards,’ ” explains Brian P. Lucas, MD, MS, chief of Cook County’s division of hospital medicine and assistant professor at Rush University. “This is another service that’s quasi-clinical but more self-contained.”
How the service works
Of the 14 hospitalists in Dr. Lucas’ group, 11 trained to staff the treadmill service, working in the hospital’s cardiology lab and completing 50 treadmill tests before working solo. The service is now available 8 a.m. to 12 noon, four days a week. On average, each of the trained physicians works one half-day shift a week, although each will do up to three shifts per week if needed.
Using testing criteria established by the American College of Cardiology and the American Heart Association, the hospitalists perform exercise treadmill testing for certain groups of low-risk patients. Those include ED-evaluated patients who have been ruled out for MI. These patients are either still in-house or have been sent home in the previous 14 days, and the discharging ED physicians want definitive testing.
The hospitalists also test patients in the observation unit for borderline chest pain. (The ED physicians run that unit.) And they test patients in the hospitalist-run short-stay unit. These patients may be at somewhat higher risk than either of the other two groups, says Dr. Lucas, because of comorbidities.
“It really works most seamlessly for those patients, when the hospitalist in the short-stay unit has ordered the ETT,” says Dr. Lucas. “The rest of the tests are ordered by the ED.”
Hospitalists’ track record
It turns out that hospitalists’ readings are nearly on a par with cardiologists’ as far as classifying results as negative, positive or indeterminate.
In a 2007 study led by Dr. Lucas, only a handful of hospitalist interpretations “3% of 349 different test results ” were not “concordant with the cardiologists,'” he says.
Cardiologists are still available for “curbside” consults on borderline results, which happen about 5% of the time, Dr. Lucas adds. And cardiologists “over-read” all hospitalists’ exercise treadmill tests within a week.
“They contact us only if it’s a false negative,” he says. “That’s happened only about twice a year.” Dr. Lucas notes that his group doesn’t bill for their treadmill testing service, simply because they don’t yet bill for any of their services. “This makes our situation extremely unique,” he points out. “Most hospitalists will want to bill for treadmill testing.”
According to Dr. Lucas, the biggest advantage of the hospitalist-run service is the improved access to and timing of tests. With the unit in place, 53% of patients for whom treadmill testing is indicated now undergo testing the same day. Dr. Lucas says that he isn’t sure what that percentage was prior to his group taking the service over, “but it was close to 0%.”
He also points out that many patients who are sent home and told to come back to the hospital for a test ” treadmill or otherwise “simply don’t show up. “The ED, anecdotally at least, is much happier,” he says. “They’re able to get definitive tests done on many more of their patients the same day.”
Freeing up physician time
Dr. Lucas’ group has yet to do a before-and-after analysis of either patient outcomes or patient satisfaction. And because his group doesn’t receive revenue or cost data, the financials of the service are “an unknown.”
What is clear, however, is that having hospitalists take over this testing frees up time for both ED doctors and cardiologists. Before, Dr. Lucas points out, the cardiologists’ treadmill-testing lab was overbooked and understaffed. Now, cardiologists can concentrate on more high-tech studies.
The service also lends an internist’s perspective to cases where ED physicians are at a loss over what to do next because of inconclusive test results.
“Internists are generally better at figuring out what the likely alternative diagnoses are,” Dr. Lucas observes, and to decide what further workup might be warranted. The hospitalists are also better equipped than cardiologists to look at potentially broader causes of chest pain.
Training and educational barriers
Because the cardiologists aren’t paid on a fee-for-service basis for procedures, there was no resistance to hospitalists doing treadmill testing. “The cardiologists were more than happy to support and train us,” Dr. Lucas says.
While his group encountered few turf issues, Dr. Lucas suggests that any group trying its hand at a similar venture should explore potential problems before moving forward. Other “must-do” steps include allowing at least three months to get the doctors trained and the service off the ground. Expect that time frame to be closer to six months, he adds, if the hospitalist medical director has no prior experience with exercise treadmill testing.
Hospitalists also need to educate other physicians about which patients are appropriate to refer. While the tests are generally very safe, having a patient referred who is either too high risk or not able to undergo testing undermines service efficiency. In the early days of the service, for instance, Dr. Lucas says that the ED would refer patients who had severe arthritis.
A more typical inappropriate referral is a patient with a baseline 1-millimeter ST-segment depression who should have pharmacologic imaging instead, Dr. Lucas says. “You have to arrange that, which can slow things down tremendously.” Other diagnostic contraindications are patients with a baseline left-bundle branch block or a pacemaker, or patients diagnosed with Wolff-Parkinson- White Syndrome, a rare condition that may be associated with sudden death.
Clinical contraindications include patients who have had an MI in the previous two days, or patients with severe electrolyte abnormalities, severe hypertension or moderate stenotic valvular disease.
Interpreting results If a patient’s results are negative and low risk, “you’re sort of done for risk-stratification purposes,” Dr. Lucas says. In such cases, hospitalists don’t need to do any further risk stratification and can send the patient home or back to the ED for discharge.
Patients with positive results may be admitted. The thorny issue is when results are indeterminate and patients don’t achieve 85% of their maximal predicted heart rate during the test.
In those cases, which can account for one-third of the patients who Dr. Lucas’ group tests, both the patient and the hospitalist are left in limbo. “That’s a major limitation of treadmill testing, and it’s a potential inefficiency of a hospitalist-run service,” he explains, because a hospitalist often isn’t the attending at the time.
On the plus side, the attendings in such cases “usually ED physicians ” likely receive more detail from the hospitalist who examined the patient before and after the test.
“There’s a whole bunch of information that we convey to referring physicians,” Dr. Lucas says. “That’s a big potential benefit.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.
Getting a testing service off the ground
Hospitalists who take over exercise treadmill testing for low-risk patients say that hospitalist groups should expect to train for several months before starting up the service, says Brian P. Lucas, MD, MS, chief of the hospital medicine division at Stroger Cook County Hospital in Chicago and assistant professor at Rush University.
He also offers the following tips:
- Be prepared to purchase the equipment. That runs to about $100,000 per unit, which includes the interpretation software.
- Know and fulfill hospital policies regarding required medical equipment in the testing lab. An “oxygen tank and a crash cart would be the minimum,” Dr. Lucas says.
- Make sure the lab’s information system can interface with the hospital’s main data system for the purpose of patient records and charges. n Think location, location, location. “Ours is physically located in the ED,” says Dr. Lucas. “This is a tremendous help when it comes to communicating with the referring ED physicians, particularly over indeterminate results.”
- Hire an exercise treadmill testing technician to prep patients and manage non-clinical tasks onsite.
“Initially, we prepped the patients, and that was horribly inefficient,” Dr. Lucas recalls. Technicians are also better than hospitalists at troubleshooting equipment problems, he adds, but hospitalists should still be familiar with common malfunctions.