Published in the September 2005 issue of Today’s Hospitalist
Editor’s note: Last month, Today’s Hospitalist examined how hospitalists were working with emergency medicine physicians to improve throughput. In this month’s issue, we look at other types of ED-hospitalist collaboration.
As hospitals around the country turn to their emergency departments to improve throughput, many are realizing that hospitalists can play a valuable role in making sure that patients move through the hospital smoothly. (See “In a new role as ‘clog-busters,’ hospitalists are helping streamline the ED” in the August issue of Today’s Hospitalist.)
But as experts are quick to point out, improved throughput is only one result of a good relationship between hospitalists and emergency medicine physicians. With a little “intrapreneurship,” the two specialties can work together to jointly develop protocols that can improve patient care and reduce length of stay.
How hospitalists can add value
If you work in a relatively new hospitalist service, you’re in a great position to define your working relationship with the ED from the start.
Steve Nahm, a consultant with The Camden Group in El Segundo, Calif., says that when he sets up a new hospitalist program, he makes sure that the program’s medical director meets with subspecialists and ED physicians. This meeting helps identify the top reasons for admission, and it gives everyone a chance to create basic protocols for who “subspecialists or hospitalists “will handle the preadmission evaluation of patients who aren’t headed for the ICU or trauma unit.
Mr. Nahm says that this meeting can serve as a good forum to clear up other issues, such as the type of clinical workup ED physicians will perform to clear an admission without consulting the hospitalist.
“There are a number of issues that you want to address as you’re implementing the ED-hospitalist team approach,” he explains, “and it’s best when you can do that up front.” Otherwise, he adds, politics and other confounding factors can get in the way of decision-making.
Mr. Nahm urges hospitalists to remember that part of the value they add to the hospitalist-ED relationship is the ability to be more available than other attendings. He notes that some programs are shooting for “and achieving “response times of 30 minutes or less.
One creative way to increase your availability is to help evaluate what he calls “gray zone” patients. Mr. Nahm says that hospitalists can be invaluable in helping ED physicians who are on the fence about whether to admit these patients or place them in observation.
The importance of face time
To keep the lines of communication open between hospitalists and emergency medicine physicians, you need a regular form of communication.
Dichton Packard, MD, chief medical officer of EmCare and chief of emergency medicine at Baylor University Medical Center, suggests convening monthly joint staff meetings to review problematic patient cases. These meetings can help identify ways to improve throughput and address system issues.
Dr. Packard also recommends that emergency medicine physicians occasionally round with hospitalists to get an idea of what happens after patients are admitted. “The ED physicians don’t always know the follow-up to what happened in the ER,” he says.
Making “face time” for your counterparts in the ED may sound like common sense, but it doesn’t happen nearly often enough, according to Stephen Shaw, MD, medical director for Community Hospitalists in Cleveland and site director of the hospitalist program at Southwest General Hospital in suburban Middleburg Heights. Ensuring that one of the hospitalists goes to the ED on a regular basis, he says, not just when there’s an urgent need, “can produce all kinds of benefits in the long run.”
One starting point: joint protocols
One of the biggest areas of opportunity lies in developing protocols to spell out how patients will be treated.
The concept of developing joint treatment protocols to determine how ED patients with common diagnoses will be treated is receiving an increasing amount of attention. Mr. Nahm says that it’s a natural starting point for hospitalist-ED collaboration.
“If you go through the top reasons for admission,” he explains, “it’s simple to identify the type of patients you’re talking about, and then to agree about treatment protocols, such as when the ED will call a hospitalist vs. a subspecialist.” In most hospitals, congestive heart failure (CHF) and community-acquired pneumonia (CAP) are obvious starting points for a joint protocol. But there’s no reason why that short list can’t be continually expanded as the two physician groups work out the kinks and tap each other’s knowledge strengths, says Dr. Packard.
“Having the ED physicians and hospitalists work collaboratively not only allows patients to receive better, faster care in the ED,” he explains, “it also allows for all the little things that need to be done to maintain a shorter hospital stay.”
Dr. Packard says that performing a diagnostic test within a few hours of a patient’s arrival in the ED “not the following morning, as often happens “pays dividends in terms of patient wellness and length of stay.
Baylor is discovering that jointly developed protocols can produce even more significant long-term benefits. When hospitalists and emergency medicine physicians use a protocol in the ED to care for a large number of patients, hospitals can track patient outcomes.
“You can find out clinically how good it is,” Dr. Packard says, “or you can decide to tweak it. That’s something that doesn’t happen enough now, but it’s possible with that closer working relationship.”
Sterling Healthcare of Coral Gables, Fla., another national emergency department management company that has branched out into hospitalist management and joint ED-hospitalist programs, is similarly finding that collaborative protocol development can help standardize care.
Based on its repository of data on patients with fl are-ups of severe asthma who come through the ED, for example, Sterling has developed a protocol that calls for skipping the extended workup and sympathomimetic drugs for patients with FEV1 measures below a certain level. Its physicians instead move straight to steroids.
“We’ve found that earlier initiation of steroids leads to shorter length of stay and costs associated with this [type of ED admission], and we’ve gotten our hospitalists to buy into that,” says Stephen Dresnick, MD, Sterling’s CEO. “That’s the way medicine will go in general, but by integrating hospitalists and EDs, you can start to achieve some of these results very quickly.”
Sterling has initially focused on diseases or conditions that, in the big picture, account for multiple admissions over the lifespan of a disease. The next step, Dr. Dresnick says, is figuring out how best to enlist ED physicians and hospitalists in dealing with those populations in their institutions.
Sterling has embarked on a company-wide effort to measure its groups’ adherence to core treatment guidelines for CAP, acute MI and other diagnoses that have been promoted by organizations like the Joint Commission on Accreditation of Healthcare Organizations. Dr. Dresnick notes that hospitalists are already playing key roles in those efforts.
As the ED and hospitalist programs work more closely together, Sterling is also working on developing protocols, pathways and treatment “bundles” in non-chronic disease areas.
For example, patients in whom an acute MI has been ruled out “the ECG shows no definitive changes “are observed for 24 hours and go either to the catheterization lab or the treadmill before discharge. And patients with acute abdominal pain now go straight to imaging for a CT scan, Dr. Dresnick notes. When appropriate, Sterling also attempts to “migrate” its ED-hospitalist protocols to other programs.
“As the ED and hospitalist group medical directors go through each protocol, they identify which ones are do-able in that setting and which ones are most important to the hospital,” says Marlene A. Drori, Sterling’s VP of corporate resources and continuing medical education. “Basically, we look at the hospital’s demographics and focus first on protocols for what are considered the highest risk cases the hospital sees most frequently, whether it’s adult pneumonia or pediatric fever.”
Ms. Drori is quick to add that ED teams have found their hospitalist counterparts invaluable in “keeping” patients who might not even make it to a protocol because they’re resisting treatment or trying to leave.
“Patients trying to bolt “leaving AMA because they’re frustrated ” is a big issue in some places, especially when there’s a wait for a bed,” she explains. “Having the hospitalist there when that happens has been very effective.”
Although Dr. Dresnick thinks that joint protocols and standardizing treatment through hospitalist-ED teams is still evolving, he predicts there are limits in how far such initiatives can go. The chief limit, he says, is the inherent complexity of many of the older adult patients who end up in the ED.
“I suspect that we may end up with 20 of these [joint protocols] at most by the time we’re done,” he explains, “because many of the patients we see in the ED have multisystem issues.” (To date, Sterling has developed nine joint protocols.)
While there may be a limit to these jointly developed protocols, most hospitals have barely scratched the surface when it comes to creating and implementing them. As a result, hospitalists working in small or mid-size hospitals that have struggled with protocol agreement, either in the ED or on the wards, can take the lead to move things forward.
In the process, says Amir Bacchus, MD, chief medical officer of Pinnacle Health System in Las Vegas, hospitalists will prove themselves invaluable to their organizations. The good news, he says, is that you don’t have to reinvent the wheel.
“There are enough [protocols] out there that you can pick and choose,” Dr. Bacchus explains. “But it’s helpful if the hospitalists can take care of issues like getting the needed pharmacy buy-off because of the hospital formulary issues. Even small hospitalist groups can do this.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.