Published in the August 2007 issue of Today’s Hospitalist.
If you’ve ever dreamed of a workday with no admissions to interrupt your rounds, you might want to talk to Fara Kardan, MD. A hospitalist and the medical director of Advanced Hospitalist Medical Group (AHMG) at Mission Hospital in Mission Viejo, Calif., he enjoys exactly that type of shift on half of the days he works.
Like a number of hospitalist programs around the country, Dr. Kardan’s practice has implemented a dedicated-admitter model: One hospitalist each day rounds on few (or no) patients and handles all of that day’s admissions, freeing the other day-time hospitalist to concentrate on rounds without being interrupted. When rounds are complete, that rounding physician’s day is done. “If he can finish by 2 p.m., he can leave at 2 p.m.,” Dr. Kardan says.
While the dedicated-admitter model is a relative newcomer to hospital medicine, its proponents have high hopes for it. They claim that it not only improves physician satisfaction by giving clinicians time to focus on either admitting or rounding, but improves a hospital’s throughput and potentially reduces length of stay.
The model, however, has its share of critics. A number of industry veterans say that dedicating hospitalists to either admissions or rounding can often backfire by creating bottlenecks in the emergency department. But an even bigger criticism of the model is that it introduces more handoffs into the patient care process.
Impact on efficiency
There are no firm statistics on the use of the dedicated-admitter model, but industry insiders estimate that between 10% and 20% of hospitalist groups are using it. That number may grow, however, as hospitalist groups face pressure to take on greater patient volumes and add new services.
“As hospitalist programs mature and start to take on more surgical co-management, the number of admissions will increase,” says Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC in San Diego. “That puts more pressure to place a full-time team in the ED to handle the triage.”
Robert Reynolds, MD, president and CEO of PrimeDoc, a physician-owned and managed private practice company that is based in Asheville, N.C., is a believer in dedicated admitters and rounders. His company uses the model in its larger programs.
“I think the model will catch on because it makes a lot of sense for the hospital,” he says, “and it makes the work environment for the physicians more enjoyable and less hectic.”
At PrimeDoc practices, physicians who work daytime shifts “generally 7 a.m. to 7 p.m. “alternate weeks in the role of either rounder or admitter. Usually only one hospitalist is designated for admitting duties, although in larger programs, the admitting staff is doubled in mid-afternoon when the emergency department gets busier.
The admitting physicians operate efficiently because they are not juggling multiple responsibilities and wasting time running from the ED to the inpatient floors. Meanwhile, the rounders devote their full attention to the patients in the beds.
“That allows our physicians to be much more efficient in their management of the patients who are already hospitalized,” Dr. Reynolds says.
The downsides of segmentation
While the idea of segregating duties makes sense on paper, critics say that the efficiency equation can also tip the other way.
Longtime hospitalist and industry leader John R. Nelson, MD, a consultant with the firm Nelson/Flores Associates and medical director of the 14-physician hospitalist group at Overlake Hospital in Bellevue, Wash., puts it simply: Because inpatient census and daily admission volume are so inherently unpredictable, any effort to segment tasks within the hospitalist corps means risking an inappropriate distribution of workload.
“By segregating the doctors to one task or the other,” Dr. Nelson explains, “you may end up with overwhelmingly busy rounders and an admitter who is sitting on his hands all day, or vice versa.”
Dr. Reynolds admits that an unequal distribution of hospitalist labor can be a problem in a low-volume hospitalist program. That’s a big reason his company limits the dedicated-admitter model to programs that generally have a high volume of admissions a day.
PrimeDoc, which has more than 100 hospitalists in 14 programs in the Southeast and Mid-Atlantic states, also addresses that issue by assigning admitters to serve as back-ups to rounders.
“On a day when there is not a lot going on in the admission realm,” Dr. Reynolds points out, “that physician helps the rounder see patients on the floor. That further improves the efficiency of our care of patients who are already hospitalized.”
The fix for patient flow
George K. Davis, MD, medical director at Presbyterian Inpatient Care Specialists (PICS) in Charlotte, N.C., believes dedicated admitters are the only viable option for the service he runs at the 531-bed Presbyterian Hospital. The hospital typically handles 28 to 30 emergency department admissions in a 24-hour period.
The group includes 40 providers, including 34 physicians and six midlevels. At Presbyterian, the admitting service includes two midlevels who work staggered shifts between 8 a.m. and 7 p.m., and a physician who works from 2 p.m. to 11 p.m. Meanwhile, six hospitalists conduct daily rounds.
Having physicians “camped out” in the emergency department is key to keeping patients moving through the care system, Dr. Davis says. Faster ED response time means patients are admitted more quickly. That frees ED space, shortening waiting-room stays.
Meanwhile, because the rounders are not disrupted by pages from the ED, they can handle discharges in a timely fashion. “That clears up a bed so you place those patients coming from the ER,” Dr. Davis explains, “as well as those patients coming in from the primary care physician’s office as direct-admits.”
While Presbyterian has enough volume to make the dedicated-admitter model work, it may not be typical of most practices. As Dr. Nelson points out, most hospitalist groups can dedicate only one physician to admissions. And as the admission rate picks up in late afternoon, the dedicated-admitter model can actually cause a bottleneck because only one person is accepting patients.
“The ER calls at 4 p.m. and says, ‘We have three here to admit,’ ” Dr. Nelson explains. “You say, ‘OK “it will take hours to see them all. Just keep them down there.’ That’s not very good service for the patient or the ER.”
The cost equation
Throughput isn’t the only consideration in a dedicated-admitter model. Even its proponents admit that it is more expensive to operate than the traditional model.
At Presbyterian, Dr. Davis’ hospitalist group schedules seven-on/seven-off, so adding a dedicated admitter means he has to hire two full-time equivalents. That expense is a factor as the group considers whether to adopt a dedicated-admitter model at one of the smaller hospitals in the system.
But supporters of the model say that such costs need to be weighed against the financial benefits that accrue to the hospital. Dedicated rounders have time to monitor their inpatients more closely, proponents say, and discharge them promptly, resulting in diminished length of stay.
For that reason, Dr. Kardan, the hospitalist at Mission Hospital, considers the extra expense to be an investment in quality and client satisfaction. In his mind, the freedom to round on patients without interruption translates into better outcomes and quality, with higher job satisfaction for the hospitalists.
“If the return on investment is good for the hospital because the model improves length of stay and quality indicators, it is worth the extra money,” says Dr. Kardan, whose group currently has four full-time and eight part-time physicians.
What physicians think
At the 317-bed Mission Hospital, Dr. Kardan and his colleagues take turns, admitting on one day and rounding on the next. If the admitter needs help, the rounder can be pressed into service, but that happens only rarely.
Dr. Kardan says that the system is so popular that when the practice recently decided to hire two new hospitalists, group members referred their friends to fill those openings.
Dr. Davis, who runs the Presbyterian Health hospitalist program, thinks the dedicated-admitter model is an antidote to the fatigue that many hospitalists suffer. Studies have consistently shown that lack of autonomy and control over one’s work schedule is strongly correlated with burnout and low job satisfaction.
“When you’re trying to be an admitter as well as a rounder,” he says, “it leads to very intense days. I don’t think you can survive too many of those intense days without burning out.”
“A good thing”
His colleague, Nicole S. Hinson, MD, agrees. When she started as a hospitalist at Presbyterian Hospital six years ago, the program used the round-robin approach, with every hospitalist on the team taking turns accepting admissions.
As the group’s patient volume grew, the situation became untenable. About three years ago, the group took the plunge and moved to a dedicated-admitter model.
“From my perspective, it’s been a good thing,” Dr. Hinson explains. “I’ve been on the other side, and it’s very stressful. You want to please everybody, but you’re only one person.”
Dr. Hinson volunteered to take on the role of admitter as her primary responsibility, although she occasionally takes rounding shifts. She works 2 p.m. to 11 p.m., so she is on hand for the busy admission hours. Midlevel practitioners handle admissions in the earlier part of the day, and a moonlighting physician helps with admissions from 6 p.m. to midnight.
Dr. Hinson admits patients from the ED, as well as direct-admits coming from community physicians who contact her via pager.
It’s a hectic pace, but Dr. Hinson says it is no worse than a day of rounding. “It depends on the volume,” she explains. “The work can be pretty intense or it can slow down to almost nothing. There’s no way to manage it, so you just take it as it comes. The same thing happens on the floor. Being a hospitalist requires that flexibility.”
Too many handoffs?
Physician satisfaction may or may not improve with dedicated-admitter systems, but skeptics worry that the model will alienate an even more important group: patients.
Mr. Buser, for example, the consultant who specializes in hospitalist practices, says that dedicated admitters and rounders introduce more handoffs into the picture. “We have found that patient satisfaction and continuity can suffer with the dedicated-admitter approach,” he explains.
That discontinuity is the primary reason Dr. Nelson avoids the dedicated-admitter model. Patients admitted to the hospital via the emergency room may already be surprised that their primary care physician did not come to the ED to treat them. The ED physician then hands off the patient to the admitting hospitalist, who then hands him off to yet another physician.
Dr. Nelson likes to put himself in the shoes of the patient in this situation: “You kind of like the hospitalist who is doing the admission and you say, ‘So when can I expect to see you tomorrow?’ And he says ‘You know what? You’re not going to see me again. Tomorrow, one of the rounders is going to take over for me. I’m not sure who it will be. We’ll figure that out tomorrow morning.’ ”
That transaction may not only diminish patient satisfaction, but it opens the possibility that vital information about the patient will be lost in the hand-off. In Dr. Kardan’s model, the physician who acts as an admitter one day will round on those patients the next day, and continue following them until discharge or the end of his or her seven-day shift. That helps continuity of care, he says, and reduces the number of handoffs.
Concerns about that “voltage drop” prompted Dr. Davis and his colleagues at Presbyterian to develop their own communication strategy. They work to diminish handoff problems by making sure the rounding physician gets the vital information about a patient directly and immediately from the admitter.
Using an index card, the admitting physician writes the crucial information “admitting diagnosis, pertinent items from the patient’s medical history and so forth “and posts it to the rounding physician’s board. The admitter also calls the rounder’s cell phone to discuss the patient or leave a message: “I’m admitting Mrs. Brown with ABC, and I did XYZ for her.”
Making the choice
Despite the pros and cons of dedicated-admitter systems, most observers say that the approach makes the most sense for large programs with a high volume of ED admissions.
“ED volumes are rising at the rate of 10% to 15% every year, which adds a lot of pressure to keep the ED off diversion,” says Mr. Buser. That pressure has led many programs to step up and provide a dedicated-admitting service, he adds. And as hospitalists increasingly take on surgical co-management duties to help ease the burden of ED call on surgical subspecialists, “a dedicated hospitalist will have plenty of work to justify the staffing.”
At PrimeDoc, Dr. Reynolds uses inpatient census to determine which scheduling model should be used. In general, once individual hospitalists are routinely rounding on 16 to 18 patients a day, PrimeDoc implements the dedicated-admitter approach.
Although the dedicated-admitter model is an easy choice for Presbyterian Health’s largest hospital, the PICS physicians also cover three smaller hospitals in the same system, where they maintain a traditional shared-responsibility model. To determine which model to use, Dr. Davis tracks emergency room response time and physician satisfaction levels. He says that when the ED starts complaining that hospitalists are slow to arrive “or physicians start complaining that their workload is too much to sustain “he takes a serious look at the dedicated-admitter model.
“If four hospitalists are admitting 10 or 12 patients in a 12-hour period of time,” he explains, “it’s probably time to start considering two distinct services, an admitting service and a rounding service.”
But don’t wait until volume is out of control, warns Mr. Buser “By the time the hospitalists are complaining bitterly, it may be too late,” he says. “Discussing the concept with administration and the ED director early on is the best way to anticipate demand.”
Lola Butcher is a health care business writer who is based in Springfield, Mo.