Published in the September 2010 issue of Today’s Hospitalist
It’s always been one of the most nerve-wracking calls for ED physicians: Should you admit a patient complaining of chest pain whose tests are inconclusive, or send him home?
Doctors who opt to admit low-risk “rule-out” patients, only to have them discharged the next day, can find themselves criticized for promoting waste and for putting the hospital at risk for Medicare recovery audit contractor (RAC) penalties.
But ED doctors who send those patients home, even with strict instructions to get an outpatient stress test, open themselves up to the most common cause of medical malpractice suits against emergency physicians. Studies show that suits for missed myocardial infarction account for one-quarter of the cost of claims paid on behalf of ED doctors.
“Rather than having a unit based on status, we now have units based on diagnosis.”
Enter hospitalists. Across the country, the high-risk, high-stakes business of ruling out MIs in short-stay units is rapidly becoming the latest domain of hospital medicine. While that shift may cause angst among individual hospitalists, many leaders of the specialty say that it’s a growth opportunity for hospital medicine as a whole.
“This is a real opportunity for hospitalists to expand,” says Peter Y. Watson, MD, head of the division of hospitalist medicine at Henry Ford Hospital in Detroit. “The pressure on ERs has become increasingly intense, and ER physicians are saying that they may not have the capability to manage this anymore.”
A boost for the bottom line
Chest pain units, which are also known as “short-stay,” “bedded outpatient” or “23-hour” units, can take any one of many forms. They can be stand-alone units that deal exclusively with chest pain, or they can be part of larger observation units that see patients with other symptoms. They can be located in the ED or on the cardiology floor, or they can function as “virtual” units using monitored telemetry beds throughout the hospital.
What makes all of these units similar is that they are run by a protocol. By wringing out the variability in the way chest pain patients are managed, the thinking goes, hospitals can offer better quality care with less liability. But hospitalist-run chest pain centers can also boost a hospital’s bottom line and give hospitals a competitive edge in local markets.
Felix Aguirre, MD, vice president of medical affairs for IPC The Hospitalist Company Inc., which is based in North Hollywood, Calif., and has hospitalist practices in more than 500 hospitals nationwide, says he has seen interest in “and development of “chest pain centers take off. Hospitalists in IPC practices now staff “one or two dozen chest pain centers,” he says, many started in the last year.
When it comes to marketing such centers, Dr. Aguirre notes, there are two questions you need to answer to assess the opportunity. “One, can the hospital be the first in the community to have such a center of excellence?” he asks. “And two, if the hospital down the street has a chest pain center, can we really compete without one?”
Tye B. Young, DO, hospitalist program department chair and medical director of the chest pain center at Billings Clinic in Billings, Mont., acknowledges that chest pain centers can enhance hospitals’ marketing efforts. But the major reason his hospitalist group established a chest pain center two years ago was to standardize treatment.
“Having a chest pain center doesn’t necessarily mean building a new facility,” says Dr. Young, who points out that Billings Clinic has a “virtual” center of 30 telemetry beds throughout the hospital. “But it does mean putting some protocols, some standardization, some quality control in place to be consistent in how you evaluate these patients.”
Dr. Young’s group follows a pathway that he helped develop and signed off on, along with the heads of the emergency department and cardiology. Patients with chest pain are now all risk-stratified using the numerical TIMI scoring system.
Those with a TIMI score of 0 or 1 can be sent home from the ED with an appointment in hand to come back in the next 48 hours for a stress test. Patients who score a 4 or greater are sent to a hospitalist-run, virtual short-stay unit, typically as an outpatient status patient occupying a bed for between six and 24 hrs.
“It definitely helps give the physician more objectivity in evaluating the patient,” Dr. Young says, particularly patients with a moderate risk profile. They are the ones who are “the exact nightmare that physicians have,” if doctors don’t give enough weight to a patient’s symptoms or story. The TIMI scoring system, he notes, helps give physicians a sense of impending problems.
“What is the chance that this person that I’m about to send out of my ER will, in the next two weeks, fall over dead at home or have to be rushed to the cath lab?” he says. “We’ll see that the patient had an ER visit 10 days ago, and my name is going to be all over it.”
More beds, fewer readmissions
But there are advantages of chest pain units that go beyond quality of care. Because the ED used to admit all these patients so they could undergo an inpatient stress test the next day, Dr. Young says that the chest pain center has freed up quite a few beds. It has also measurably increased the utilization of outpatient stress testing.
“The more testing of low and low-moderate risk patients we can shift to the outpatient realm,” he points out, “the more telemetry beds we can preserve for higher risk patients who need an inpatient stay.”
At Detroit’s Henry Ford Hospital, putting the hospitalists in charge of managing chest pain likewise could pay a financial dividend for the hospital. While nationally, about 5% of chest pain patients end up being admitted as inpatients, that figure is 10% in his hospital, Dr. Watson says, due to hospitalists’ ability to manage patients’ complexity and comorbidities, and to do a thorough job documenting those.
“The primary reason to have a cardiac unit is that it’s the right thing to do, but there’s also a potential return on investment for the hospital,” Dr. Watson points out. “That return is in reduced readmissions, managing complex observation patients and greater facility charges.”
While protocols help standardize care, chest pain centers also reduce variability by limiting the number of doctors taking care of chest pain patients.
At Nebraska Methodist Hospital in Omaha, chest pain patients are managed in what physicians there call a clinical decision unit (CDU). In addition to chest pain, the unit treats patients who need outpatient observation for syncope, transient ischemic attack and deep venous thrombosis.
Nebraska Methodist put hospitalists in charge of the CDU to streamline the unit’s management. Hospitalist Nicole Paulman, MD, the CDU’s medical director, explains that previously, observation patients were cared for by ED nurses, “who sometimes had to split their duties between doing patient intake in the ER and more floor-type duties in the CDU.” ED physicians either consulted hospitalists or cardiologists for those patients.
Making the CDU the responsibility of the hospitalists, Dr. Paulman notes, didn’t mean additional work; after all, the hospitalists were being called to take care of these patients anyway and were in the ED regularly. But taking over the unit did give the hospitalists the authority to hire their own nurses, as well as institute procedures and protocols. The average length of stay now in the unit is between 10 and 12 hours, which is lower than for floor admissions.
Taking control of the unit may also increase the business of the 13-member hospitalist group because the CDU is now effectively “closed,” except to hospitalists and cardiologists. “Our protocol says that patients in the CDU will be seen within 60 minutes,” Dr. Paulman explains. “We have set ground rules that only hospitalists and cardiologists are allowed to admit to the CDU for chest pain because we are in-house 24/7.”
The hospitalist service, which is part of a multispecialty group, currently cares for about one-third of the hospital’s 250-bed inpatients. But many more of the primary care physicians who continue to follow their patients when admitted to the hospital now elect to use the hospitalists for their short-stay cardiac patients.
Far from pushing back, Dr. Paulman points out, primary care physicians “appreciate the quick turnaround and evaluation. If the patient ends up needing to be admitted, the primary care physician takes over at that point.”
Control of direct admissions
The 450-bed Banner Baywood Medical Center in Mesa, Ariz., is making plans to broaden the scope of its eight year-old chest pain evaluation unit. In addition to expanding from eight to 20 beds this winter, the unit will also take in patients with symptoms besides chest pain.
The chest pain unit has been staffed by several cardiac nurses who work with hospitalists under a protocol. The new rapid evaluation unit will continue to be under hospitalist leadership, and it will also deal with the issue of direct admissions.
Adam Horeish, MD, an IPC hospitalist who has been practicing at Banner Baywood since 2002, says that primary care physicians and small EDs in outlying hospitals can currently admit patients directly to the hospital, resulting in admissions that are sometimes unnecessary. Once the larger unit is up and running, all direct admissions will go to the hospitalist-run rapid evaluation unit first.
As for staffing that larger unit, two of the group’s physicians have expressed interest, Dr. Horeish adds. “They will be meeting regularly with administration to run the data,” he says, “but more likely, we will have to rotate all the hospitalists through that unit.”
That’s because unless all 20 beds in the new unit stay full, there won’t be enough patients to justify dedicated hospitalists. “Financially,” says Dr. Horeish, “it wouldn’t make sense.”
Skills and temperament
That leads to this thorny question: Should all hospitalists rotate through these units, or should a small group of dedicated hospitalists take care of most patients?
At Detroit’s Henry Ford, Dr. Watson has more than enough manpower in his 50-physician group to spread the staffing of his 33-bed cardiac unit around. But while many of the program’s physicians rotate through the unit to maintain their baseline skills, the unit is staffed most of the time by a group of about seven doctors.
Establishing a core group of dedicated hospitalists, Dr. Watson says, is important because working in a chest pain unit demands a different set of physician skills and temperament than straight hospital work. “Not all hospitalists may feel comfortable managing patients with a little uncertainty,” he explains. “You may not make the absolute perfect diagnosis and wrap it all up neatly prior to the patient leaving.”
Internists in particular, he adds, are trained “to work up every last little problem” and may find themselves out of their comfort zone. “In a chest pain center, that’s not our job,” he says. “We’re trying to determine if a patient has unstable coronary artery disease. And if they don’t, we’re getting them to a point where they can safely leave and continue further risk reduction as an outpatient.”
Opting for specialization
In May of this year, Henry Ford took that notion of specialization even farther. Since 2002, the hospitalists had been seeing chest pain patients in an all-purpose observation unit where between 60% and 70% of the patients were cardiac-related. Now, however, instead of an all-purpose observation unit, the center is restricted to cardiac cases and treats patients with chest pain, heart failure and arrhythmias. Other patients who the hospitalists used to see for observation, such as TIA patients, are now sent to a neurology observation unit elsewhere in the hospital.
While other hospitals are expanding their chest pain units to include other diagnoses, Henry Ford is taking the opposite tack. “Rather than having a unit based on status,” Dr. Watson says, “we now have units based on diagnosis that include all kinds of status.” The cardiac unit where the chest pain patients are seen, for instance, also includes full cardiac admissions as well as short-stay and observation patients.
One benefit of such consolidation is that low-risk chest pain patients who become high-risk when labs come in don’t have to be moved or handed off.
“Same doc, same nurse, same unit,” Dr. Watson says. In the first 90 days since the unit switched from all-purpose observation to cardiac only, he points out, the length of stay “about 24 hours “has stayed the same, but patients have had fewer handoffs.
Furthermore, Dr. Watson says, the hospital is planning to expand the cardiac unit to include heart failure patients. Instead of being automatically admitted, certain patients will be routed to the cardiac unit for a rapid CHF observation.
“We’re looking to create heart failure observation in the same unit,” says Dr. Watson. “We think that will reduce readmissions and standardize care.”
“We have set ground rules that only hospitalists and cardiologists are allowed to admit to the CDU for chest pain.” ‘Nicole Paulman, MD Nebraska Methodist Hospital
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto.
Getting a chest pain center off the ground
WANT TO MAKE THE MOST of a chest pain evaluation center? Hospitalists who have established one offer the following tips:
- Develop protocols. “This is prework you need to do because length of stay is hours, not days,” says Peter Y. Watson, MD, head of the division of hospitalist medicine at Henry Ford Hospital in Detroit. “Protocols become extremely important.”Instead of reinventing the protocol wheel, take a look at what’s in the literature. When Tye B. Young, DO, hospitalist program department chair and medical director of the chest pain center at Billings Clinic in Billings, Mont., was setting up a hospitalist-run chest pain center two years ago, he met with the head of the emergency department and cardiology. Together, they searched the literature and adapted the chest pain evaluation protocols of several medical centers.
- Emphasize teamwork and education. To work, protocols must be accepted by hospitalists, emergency physicians and cardiologists. The hardest part of establishing a center, says Dr. Young, was getting everyone in the various departments on the same algorithm page.To do so, he met with staff in different departments, not once, but twice. Before the chest pain center went live, he explained the algorithm to everyone and how they’d be doing things differently.Once the center was live and data still showed protocol variations, he went back and explained the algorithm again. “You’d like to think you have to deliver the message once,” says Dr. Young. “But people forget or get in a hurry, or they feel their patient is a little different.”
- Collect data and make improvements. Nicole Paulman, MD, heads up the clinical decision unit at Nebraska Methodist Hospital in Omaha, which sees chest pain patients as well as patients with other observation-type symptoms. The unit’s admission percentage to the hospital for chest pain patients is only between 1% and 2%, lower than the 5% national benchmark.That means that the hospital’s physicians (ED, primary care and hospitalists all) perhaps are being too cautious and admitting some patients directly to the cardiac floor instead of to observation. According to Dr. Paulman, the data are “helping us think critically about the fact that maybe this patient can go to the CDU” and then home, avoiding a hospital admission altogether.
Going the distance with accreditation
CHEST PAIN CENTERS “either in specific units or “virtual” ones with beds spread throughout a hospital “come with several levels of possible accreditation from the Society of Chest Pain Centers. The nonprofit organization, which is based in Columbus, Ohio, has accredited centers in more than 600 facilities over its 10-year history. (All the chest pain centers mentioned in this article are accredited.)
What’s involved in accreditation? According to Deborah Koeppen, RN, the society’s director of business development, hospitals have to meet criteria on eight different elements, as well as pass an onsite visit. Elements address process improvement; personnel and training; organizational structure; and ED integration with the emergency medical system. (The society also offers heart failure accreditation, as does the Joint Commission.) It usually takes hospitals about six months, says Ms. Koeppen, to prepare to become accredited, which is good for a period of three years.
Hospitalists say that accreditation is the key to making the most of marketing efforts related to having a chest pain unit. “Accreditation is basically the only safe way to advertise them,” says Felix Aguirre, MD, vice president of medical affairs for IPC The Hospitalist Company Inc., which has hospitalist practices in more than 500 hospitals nationwide. “Hospitals would be crucified for claiming they had a chest pain center without an intention to certify them.”
In Billings, Mont., where two hospitals vie for market share, “this idea of having an accredited chest pain center and being able to tell patients we have gone through some additional steps to distinguish ourselves in evaluating chest pain,” was a factor in the facility’s decision two years ago to create a hospitalist-run chest pain center, explains Tye B. Young, DO. Dr. Young is the hospitalist program department chair and medical director of the chest pain center at Billings Clinic.
“It started out clinically driven”, he says, “but as we started talking to our organization about it, it became a way to have a marketing edge.”
Accreditation, he adds, helps physicians take a standardized approach that has accountability built in through data collection and analysis. But at the same time, says Dr. Young, the process emphasizes flexibility in treating individual patients.
“We do recognize some patients don’t want to be admitted,” Dr. Young says. “Conversely, they may be too anxious about going home for outpatient testing. His group is in the process of considering the next tier of SCPC accreditation for its virtual chest pain center as well as heart failure accreditation from the society.
“And we hear that the SCPC is planning to offer atrial fibrillation accreditation,” says Dr. Young. “We’ll consider doing that as well.”