No one taking your calls?

WHEN THE HOSPITALISTS at Meadows Regional Medical Center in Vidalia, Ga., used to prepare for a weekend without any intensivist back-up, they’d spend their Thursday or Friday arranging transfers out of the small regional hospital. Many critically ill patients on ventilators were sent to big hospitals 90 miles away in Savannah or Macon.

A good number of those transfers could be considered prophylactic; patients weren’t suddenly deteriorating, nor did they suddenly need procedures that Meadows couldn’t provide. Many of the transfers were requested only because the five hospitalists at the 57-bed facility were “not comfortable” managing vent patients when neither of the hospital’s two pulmonologists were available to come in.

“We would see this pretty regularly,” says Karen McColl, MD, Meadows’ chief medical officer. “Dad was on a ventilator on Wednesday and now it’s Friday, but we can’t have him.”

“Transfers, at least down here in these small towns, can be very complex.”

~ David Aymond, MD
Byrd Regional Hospital

That situation turned around only a year ago when the hospital began contracting with Eagle Telemedicine for weekend tele-ICU services. Instead of having vent patients transferred out on Thursday, the e-ICU now provides the back-up assurance the hospitalists need.

The Georgia hospitalists are in no way out of the ordinary. According to a recent study, two-thirds of the nation’s hospitalists serve as primary physicians for ICU patients.

That study—based on a survey done by the critical care task force of the Society of Hospital Medicine (SHM), with results published in the January 2018 issue of the Journal of Hospital Medicine (JHM)— found that many of those physicians feel “obliged to practice beyond their scope.” They also report that, at least occasionally, they operate with “insufficient support” from board-certified intensivists.

The study also identified several key moments when these de facto intensivists feel particularly vulnerable: when they need to bring
the right specialists and consultants to the right patients at the right time, whether in person or virtually, and when they have to get patients to the right providers via inter-hospital transfer.

The need for skills and support
Explanations abound for the country’s crisis in critical care: the growing shortage of intensivists to treat an increasing number of older, sicker patients; the shrinking number of hospital beds; changes in internal medicine education that have put more emphasis on primary care; and the “closing” of many academic ICUs, which has led to many hospitalists “completing medicine training without the skills to perform bread-and-butter critical care,” explains David Aymond, MD.

A co-author of the JHM study, Dr. Aymond is a family medicine-trained hospitalist who practices in several small community hospitals, including Byrd Regional Hospital in Leesville, La. A faculty member for SHM’s online “critical care for the hospitalist” courses, he says his colleagues refer to him as a “hospitensivist” because he spends 50% of his time in the ICU.

“I certainly wish the process was more streamlined.”

~ Reaford Blackburn Jr., MD
Lake Cumberland Regional Hospital

“If you are doing hospital medicine, critically ill patients are going to fall in your lap,” he says. “And if you don’t have the skills, you are going to be uncomfortable, which typically leads to a transfer.” Such transfers, he adds, are very often not needed. “You would be able to correct the reason for that transfer by being familiar with some commonly encountered ICU issues.”

Further, “transfers, at least down here in these small towns, can be very complex,” says Dr. Aymond, referring not to patient outcomes (although those come into play) but to transfer processes. The phone at the transfer center you’re trying to reach may not be answered and go only to voicemail, although some answer all the time.

But “regardless of who you eventually speak with,” he says, “beds or specialists are seldom available.”

The benefit of big systems
There have been times that Dr. Aymond, like the hospitalists in Georgia, initiated prophylactic transfers because he wasn’t confident some hospitalist colleagues would be able to provide essential critical care when he was off service. Even hospitalists who don’t have critical care skills, he points out, can be litigated, and they would be held to the same medico-legal standard as an intensivist, if a bad outcome occurred.

“Learning and maintaining these skills,” he says, “are essential.”

While Dr. Aymond’s experiences with unresponsive transfer centers and unavailable specialists are common, they aren’t universal. Some rural hospitalists, especially those whose facilities are part of larger systems, report much better support.

“I can only imagine how stressful critical care is for a hospitalist who doesn’t have procedural confidence.”

~ Michael Menolasino, DO
Lake Health System Martin Healthcare Group

At the 16-bed Westfields Hospital in New Richmond, Wisc., for instance, hospitalist Yonatan Platt, MD, says he rarely feels he is on his own. He and his critical access hospital are part of HealthPartners, the large integrated health system. Dr. Platt makes frequent use of the “Regions Direct” transfer center’s toll-free phone line and is instantly connected to intensivists or other specialists at Regions Hospital, the HealthPartners’ mothership an hour away in St. Paul, Minn.

“If the critical care physician I am speaking with says, ‘Why don’t you speak to a cardiologist to make sure you don’t need to do anything before you transfer?’, the person on the phone at Regions Direct calls the cardiology service so we can have a three-way conversation,” Dr. Platt says. “We are all looking at the same images while talking about the patient through the EMR.” The transfer center staffer does “all the legwork getting the bed, getting the nurses to talk to each other and telling me what the wait time is.”

For the hospitalists who cover ICUs at Mercy Medical Group’s two smaller community hospitals in the Sacramento, Calif., area, support also comes from being part of a bigger system. As hospitalist Thomas McIlraith, MD, explains, outlying hospitalists have an insider track to a “well-oiled” transfer system into Dignity Health’s big hospitals, and both the smaller and the larger tertiary hospitals share the same EMR. Mercy Medical’s intensivists also maintain a telemedicine consult service to help providers in area hospitals that don’t have critical care coverage.

But what’s most helpful for hospitalists doing critical care in smaller hospitals that don’t always have that coverage, Dr. McIlraith says, is a requirement that everyone in the hospitalist group—including those who work in the larger hospitals—have certification in Fundamental Critical Care Support, a two-day course designed by the Society of Critical Care Medicine.

Providers who are not certified in critical care take it every four years. (All group members have privileges at all the hospitals, and many work in both big and small facilities.) Dr. McIlraith says that while the required course doesn’t replace board-certified intensivists, it does allow hospitalists to extend intensivist coverage.

“It has given a lot of comfort and competence to a lot of our hospitalists,” he says.

Workarounds
Given the transfer and support problems that hospitalists in small hospitals face, some rural groups develop workarounds. The physicians at Lake Cumberland Regional Hospital in Somerset, Ky., for instance, make sure that at least one hospitalist knowledgeable about and comfortable with critical care procedures is assigned to every shift, says Reaford Blackburn Jr., MD. “Three of us”—out of the 12 in the group—”feel exceedingly comfortable, but there are others who don’t.” Making sure shifts are staffed with doctors who have solid critical care skills helps keep the number of transfers down.

“Folks at bigger hospitals will say, ‘We can’t bring everybody in just because you are not comfortable treating them.’ “

~ Sanjay Dhar, MD
Summit Health

That’s a good thing, Dr. Blackburn points out, because arranging transfers can be tough, due to overcrowding and bed shortages. During this winter’s flu season, for example, finding an available bed was particularly frustrating.

He appreciates that the university specialists are always courteous and take his calls. But “they don’t have any beds and they don’t know when they will have any,” Dr. Blackburn says. Recently, when he needed to transfer a patient for a transjugular intrahepatic portosystemic shunt procedure, he spent more than an hour calling six different hospitals before he found an available bed. All the while, he had to provide labor-intensive supportive care to this very sick patient and continue treating his own regular panel of between 16 and 20 patients. (On an average day, four to six of those will be critically ill.)

“The family kept asking me when they would to be able to go, and I just had to say, ‘I’m trying. I don’t know.’ ” says Dr. Blackburn. “I certainly wish the process was more streamlined.”

Sharing an EMR—which he’s not able to— would be a big help. “If we have to wait on a bed for a day, it would be great if university intensivists could look over the patient’s record and call us back and say, ‘Why don’t you add on rifampin?’ That might keep us from having to transfer at all, which can be a huge risk.”

Getting up to speed
At the University of Kentucky’s division of hospital medicine in Lexington, Joseph R. Sweigart, MD, says that efforts are underway to smooth the sometimes bumpy transfer process that Dr. Blackburn and his colleagues encounter when they call requesting a bed. Hospitalists now meet daily with ICU staff as well as bed control and nursing to “streamline the process of moving patients quickly and efficiently out of the ICU” onto medical floors. The goal, says Dr. Sweigart, who was lead author of the January JHM study, is to make sure there is always an ICU bed available when community hospitalists need a transfer.

Sometimes, however, hospitalists make a tough situation even more complicated, says Michael Menolasino, DO, a hospital medicine director in suburban Cleveland at Ohio’s Lake Health System and Martin Healthcare Group. In addition to not seeking out ways to enhance their critical care skills, he’s heard colleagues gripe about how difficult it is to reach consultants when “they haven’t bothered to get their cell numbers,” he says. “Some of the frustration with inadequate support is on us in terms of how we communicate.”

There are times, he points out, that hospitalists “just send texts or put an order in the computer” and expect an immediate response. But until physicians pick up a phone and speak directly to colleagues whom they have spent time developing relationships with, specialists, who are busy themselves, won’t “know how important this may be.”

Meanwhile, he encourages all of Martin’s hospitalists to bone up on critical care procedural skills in refresher courses and a simulation lab that Dr. Menolasino runs every couple of months. Why not make participation mandatory, as Dr. McIlraith’s group in Sacramento does? “I can only imagine how stressful critical care is for a hospitalist who doesn’t have procedural confidence,” he says. But “I need to meet the adult learner halfway.”

The role of tele-ICU
Given the risks and limitations of transfers and insufficient intensivist support, University of Kentucky’s Dr. Sweigart believes that telemedicine could be “a game-changer.” The SHM survey he helped analyze did not address the use of tele-ICU to support hospitalists in smaller communities. Anecdotally, he says, the jury seems to be out, with some hospitalists saying tele-ICU support is “amazing” and others claiming “it hasn’t changed the way I practice.”

Sanjay Dhar, MD, a hospitalist and medical director for clinical improvement, connected health and the stroke program at Summit Health’s two hospitals in south-central Pennsylvania, falls on the side of telemedicine as a game changer for small, rural hospitals—even though, he notes, it’s a costly one.

Between 2013 and 2017, transfers out of the 55-bed Waynesboro Hospital’s eight-bed ICU dropped more than 26%, nearly all of which was due to increased availability of specialists, including infectious diseases and nephrology via telemedicine. At the same time, the hospital’s case mix index has increased, suggesting that the facility can now hold on to sicker (and more lucrative) patients.

The overall length of stay has also dropped, saving the hospital money—and leading Dr. Dhar to conclude that the program’s benefits may well be worth its cost. Summit Health has also contracted with Mercy Virtual for intensivist coverage at critical care units in both its hospitals at night.

One thing that is clear, he adds, is that the hospitalists are happier. “Before we started tele-ICU, the ICU coverage was on the hospitalists’ shoulders, but most of our hospitalists did not do any procedures.” That meant additional stress for many doctors working alone at night.

He also thinks that having tele-ICU may reduce the need for many transfers. “Folks at bigger hospitals will say, ‘We can’t bring everybody in just because you are not comfortable treating them,’ ” Dr. Dhar says. With tele-ICU, however, “we are more likely to be able to keep sicker patients at Waynesboro Hospital.”

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

Steps forward
A POSITION PAPER issued by both the Society of Hospital Medicine (SHM) and the Society of Critical Care Medicine (SCCM) in the May/June 2012 Journal of Hospital Medicine put forward this proposal: The two specialties should develop a one-year critical care fellowship track for experienced hospitalists that would allow them to become full-fledged intensivists and help ease the intensivist shortage.

But the pulmonary/critical care community swiftly squashed that idea, concerned that hospitalists were trying to muscle in on their specialty and patients. Six years later, with hospitalists still providing a great deal of the country’s critical care, how should they get the skills they need?

According to David Aymond, MD, a member of SHM’s critical care task force, SHM is still in discussions with SCCM about how to develop non-intensivist training. Those discussions are “a work in progress,” says Dr. Aymond, but there is consensus on developing comprehensive review courses with online modules in conjunction with in-person procedure courses.

But there’s no longer any talk about hospitalists being able to certify as full-fledged intensivists after an abbreviated fellowship, a definite line the intensivist community doesn’t want to see crossed. One positive sign: SHM has approached the American Board of Family Medicine, suggesting that family medicine physicians be able to apply for critical care fellowships. “That board has agreed it is an important topic,” Dr. Aymond says, “and something it will consider.