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Scope-of-practice creep

January 2010

The December cover story of Today’s Hospitalist on admitting intracerebral hemorrhage (ICH) patients confirms a trend that I’m witnessing and find both inevitable and concerning: the ever-expanding scope of practice for many of us as hospitalists.

The degree of expansion varies widely depending on how available specialists are in a facility and how willing they are to consult and attend to patients. The bottom line, however, is that we see an ongoing exodus of medical staff from the hospital almost everywhere we go. Gastroenterologists are spending more time in the outpatient GI lab, while neurologists are reading sleep studies and EMGs rather than doing consults.

Nephrologists have outpatient dialysis centers, and neurosurgeons are spread thin among several hospitals. With Medicare eliminating the use of consultation billing codes, this trend stands to only get worse.

Holding the bag
That leaves hospitalists, most of who are employed by or contractually obligated to the hospital, as the supposed solution. For those of us on the front lines, however, that’s a frightening proposition. We see other specialists or administrators making inappropriate decisions as to what is safe to admit to the hospitalist service; sometimes, these decisions are made without the hospitalists’ collaboration. That makes it all the more important for hospitalist leadership to engage the administration and medical staff on these issues and focus on what is right for the patient.

Be part of the solution
When it comes to these admissions, we’ll get much further with those discussions if the hospitalist program is willing to be a part of the solution, albeit not the whole solution. As December’s lead story pointed out, ICH patients almost always seem to be a bone of contention. In medical school and residency, these patients were all admitted to the neuro ICU, and the medical service was hardly involved at all. Now, in the absence of house staff, these patients are diverted to the hospitalist service–which is OK, with the right support mechanisms and appropriate education and training.

Rules of engagement
One approach that I have found successful is to lay down the “rules of engagement” for each specific diagnosis. When we finally got the neurosurgeons at one hospital to the table, many of the reasons why they were asking us to take over ICH admissions had to do with their needing to cover several hospitals and their inability to respond emergently to a request to admit a “non-surgical” bleed. I certainly understand their rationale, and I respect that they work long hours and need to be “fresh” for their time in the OR. Because we were willing to be part of the solution, we were able negotiate the following as it pertains to the care of these patients:

– The on-call neurosurgeon would speak to the ED physician and review the CT images remotely to decide if this was a non-surgical ICH. Any bleed requiring surgical intervention went directly to their service.

– If the ICH was deemed non-surgical, the hospitalist service would admit the patient–with the neurosurgeon making a consult within 12 hours.

– The neurosurgeon would round on the patient daily and would be available to speak to the family daily if needed.

– The neurosurgeon would not “sign off” until the hospitalist service agreed to that sign-off.

– The neurosurgeon would be available for a STAT, in-person evaluation at the request of the hospitalist if the patient’s condition changed.

Finding a middle ground
These simple guidelines enabled us to forge a stronger relationship with a specialty group that previously had been hard to work with. More importantly, it allowed us to provide patient care that was timely, efficient and safe, and it provided the justification we needed for additional staffing to grow the program. It’s amazing what a little “roundtable” discussion can do. I would suggest you take a similar approach if your program experiences some “creep of scope.”