Published in the May 2006 issue of Today’s Hospitalist
You probably know that surgical co-management can pay big dividends in terms of standardized and improved patient care for patients undergoing hip replacement and other orthopedic procedures. You also likely know that this growing area represents a tremendous opportunity for you as a hospitalist to grow your practice and cement your reputation in the hospital. But do you know what it takes to create and run a successful surgical comanagement program?
According to two pioneers of the hospitalist movement who have more than a decade of experience of working with surgeons, co-managing surgical patients requires planning, patience and the ability to juggle the competing demands of multiple partners.
Some of the keys, such as standardizing the care of patients, will be old hat to hospitalists. When it comes to skills like navigating surgeons’ firmly held beliefs about topics like DVT prophylaxis and cardiac risk, however, hospitalists are likely to discover some new challenges. And some of those have more to do with temperament than clinical care.
In an interview with Today’s Hospitalist, Ronald Greeno, MD, and Andrew Fishmann, MD, both co-founders of Cogent Healthcare, offer advice on what hospitalists need to know about co-managing surgical patients.
It’s all about standardization …
Nearly 12 years ago, several of the hospitalists who would eventually form Cogent initiated a partnership with the orthopedic surgeons at Good Samaritan Hospital in Los Angeles. The idea was to improve the efficiency of caring for hip fracture patients by having hospitalists take care of the medical needs of the hospital’s orthopedic patients. That included everything from pre-operative assessments to inpatient medical care and preparation for discharge.
Dr. Greeno, chief medical officer of Cogent, says that surgical co-management is “markedly superior in terms of reducing patient risk because it’s the only way to standardize it. Without standardization,” he explains, “there is so much room for error.”
To get an idea of the problem with the pre-operative care that many patients receive, Dr. Greeno says, consider a typical community where three to 10 surgeons perform 20 to 40 surgeries a week.
“How do they coordinate the pre-operative care amongst 40 different medical groups?” he asks. “How do they make sure that all their patient testing gets done, that reports are dictated, that history and physicals are available, and that patients are cared for post-operatively?”
That’s where hospitalists enter the picture. “Compare that to if you have one group doing all that work, handling it for all the surgeons,” Dr. Greeno says. “There is no second-guessing. You know the patients. All the work is getting done.”
… and timing
The Cogent approach to surgical comanagement starts with seeing patients immediately after surgery.
“Rather than waiting until the third post-op day when they have a blood pressure problem or a diabetes problem that is out of control, we have historically found it best to see these patients immediately post-op and deal with the medical management issues going forward,” says Dr. Fishmann, who is a Cogent board member and director of the ICU at Good Samaritan Hospital in Los Angeles.
But an even better strategy, he adds, is to see patients pre-operatively, so you can anticipate problems and plan postoperative care. While Drs. Fishmann and Greeno acknowledge they may be among a relatively limited number of hospitalists who see surgical patients pre-operatively, they say it’s a model that any program could follow.
“It may take special arrangements by the hospital” in terms of space and hospital resources to allow hospitalists to see and medically evaluate surgical patients several days before scheduled surgery, Dr. Greeno explains, “but it can be done in the hospital by the hospitalist” who then follows those patients for the rest of their stay.
Seeing patients before surgery
Dr. Greeno advises hospitalists who want to see patients before surgery to negotiate with their hospitals and surgeons for extra resources, typically in the form of hospital personnel. At the very least, hospitalist groups will need a nurse and clerk to schedule pre-operative evaluations, check patients in, gather pertinent records and make sure pre-operative tests and procedures are accomplished, and to act as a liaison with the orthopedic surgeons and the patients and their families. Hospitalists also need timely access to radiology or other non-invasive cardiac testing facilities.
It’s even more important to negotiate for these resources if the pre-operative evaluations will be taking place in a location outside of the hospital. While he says it isn’t his preferred model, Dr. Greeno explains that the hospitalists in one Cogent program pre-operatively evaluate patients in an orthopedic surgeon’s office.
“The hospitalist leaves the hospital,” he says, “walks across the parking lot and spends an afternoon doing pre-operative evaluations in the orthopedic surgeon’s office. The clinic is entirely staffed by people who are employed by the orthopedic surgical group.”
The model isn’t ideal, Dr. Greeno explains, because it may rub community-based physicians the wrong way. Some outpatient physicians have long feared that hospitalists would ultimately reach outside the hospital and compete with them, and the notion of hospitalists seeing patients in a private practice may raise questions. As a result, Dr. Greeno advises his colleagues to “try to keep everything hospitalists do within the walls of the hospital.”
Ironing out protocols
In addition to making sure that hospitalists co-managing surgical patients have adequate resources, a successful surgical co-management program must have standardized processes and protocols in place. When many different health care providers are involved in the care of a patient, Drs. Greeno and Fishmann say, it’s too easy for important details to fall through the cracks.
“If hospitalists are seeing patients from multiple orthopedic surgical groups,” Dr. Greeno says, “the processes won’t be the same, but the important thing is that everybody knows what’s going to be done on each patient.” Without a standardized process, he adds, “Things get missed, and patients are put at risk.”
For Cogent’s hospitalist groups, Dr. Greeno explains, “We sit down with each of the major orthopedic surgical groups that we provide service for, and we come to an agreement about how we’re going to treat patients.” He adds that the process can be difficult at times because many orthopedic surgeons “are very set in their ways in terms of how they want their patients to be treated and approached.” They’re also very competitive with each other and don’t necessarily like to talk about how they practice, lest they give the competition an edge.
Because most surgeons have a fixed idea of how they want their patients cared for, it’s critical to work out a number of issues before taking on surgical co-management. The first step, Dr. Greeno says, should be to listen to the orthopedic surgeons to learn how they want their patients to be approached, not only clinically but also administratively. Different surgeons, for example, will want hospitalists to communicate differently “in terms of which patients are cleared from surgery and which are not.”
What surgeons want
Also be aware that surgeons will vary in their preference for how DVT prophylaxis is done. “There is more than one adequate approach,” Dr. Greeno explains, “but how it’s going to be done for those patients has to be laid out in advance, or it’s going to lead to friction between the hospitalists and the orthopedic surgeons.”
And don’t be surprised, Dr. Fishmann adds, if debates arise about what is the best form of DVT prophylaxis. Some orthopedic surgeons concerned about bleeding complications are opposed to the use of low-molecular-weight heparin-like agents such as Lovenox, Fragmin or Arixtra and prefer the use of aspirin in elective hip replacements. While guidelines from organizations like the American College of Chest Physicians don’t recommend aspirin as a singe agent, he says, there is no evidence to contraindicate aspirin when used in conjunction with medical compression devices.
If there is scientific evidence about a practice, however, Dr. Fishmann says, hospitalists have an obligation to make sure orthopedic surgeons they are working with are aware of those data. They must also make sure to discuss any preferences that are contradicted in the medical literature.
Discharge is another area where orthopedists may tend to express strong preferences. “One orthopedic surgeon may want his patients discharged on iron to overcome the anemia that they have postoperatively,” Dr. Greeno says, “while others will tell you they absolutely do not want to have patients on iron because it makes them constipated.”
Because there is no definitive evidence for either strategy, he adds, hospitalists should respect the surgeons’ preferences. It’s an important part of consensus-building that is critical for a surgical co-management program.
Assessing cardiac risk
A third area that hospitalists should make sure they are on the same page as orthopedic surgeons has to do with assessing cardiac risk.
Dr. Fishmann, who is also a member of the National Advisory Council for the Agency for Healthcare Research and Quality, says that the hospitalists at Good Samaritan pay close attention to cardiac risk, and they tend to be more aggressive than some community internists or family physicians in terms of cardiac clearance.
They will order non-invasive or nuclear stress tests when their community-based physicians are less inclined, and patients with diabetes, high cholesterol, strong family histories or ex-smokers would be screened. He notes that the absence of angina or chest pain in persons with limited exercise tolerance does not rule out coronary artery disease or silent ischemia.
Dr. Fishmann chalks that up as another advantage of having hospitalists coordinate surgical co-management and pre-operative evaluations. While a family physician or outpatient-based general internist may evaluate a dozen or so patients a year for orthopedic surgery, hospitalists involved in surgical co-management see hundreds.
He adds that in his experience, surgeons prefer physicians conducting pre-operative exams to take a cautious approach. “Our surgeons would rather cancel a case than have a death in the OR or post-op from a preventable event,” Dr. Fishmann says.
Dr. Greeno notes that it’s one more example of the benefit of standardization. “You want as few things as possible dependant on an individual physician’s decision,” he explains. “You want as much as possible to be hard-wired in so that it happens in every single patient, and the only time it doesn’t happen is by exception. That is the only way you can come even close to really keeping patients as safe as possible.”
Is it right for you?
Another caveat of surgical co-management, Dr. Greeno notes, is that processes tend to be a moving target. Just because you work out a process once, he says, doesn’t mean you can forget about it.
Expect to revisit policies and procedures periodically because both medical and surgical techniques continue to change. For instance, he explains, different drugs may need to be used when a patient stays in the hospital for two weeks after hip replacement vs. when they are out in two days.
Dr. Fishmann says that some particular areas to pay attention to include Coumadin being subtherapeutic at discharge after 36 hours compared to daily INR management over a seven- to 14-day hospital stay. In addition, the length of DVT prophylaxis needs to be agreed upon with the orthopedist because the literature is still open to debate regarding length of time for prophylaxis.
Finally, Drs. Greeno and Fishmann say, not all hospitalists may have a temperament suited to surgical co-management. They have to be willing and able to act as the middleman between surgeons and hospitals when disputes arise.
Dr. Greeno offers the following example: “An orthopedic surgeon may feel very strongly that a certain antibiotic needs to be given to their patients for post-operative prophylaxis, and it’s very expensive. Because the hospitalist is writing the postoperative orders for that antibiotic, the hospital will come to them and say that’s not the appropriate antibiotic.”
“There is the hospitalist caught in between the desire of the hospital and the desire of the orthopedic surgeon,” he says. “Hospitalists have to be able to be deal with those kinds of situations all the time. If you do not have a tolerance for that kind of thing, this is the wrong business.”
If you can deal with the headaches, Dr. Greeno says, surgical co-management is work worth doing. First of all, patients undergoing elective surgery tend to have insurance, and they tend to require less work on average than a sick medical patient. Caring for a census of 12 sick medical patients plus six orthopedic patients is much easier than handing a roster of 18 sick medical patients, he explains.
“Plus, there is the satisfaction of having patients who get well and go home and are grateful for their care,” Dr. Greeno says. “It’s a great group of patients to take care of for a hospitalist.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.