Published in the March 2016 issue of Today’s Hospitalist
AT FIRST GLANCE, trauma surgeons and hospitalists might seem like unlikely bedfellows. But they have turned out to be a better pairing than even the health system that put them together expected.
At Christiana Care Health System in Newark, Del., the decision among the hospital-employed hospitalist group—Christiana Care Hospital Partners—to embed medicine hospitalists in the trauma service has resulted in better medical management of trauma patients with comorbidities. But it’s also improved mortality and reduced readmissions in those patients. A 2014 randomized trial in which 469 trauma patients were placed under hospitalist comanagement (and 938 were not) found a significant mortality reduction among the comanaged cohort (0.4% vs. 2.9%), while 30-day trauma-related readmissions fell from 2.3% to 0.6%.
The research also found that the hospitalist-managed trauma patients had longer lengths of stay—1.5 days longer on average—than those managed exclusively by the surgical service. But that increase was viewed as good news, according to Erin Meyer, DO, trauma hospitalist program leader and assistant medical director of clinical integration for Christiana Care Hospital Partners.
“Our presence on the floor enabled us to be more acutely aware of patients’ status.”
“We had noticed a trend toward patients being readmitted after their trauma discharge due to some exacerbation of their medical comorbidities,” Dr. Meyer says. “There’s an increased length of stay in hospitalist-managed patients, but it has been offset by reduced in-hospital mortality and readmission rates.”
More proactive care
Readmissions weren’t the reason why the new care model was created in 2013. The original intent was to better serve the needs of the growing number of elderly trauma patients. The hospital also wanted to reduce the number of those patients who ended up being admitted to a nonsurgical service.
“The two departments had a good relationship to start with,” Dr. Meyer says. “That prompted a conversation about how we could improve communication around the care of these patients and streamline their care.”
Mark Cipolle, MD, medical director of trauma surgery at Christiana Care, acknowledged that having hospitalists on board has been a boon for all involved. When Dr. Cipolle presented the study findings at a recent meeting of trauma surgeons, he pointed out that many of these patients now “go home with their comorbidities better managed” under hospitalist comanagement. Hospitalists’ involvement has also boosted patient satisfaction for this subset of patients cared for at the 1,100-bed hospital.
Dr. Meyer notes that the hospitalists also transferred more patients to the ICU than surgeons (4.3% vs. 2.1%). That may have contributed to longer stays.
“Our presence on the floor enabled us to be more acutely aware of patients’ status, which spurred us to provide more proactive care,” Dr. Meyer said. “That effort improved our ongoing communication with both the nursing staff and the trauma advanced practice nurses, which also increased our awareness of patient status.”
Meanwhile, the two patient cohorts in the study had no significant differences in terms of their number of neurology, cardiology, nephrology or endocrinology consults. Nor were there differences in patients’ rates of developing venous thromboembolism (VTE), pneumonia or UTIs.
For the 30-hospitalist program, the new service proved relatively straightforward to start. The group anticipated a census of between 15 and 18 patients for the trauma hospitalists, based on hospital data. That’s close to the average daily census for Christiana Care Hospital Partners’ hospitalists on the medical service: 16.8.
A dedicated group of eight hospitalists staff the service seven days a week from 8 a.m. to 5 p.m., caring for the majority of trauma patients with multiple medical comorbidities—particularly those with multiple comorbidities who are elderly. Each hospitalist is scheduled for at least five consecutive days on service, with one physician at a time covering those patients. (The trauma hospitalists have no other coverage responsibilities when they are on service.) Night coverage falls to the trauma service first and then, if needed, to the in-house hospitalist.
“We were able to streamline care, so there was no need for us to increase full-time employees” to provide the comanagement, Dr. Meyer says.
The average census-per-hospitalist prediction wasn’t too far off, but the census spread over the year has ended up being larger than expected, ranging from between 10 and 25 patients per day. That made it necessary to tweak some staffing, says Dr. Meyer.
“When the census is higher, the trauma hospitalists focus on newer or more acute patients, and they work with the trauma advanced practice nurses—who are hired by the trauma service—to manage the less critical patients,” she says. That makes the census “about the 15 to 18 that we anticipated.”
Defining respective roles
Deciding how clinical care would be divvied up between the surgeons and the hospitalists took some discussion. The two groups headed off potential conflicts, Dr. Meyer explains, by delineating their respective roles before they started the program, using a formal comanagement agreement. Per that agreement, for instance, the trauma physicians manage VTE prophylaxis, anticoagulation therapy and pain control.
The hospitalists, for their part, “make recommendations about when aspirin, Plavix or other anticoagulants should be restarted,” Dr. Meyer says, “but this is ultimately the surgeons’ domain.” Both the hospitalists and surgeons follow the anticoagulation management protocol that was developed by the trauma team with cardiology, which simplifies matters.
The trauma hospitalists focus primarily on managing chronic medical problems such as coronary artery disease, hypertension, renal issues and diabetes, Dr. Meyer points out. “Our goal is to keep patients at their baseline in lieu of the traumatic injuries they’ve suffered,” she says.
Hospitalists are assigned to the service primarily based on their interest in perioperative management, she notes. But the group also looks for hospitalists who function well in a team setting and who are good communicators.
As Dr. Cipolle observed when he presented study findings, the model has been so successful that, if the hospital wanted to stage a similar trial, it would be hard to convince the surgeons to allocate patients to a nonhospitalist-managed cohort. Dr. Meyer points out that there’s also been little need to modify the hospitalists’ role outside of the arrangement with advanced practice nurses when census is high.
The health system hasn’t performed a cost analysis to determine the economic impact of the service, but the readmissions reduction is sufficient proof that the model works. Whether it could be replicated in a smaller system would depend on the dynamics and relationships in place, says Dr. Meyer.
“Communication pathways and role delineation need to be at the forefront of any good comanagement program, which we definitely prepared for,” she says.
Bonnie Darves is a freelance health care writer based in Seattle.