Hospitalist Programs Take Quality Hospital Care To The Next Level.

So you're the CEO of a major hospital organization and you're wondering whether or not hospitalist programs add value to your bottom line.  I'm here to tell you that only a fool would ignore the powerful contribution well run and well funded hospitalist programs can add to the patient care experience. Hospitalist programs, with an eye on quality, can add millions of dollars to the hospital's bottom line.

Let's say you've made the wise decision that having hospitalists will add value to your hospital's bottom line.  You're probably wondering what kind of hospitalist model to implement . Should you have a shift model program with in house hospitalists or a traditional take call from home type hospitalist program?  Should you employ your hospitalists or allow a local or national group of doctors to run  the day to day financial operations of the hospitalist program.  How you implement the financial relationship is up to you.  If you want to know how to staff your hospitalist program, read on for my completely unbiased opinion on hospitalist program staffing.

I've been a hospitalist now for seven years and I can tell you that nothing beats the value of a bed side in-house physician evaluation.  Hospitalist programs have added value  benefits that can't be reliably measured, but take them away and patient care suffers.  I tell you this because I live that experience every day I'm available by nursing or physician request to evaluate a patient who isn't doing well.

Dr Centor over at DB's Medical Rants asks the question:  Do Hospitalists really provide better care?  The answer is a resounding yes, not only because hospitalists become experts in the efficient allocation of resources within the hospital walls, but in-house hospitalist programs  also offer immeasurable value to  bedside patient care when clinical changes occur.  If you're thinking of implementing a hospitalist program without the in-house physician model, you are going to lose major benefits that your hospitalist program could offer.  I present to you  two cases in point.

I was recently notified by nursing staff  that the son of a patient was upset and beligerent, threatening to transfer his father to another hospital because of the terrible care his father was receiving.  What was his concern?  His father was confused.
"He didn't look like this yesterday.  What are you guys doing to him?", he demanded to know.
Unless you are a hospitalist program with in-house physicians, it's unlikely that any physician would be available for a bed side evaluation and discussion with the patient's family. My main concern was obviously that the patient's altered mental status was not a critical change in clinical relevence.  The patient had delirium.  Delirium is an altered state of consciousness. Delirium is always transient and it always gets better, even for the 94 year olds that threaten to sue you.

Some in government consider delirium to be a  never event.  Unfortunately, despite all our best efforts to minimize and avoid delirium, patients will always get confused in the hospital.  Most of my elderly patients will experience some sort of delirium event in the hospital if they are admitted long enough.  Our goal as physicians is to minimize the associated complications with preventative measures.

In the pre hospitalist program days, how would this situation have been handled?  Would the internist drive 10 miles to evaluate their confused patient and talk with an irrate son?  Or would they ask for a neuro consult and begin the polyconsult process?  I have heard loud and clear that before our involvement in patient care, other doctors' lives were inundated with middle of the night convenience consults by primary care physicians for problems that required basic bedside effort.

My ten minute bedside evaluation and discussion extinguished  the son's angry tendencies.    He now understood why his father was calling for Jesus and dropping F bombs in the same sentence. How do you measure this in patient outcomes?  It's difficult if not  impossible to appreciate the value that in-house hospitalist programs bring to patient care.  This type of quality is rarely measured because it has no measurable standard.  Yet these encounters are a normal daily existence for hospitalist programs every where. 

At the same time, it's important to understand the distinct difference between being in-house for convenience and being in-house for patient care.  When I started seven years ago, we were being asked to read chest xrays for central line placement by surgeons who had already left the buiilding.  We were being asked to write opiate prescriptions for patients being discharged by doctors who had already left for the evening.  We were being asked to make death declarations on vented patients we had no involvment with.

We put a quick end to the idea of in-house hospitalists being available as a matter of convenience.   We are not a convenience store.  We are a hospitalist program providing high quality care for the benefit of our patients while playing the documentation games as directed by the Medicare National Bank.  Consider us the Saks Fifth Avenue of the medical subspecialties:  We offer a lot of high quality goods and services but not the convenience of access on every corner.

If you want high quality hospitalist groups for convenience, you are going to be disappointed in your ability to retain high quality doctors to provide high quality care.  Boundaries must be established with nursing staff and physicians in the community as to the appropriate use of hospitalist program services.  Calling critical lab values to the hospitalist, that were ordered by the oncologist, is a convenience problem which involves  education at the nursing level.  Calling the hospitalist at 3 am for a   preoperative clearance   history and physical examination  on a  25 year old with a wrist fracture requires education at the physician level.

Bedside  evaluation is an invaluable asset of in-house hospitalist programs.  Just the other day I was asked to evaluate an 87 year old female patient at three in the morning  with a painful right arm after falling out of bed.  Under pre hospitalist program days perhaps the at home internist or family medicine doctor or even  the home call hospitalist would order an xray of the arm and an orthopaedic consult for good measure.

What did I do?  I did a bed side evaluation.  I listened to her heart  and realized she was in rapid atrial fibrillation. At 3:35 in the morning, I documented 35 minutes of critical care work, initiated a diltiazem drip for the  acute treatment of rapid atrial fibrillation and transferred her to a higher level of care.  Oh yeah, I also evaluated the arm.  This is the type of quality care you can expect from having establishing in-house hospitalist programs running the show with defined parameters that weed out the convenience characteristics of having in-house physicians from the real patient care responsibilities. If you want to take your hospital to the next level in all measurable standards, you need to get yourself an in-house hospitalist program and set your hospital free from the constraints of 19th century standards.


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