Comparison of hospitalist service staffing models at Baylor University Medical Center.

Background: Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods: The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results: There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions: These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Evaluation and stages of surgical innovations.

Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.

No surgical innovation without evaluation: the IDEAL recommendations.

Surgery and other invasive therapies are complex interventions, the assessment of which is challenged by factors that depend on operator, team, and setting, such as learning curves, quality variations, and perception of equipoise. We propose recommendations for the assessment of surgery based on a five-stage description of the surgical development process. We also encourage the widespread use of prospective databases and registries. Reports of new techniques should be registered as a professional duty, anonymously if necessary when outcomes are adverse. Case series studies should be replaced by prospective development studies for early technical modifications and by prospective research databases for later pre-trial evaluation. Protocols for these studies should be registered publicly. Statistical process control techniques can be useful in both early and late assessment. Randomised trials should be used whenever possible to investigate efficacy, but adequate pre-trial data are essential to allow power calculations, clarify the definition and indications of the intervention, and develop quality measures. Difficulties in doing randomised clinical trials should be addressed by measures to evaluate learning curves and alleviate equipoise problems. Alternative prospective designs, such as interrupted time series studies, should be used when randomised trials are not feasible. Established procedures should be monitored with prospective databases to analyse outcome variations and to identify late and rare events. Achievement of improved design, conduct, and reporting of surgical research will need concerted action by editors, funders of health care and research, regulatory bodies, and professional societies.

Challenges in evaluating surgical innovation.

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.