Association Between Consecutive Days Worked by Intensivists and Outcomes for Critically Ill Patients.

OBJECTIVE: To evaluate the association between consecutive days worked by intensivists and ICU patient outcomes. DESIGN: Retrospective cohort study linked with survey data. SETTING: Australia and New Zealand ICUs. PATIENTS: Adults (16+ yr old) admitted to ICU in the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Registries (July 1, 2016, to June 30, 2018). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We linked data on staffing schedules for each unit from the Critical Care Resources Registry 2016-2017 annual survey with patient-level data from the Adult Patient Database. The a priori chosen primary outcome was ICU length of stay. Secondary outcomes included hospital length of stay, ICU readmissions, and mortality (ICU and hospital). We used multilevel multivariable regression modeling to assess the association between days of consecutive intensivist service and patient outcomes; the predicted probability of death was included as a covariate and individual ICU as a random effect. The cohort included 225,034 patients in 109 ICUs. Intensivists were scheduled for seven or more consecutive days in 43 (39.4%) ICUs; 27 (24.7%) scheduled intensivists for 5 days, 22 (20.1%) for 4 days, seven (6.4%) for 3 days, four (3.7%) for 2 days, and six (5.5%) for less than or equal to 1 day. Compared with care by intensivists working 7+ consecutive days (adjusted ICU length of stay = 2.85 d), care by an intensivist working 3 or fewer consecutive days was associated with shorter ICU length of stay (3 consecutive days: 0.46 d fewer, p = 0.010; 2 consecutive days: 0.77 d fewer, p < 0.001; ≤ 1 consecutive days: 0.68 d fewer, p < 0.001). Shorter schedules of consecutive intensivist days worked were also associated with trends toward shorter hospital length of stay without increases in ICU readmissions or hospital mortality. CONCLUSIONS: Care by intensivists working fewer consecutive days is associated with reduced ICU length of stay without negatively impacting mortality.

The Influence of Academic Hospitalists on Labor and Delivery Outcomes.

BACKGROUND: Our goal was to examine differences in maternal and neonatal outcomes following the transition from a private practice to an academic model at a community hospital. METHODS: This is a retrospective cohort study of a high-volume community hospital labor and delivery unit. A private practice hospitalist group was replaced with academic hospitalists. Maternal and neonatal outcomes for patients cared for by these groups were compared. The primary outcome was a composite of maternal morbidity that included blood transfusion, anal sphincter injuries, dilation and curettage, hysterectomy, chorioamnionitis, endometritis, wound infection, intensive care unit admission, and readmission. The secondary outcomes were cesarean delivery rate and a composite of neonatal morbidity that included Apgar score ≤3 at 5 min, shoulder dystocia, birth trauma, seizure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, or mechanical ventilation. RESULTS: 245 patients were delivered by private physicians and 447 by academic physicians over the study period. No difference in the composite maternal morbidity between private and academic hospitalist groups was identified (21 vs. 25%; aOR 1.37, 95% CI: 0.36-5.21). The academic hospitalist group had a higher cesarean delivery rate compared to the private group (25 vs. 18%; aOR 2.03, 95% CI: 1.17-3.53). There was no difference in a composite neonatal morbidity (9 vs. 8%; aOR 0.92, 95% CI: 0.052-1.63). CONCLUSION: Women cared for by academic hospitalists were more likely to have a cesarean delivery, but there was no difference in maternal or neonatal morbidity in patients delivered by private or academic hospitalists.

Triaging Inpatient Admissions: an Opportunity for Resident Education.

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.

External Intensivists Versus In-House Intensivists: Analysis of Outcomes of Nighttime Coverage of ICUs by External On-Call and In-House On-Call Intensivists.

A 24/7 intensivist model may improve important outcomes such as mortality, length of stay, and number of ventilator days. In this retrospective, single-center study at Saint Luke's Hospital in Kansas City, Missouri, we examined patient outcomes before and after adopting a 24/7 model from 2014 to 2016. The addition of a nighttime intensivist did not lead to a statistically significant improvement in mortality (hospital and ICU) and LOS (hospital and ICU).

Optimizing Hospitalist-Patient Communication: An Observation Study of Medical Encounter Quality.

BACKGROUND: Optimizing patient-hospitalist interactions heightens patient satisfaction, improves patient health outcomes, and improves hospitalist job satisfaction. A study was conducted to recognize hospitalist communication that enhance encounters, identify hospitalist behaviors for improvement interventions, and explore the association of time and gender with communication quality. METHODS: Researchers observed encounters between 36 hospitalists and 206 adult patients. All but 1 of the hospitalists was observed at a 410-bed, general medical and surgical facility in the Midwest. RESULTS: On the adapted Kalamazoo Essential Elements of Communication Checklist (KEECC), hospitalists scored highest on the Builds a Relationship, Shares Information, and Gathers Information dimensions. Participants were seen using multiple, effective verbal and nonverbal techniques to show care and concern, as well as create relational rapport, often while successfully sharing and obtaining clinical information. Hospitalists scored lowest on the Understands the Patient Perspective and Reaches Agreement dimensions. Hospitalists were observed infrequently and inconsistently empathizing with patients and rarely attempting to gain shared understanding and agreement from patients. Significant difference was found in sharing information (t [194] = 2.47; p = 0.01), with male hospitalists (mean [M] = 4.14; standard deviation [SD] = 1.01) more highly rated than female hospitalists (M = 3.78; SD = 0.90). Hospitalist and patient gender match revealed significant difference in sharing information (F [3,192] = 2.60; p = 0.05). Male hospitalists were rated higher interacting with female patients than female hospitalists interacting with male patients. CONCLUSION: Results identify specific hospitalist communication techniques that may ultimately contribute to better-quality medical encounters. Communication interventions are recommended.

Development and Implementation of an Inpatient Otolaryngology Consultation Service at an Academic Medical Center.

OBJECTIVES: To design and implement a formal otolaryngology inpatient consultation service that improves satisfaction of consulting services, increases educational opportunities, improves the quality of patient care, and ensures sustainability after implementation. METHODS: This was a retrospective cohort study in a large academic medical center encompassing all inpatient otolaryngology service consultations from July 2005 to June 2014. Staged interventions included adding fellow coverage (July 2007 onward), intermittent hospitalist coverage (July 2010 onward), and a physician assistant (October 2011 onward). Billing data were collected for incidences of new patient and subsequent consultation charges. The 2-year preimplementation period (July 2005-June 2007) was compared with the postimplementation periods, divided into 2-year blocks (July 2007-June 2013). Outcome measures of patient encounters and work relative value units were compared between pre- and postimplementation blocks. RESULTS: Total encounters increased from 321 preimplementation to 1211, 1347, and 1073 in postimplementation groups (P < 0.001). Total work relative value units increased from 515 preimplementation to 2090, 1934, and 1273 in postimplementation groups (P < 0.001). CONCLUSIONS: A formal inpatient consultation service was designed with supervisory oversight by non-Accreditation Council for Graduate Medical Education fellows and then expanded to include intermittent hospitalist management, followed by the addition of a dedicated physician assistant. These additions have led to the formation of a sustainable consultation service that supports the mission of high-quality care and service to consulting teams.

[Fast-tract: Therapist's role]. / Fast Track: rol' terapevta-gospitalista.

The modern model of inpatient surgical care of private and optimized state/govermental medical institutions allows us to change the paradigm of nosological attachment of the hospital bed to one profile of specialists for an adaptive model, when the wards can be reassigned depending on the needs of the hospital. In such multidisciplinary medical centers with mixed hospital beds without a nominal distinction in the nosological departments, a new therapeutic service is being developed - hospitalists, which provide a consistent curation of hospitalized patients, compensation of chronic therapeutic illnesses with patient's preparation for surgical interventions. Our work describes the experience of Fast Track recovery program with the active participation of a hospitalist in a surgical team, which is a new experience in the practice of Russian colorectal surgery.

New Models of Care.

The practice of obstetrics and gynecology continues to evolve. Changes in the obstetrician-gynecologists workforce, reimbursement, governmental regulations, and technology all drive new models of care. The advent of the obstetric hospitalist is one new model, and the development of team-based care is another. Increasingly, obstetrician-gynecologists are becoming employees of health care delivery systems, and others are focusing the scope of their practices to subspecialites. As new practice models emerge, the specialty of obstetrics and gynecology will continue to change to meet the health care needs of women.

The efficient, effective community hospital inpatient dermatology consult.

Hospital dermatology is often thought to be too cumbersome for the private practicing dermatologist to handle, leaving patients in our communities without needed care and our medical colleagues in the dark when it comes to diagnosing and/or managing skin disease in the hospitalized patient. This notion that "someone else will figure it out" undervalues our expertise as a specialty and threatens the appropriate health outcomes we knowingly understand patients deserve. In this manuscript, we intend to break down the hospital consult conceptually so as to make clear how simple it can be to help our physician colleagues and make an important impact upon patients at their most vulnerable time.

Beyond Hospital Discharge Mechanics: Managing the Discharge Paradox and Bridging the Care Chasm.

Hospital discharge processes are complex and confusing, and can detrimentally affect patients, families, and providers. This qualitative study investigated pediatric hospital discharge experiences from the perspectives of parents of children with acute and chronic health conditions, primary care providers, and hospitalists. Focus groups and interviews with parents, primary care providers, and hospitalists were used to explore discharge experiences and ideas for improvement offered by participants. Using an iterative approach to analyze data resulted in five major themes for discharge experiences: (a) discharge problems, (b) teamwork, (c) ideal discharge, (d) care chasm, and (e) discharge paradox. The first three themes concern practical issues, whereas the last two themes reflect negative emotional experiences as well as practical problems encountered in the discharge process. Improvements in communication were viewed as a primary strategy for improving the discharge process for better outcomes for patients, their families, and providers.

Exploration of a new model of care in a psychiatry unit.

The model established at Orillia Soldiers Memorial Hospital involves family physicians as the most responsible physician. They act as "admission gatekeeper" for all unattached patients who are admitted to the psychiatry in-patient unit. A PubMed, EBSCO, OVID Medline, Embase, CINAHL, and Web of Science database review of the last 10 years (2006-2016) was undertaken. A satisfaction survey was undertaken. An intensive literature review found this model to be unique. The model has proved to be extremely efficient and cost-effective.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility.

BACKGROUND: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement. METHODS: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location. RESULTS: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions. CONCLUSION: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes.

BACKGROUND: Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role. OBJECTIVE: To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks. DESIGN: Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program. PARTICIPANTS: All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation. INTERVENTION: An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers. MAIN MEASURES: Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively. KEY RESULTS: During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts. CONCLUSIONS: Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

A qualitative evaluation of geographical localization of hospitalists: how unintended consequences may impact quality.

BACKGROUND: Geographical localization of hospitalist teams to nursing units may have an impact on the quality of inpatient care. The perceptions of individuals who provide patient care in a localized model of care have not been adequately studied. OBJECTIVE: To determine the impact of geographic localization of hospitalist teams by evaluating the perceptions of hospitalists (faculty and physician assistants) localized to a single nursing unit and the nurses who staffed that unit. DESIGN: Focus group study. SUBJECTS: Six hospitalist faculty and three hospitalist physician assistants who provided patient care while localized to a single nursing unit, as well as 29 nurses who staffed the nursing unit where localization occurred. MAIN MEASURES: Themes that emerged from grounded theory analysis of focus group transcripts. KEY RESULTS: Participants perceived an overall positive impact of localization on the quality of patient care they provide and their workflow. The positive impact was mediated through proximity to patients and between members of the healthcare team, as well as through increased communication, decreased wasted time and increased teamwork. The participants also identified increased interruptions, variability in patient flow, mismatches in specialization and perverse incentives as mediating factors leading to unintended consequences. A model emerged that can inform future deployment and evaluation of localization interventions. CONCLUSIONS: Geographical localization of hospitalist teams is perceived to be desirable by both hospitalists and nurses. Others who attempt localization could use our conceptual model as a guide to maximize the benefit and minimize the unintended consequences of this intervention.

The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction.

BACKGROUND: Achieving patient-physician continuity is difficult in the inpatient setting, where care must be provided continuously. Little is known about the impact of hospital physician discontinuity on outcomes. OBJECTIVE: To determine the association between hospital physician continuity and percentage change in median cost of hospitalization, 30-day readmission, and patient satisfaction with physician communication. DESIGN: Retrospective observational study using various multivariable models to adjust for patient characteristics. PARTICIPANTS: Patients admitted to a non-teaching hospitalist service in a large, academic, urban hospital between 6 July 2008 and 31 December 2011. MAIN MEASURES: We used two measures of continuity: the Number of Physicians Index (NPI), and the Usual Provider of Continuity (UPC) index. The NPI is the total number of unique physicians caring for a patient, while the UPC is calculated as the largest number of patient encounters with a single physician, divided by the total number of encounters. Outcome measures were percentage change in median cost of hospitalization, 30-day readmissions, and top box responses to satisfaction with physician communication. KEY RESULTS: Our analyses included data from 18,375 hospitalizations. Lower continuity was associated with modest increases in costs (range 0.9-12.6 % of median), with three of the four models used achieving statistical significance. Lower continuity was associated with lower odds of readmission (OR = 0.95-0.98 across models), although only one of the models achieved statistical significance. Satisfaction with physician communication was lower, with less continuity across all models, but results were not statistically significant. CONCLUSIONS: Hospital physician discontinuity appears to be associated with modestly increased hospital costs. Hospital physicians may revise plans as they take over patient care responsibility from their colleagues.

Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease.

BACKGROUND AND GOALS: Our institution shifted the care of patients with chronic liver disease (CLD) from Internal Medicine faculty, house staff, and consulting hepatology service to a co-managed unit staffed by academic hospitalists and hepatologists. The effect of co-management between hospitalists and hepatologists on the care of patients hospitalized with complications of CLD such as spontaneous bacterial peritonitis (SBP) is unknown. STUDY: A retrospective chart review of 56 adult patients admitted with CLD and SBP from July 1, 2004 to June 30, 2010 was performed. Adherence rates to current management guidelines were measured along with costs and outcomes of care. RESULTS: Patients admitted under the 2 models of care were similar; however, they consistently underwent paracentesis within 24 hours (100% vs. 79%, P=0.013), had appropriate avoidance of fresh-frozen plasma use (75% vs. 43%, P=0.05), received albumin (97% vs. 65%, P=0.002), and were discharged on SBP prophylaxis (91% vs. 37%, P<0.001) under the co-managed model compared with the conventional model. Costs of care were similar between the 2 groups. We note a trend toward improved outcomes of care under the co-management model as measured by transfer rates to the intensive care unit, inpatient mortality, 30-day readmission, and mortality rates. CONCLUSIONS: These results support co-management between hospitalists and hepatologists as a superior model of care for hospitalized patients with SBP. Furthermore, this study adds to the growing literature indicating that efforts are needed to improve the quality of care delivered to CLD patients.

Oncology house physician model: a response to changes in pediatric resident coverage.

BACKGROUND: Given decreasing resident duty hours, subspecialty hospitalist models have emerged to help compensate for the restructured presence of residents. We sought to examine the impact of our pediatric oncology hospitalist model on the oncology unit staff. PROCEDURE: The survey was developed after a literature review of subspecialty hospitalist models. The final surveys were designed using a 5-point Likert scale. Descriptive statistics were used to compile baseline demographic characteristics of respondents and overall responses to survey questions. RESULTS: Respondents agreed that house physicians provide better continuity of care (96.8%), are more comfortable with the experience level of the physician (98.4%), and are better able to answer questions (92%). Respondents also agreed that house physicians serve as backup for system-related and patient-related questions and found security knowing an experienced provider was on the floor (87.5%). Responses to open-ended questions indicated that the house physician model has impacted fellow education. CONCLUSIONS: Our oncology house physician model helps account for decreased residency duty hours. This can serve as a model for other institutions requiring subspecialty inpatient coverage, given resident work hour restrictions. Adjustments in the clinical education of hematology/oncology fellows need to be considered in the setting of competent, consistent, and experienced front-line providers.

The role of the hospitalists in the workforce to address the shortages of intensivists in hospitals here in Thailand.

The problem of a shortage of intensivists in Thailand is increasing annually. As stated in The Thai Society of Critical Care Medicine Database, 2013, the number of qualified intensivists currently is 163, working in 76 provinces in Thailand. This disproportion in the ratio of intensivists has affected patient outcomes. In an attempt to solve this problem, there has been an increased number of hospitalists working in place of the intensivists. Medical specialties are not available in many hospitals of Thailand. Thus, the hospitalists, who care for Intensive Care Unit (ICU) patients, are not trained to care for the acutely ill, hospitalized patients. Their competencies vary depending on their experience and training. In other countries, there has been evidence that properly trained hospitalists can work effectively in the ICU. This awareness of the importance of intensivists in Thailand is one of the stifling factors; the improvement of the hospitalists, determining the hospitalists' workforce and increasing the number of the intensivists to match future demands are needed.