G. Randy Smith, MD, MS, SFHM

Hospital admission represents a time period during which patients are at risk for poor clinical outcomes. Although some risk is directly generated by illness pathophysiology, some additive risk is generated by the emergency department (ED)inpatient service handover inherent in the admission process.[1] Increased risk of suboptimal outcomes can result from ED overcrowding, which has been associated with increased mortality, difficulty in patient disposition, and delays in provision of care.[2] Inpatient bed occupancy, as well as availability and organization of accepting inpatient service healthcare staff, can affect ED overcrowding as well.[3, 4]

The overwhelming majority of hospitalist groups accept a significant portion of their admissions via the ED.[5] Hospitalist services must balance their daily group workload between ongoing care and discharge of inpatients and the activity of admitting new patients to their service. Two major models of admission processing exist for hospitalist groups to accomplish these competing tasks. One model, called the general model, employs the use of individual hospitalists to simultaneously perform admission activity as well as ongoing ward‐based care for inpatients during their workday. In the general model, a hospitalist who admits patients on their first hospital day will generally continue to see them on their second hospital day. The other model, called the admitter‐rounder model, divides the hospitalist daily group workflow between hospitalists who are assigned to perform only admission activity (admitters), and hospitalists who are assigned to perform only ongoing care for patients who are already admitted (rounders). In the admitter‐rounder model, the admitter on a patient's first hospital day will generally not serve as the patient's rounder on subsequent hospital days.

Limited evidence exists to guide hospitalist groups on which model their service design should adopt. Conflicting evidence exists as to whether the fragmentation of care generated by an admitter‐rounder admission model is beneficial or harmful.[6, 7, 8, 9] Increased availability of attending inpatient physicians during the EDinpatient admission process has been associated with improved hospital mortality and decreased readmissions in hospital settings outside the United States, where attending availability may otherwise be limited.[10, 11, 12] Separation of admission and rounding activity within a hospitalist workforce may allow each group of hospitalists to provide more timely and effective care related to their respective tasks. Our division implemented a change from a general model to an admitter‐rounder model of care on January 2, 2012. We hypothesized that changing from a general admission model to an admitter‐rounder model of care would be associated with a decreased rate of transfer to the intensive care unit (ICU) 24 hours after floor arrival and shortened ED length of stay (LOS), due to improved availability of hospitalists during the admission process. Due to the introduction of discontinuity, we hypothesized that adoption of the admitter‐rounder model would be associated with a prolongation of hospital LOS and no overall effect on 30 day postdischarge readmission rate. We sought to examine the relationship between our division's service design change and our hypothesized variables of interest.

METHODS

RESULTS

DISCUSSION

Our observations were revealing for a statistically nonsignificant trend toward increased ICU transfers 24 hours after floor arrival after adoption of the admitter‐rounder model by the hospital medicine service. Despite prior publication of early transfer to the ICU being associated with adverse outcomes, including increased inpatient mortality, we observed no difference in mortality in our study groups.[13] We suspect that earlier transfer to the ICU in our study cohort may instead represent a protective action taken more frequently by admitting hospitalists in the admitter‐rounder model in response to provider discontinuity risks embedded in the admission process. Requests for transfer to the ICU at our institution require approval by the ICU team, and requests from attending hospitalists may be responded to differently from requests enacted by teaching team members, which as a factor also may account for some of the adjusted differences in transfer incidence. Taken together, increased availability of hospitalists during the admission process may result in earlier implementation of an overall lower threshold for implementation of ICU transfer. Our conclusion is limited by our study cohort's overall inpatient mortality rate, which is sufficiently low to preclude further assessment of the relationship of adverse outcomes with ICU transfer rate in our study groups. Therefore, clinical significance of our primary outcome findings, as well as the workload factors that impact ICU transfers initiated by hospitalist and teaching services, require further examination.

Despite a hypothesized increase in hospital LOS caused by additional discontinuity of hospitalist care in the admitter‐rounder model, adoption of the admitter‐rounder model was not associated with an increased hospital LOS. We suspect this finding may represent the presence of action(s) proximal to the admission process, on the part of either admission and/or rounding hospitalists, which decrease hospital LOS to a degree offsetting the expected LOS increase generated by provider discontinuity. Examples of such actions include more efficient testing or consultation, or improved detection of diagnostic errors.

Adoption of the admitter‐rounder model by the hospital medicine service was also associated with decreased hospital readmission rates compared to the time‐matched teaching service. We suspect that assignment of daily discharge and admission service activity to separate hospitalists in the admitter‐rounder model may allow more opportunity for rounder hospitalists to engage in activity protective against readmissions, such as greater direct engagement with postdischarge resources, or improved hospitalist availability for multidisciplinary inpatient efforts focused on discharge planning.

Adoption of the admitter‐rounder model was found to be associated with a median 29‐minute increase in ED LOS compared to the time‐matched teaching service. As a floor team member's physical presence in the ED was not required for ED‐floor transfer during the study period, increased physical availability of admitting hospitalists in the admitter‐rounder model may allow for increased opportunity for a hospitalist to disrupt ED‐specific workflows related to patient transfer (eg, disruption of transportation service activity by an earlier bedside visit from the admitting hospitalist). Hospitalists in the general model were allowed to leave after performing their daily duties, whereas admitting hospitalists in the admitter‐rounder model were assigned to stay for a timed shift, regardless of the completion of admissions; the difference in duty assignment may be associated with different hospitalist behaviors during the admission process. Improved ease for ED staff to contact hospitalist staff in the admitter‐rounder model may have led ED staff to prioritize other tasks more demanding of their continuous engagement at the expense of initiating admissions, thereby paradoxically delaying admissions to hospital medicine.

Other studies exist that attempt to describe changes in admission service structure, particularly with regard to housestaff admission activity in relation to changes in resident work hours. Many of these studies vary with regard to implementation of separate physician teams for day and night coverage, or are focused on a specific medical condition, thereby limiting their applicability to a hospital medicine service free of work‐hour restrictions and engaged in care of a wide variety of medical conditions.[18, 19, 20] In contrast, our study is an attempt to examine, in isolation, outcomes associated with adoption of an admitter‐rounder model of care as a specific discontinuity risk during the admission process, within the context of a stable system of night coverage in place for all medical teams engaged in admission activity of undifferentiated medical patients.

Limitations of our study include the inability to ascertain causality of observed outcomes, due to our observational study design. Our study was of a single hospital, which may limit applicability of our results to other hospital environments. However, the admission models examined in our study are common among hospital medicine groups. Clinically relevant outcome metrics, such as mortality and unexpected transfer to the operating room, were measured but of too low incidence to allow for further meaningful analysis. The clinical consequences and workflow practices that correlate with our study's findings likely require case review and time‐motion analyses, respectively, to further delineate the relevance of our findings; these analyses were outside of the scope of our study, and further investigation is required. In summary, our observations suggest that adoption by hospitalist services of an admitter‐rounder model of care for admissions is associated with a decreased rate of hospital readmission 30 days after discharge, with no effect on median hospital LOS, a statistically nonsignificant trend toward more ICU transfers in the first 24 hours of a patient's hospital stay, and a slight increase in median ED LOS.

Hospital admission represents a time period during which patients are at risk for poor clinical outcomes. Although some risk is directly generated by illness pathophysiology, some additive risk is generated by the emergency department (ED)inpatient service handover inherent in the admission process.[1] Increased risk of suboptimal outcomes can result from ED overcrowding, which has been associated with increased mortality, difficulty in patient disposition, and delays in provision of care.[2] Inpatient bed occupancy, as well as availability and organization of accepting inpatient service healthcare staff, can affect ED overcrowding as well.[3, 4]

The overwhelming majority of hospitalist groups accept a significant portion of their admissions via the ED.[5] Hospitalist services must balance their daily group workload between ongoing care and discharge of inpatients and the activity of admitting new patients to their service. Two major models of admission processing exist for hospitalist groups to accomplish these competing tasks. One model, called the general model, employs the use of individual hospitalists to simultaneously perform admission activity as well as ongoing ward‐based care for inpatients during their workday. In the general model, a hospitalist who admits patients on their first hospital day will generally continue to see them on their second hospital day. The other model, called the admitter‐rounder model, divides the hospitalist daily group workflow between hospitalists who are assigned to perform only admission activity (admitters), and hospitalists who are assigned to perform only ongoing care for patients who are already admitted (rounders). In the admitter‐rounder model, the admitter on a patient's first hospital day will generally not serve as the patient's rounder on subsequent hospital days.

Limited evidence exists to guide hospitalist groups on which model their service design should adopt. Conflicting evidence exists as to whether the fragmentation of care generated by an admitter‐rounder admission model is beneficial or harmful.[6, 7, 8, 9] Increased availability of attending inpatient physicians during the EDinpatient admission process has been associated with improved hospital mortality and decreased readmissions in hospital settings outside the United States, where attending availability may otherwise be limited.[10, 11, 12] Separation of admission and rounding activity within a hospitalist workforce may allow each group of hospitalists to provide more timely and effective care related to their respective tasks. Our division implemented a change from a general model to an admitter‐rounder model of care on January 2, 2012. We hypothesized that changing from a general admission model to an admitter‐rounder model of care would be associated with a decreased rate of transfer to the intensive care unit (ICU) 24 hours after floor arrival and shortened ED length of stay (LOS), due to improved availability of hospitalists during the admission process. Due to the introduction of discontinuity, we hypothesized that adoption of the admitter‐rounder model would be associated with a prolongation of hospital LOS and no overall effect on 30 day postdischarge readmission rate. We sought to examine the relationship between our division's service design change and our hypothesized variables of interest.

METHODS

RESULTS

DISCUSSION

Our observations were revealing for a statistically nonsignificant trend toward increased ICU transfers 24 hours after floor arrival after adoption of the admitter‐rounder model by the hospital medicine service. Despite prior publication of early transfer to the ICU being associated with adverse outcomes, including increased inpatient mortality, we observed no difference in mortality in our study groups.[13] We suspect that earlier transfer to the ICU in our study cohort may instead represent a protective action taken more frequently by admitting hospitalists in the admitter‐rounder model in response to provider discontinuity risks embedded in the admission process. Requests for transfer to the ICU at our institution require approval by the ICU team, and requests from attending hospitalists may be responded to differently from requests enacted by teaching team members, which as a factor also may account for some of the adjusted differences in transfer incidence. Taken together, increased availability of hospitalists during the admission process may result in earlier implementation of an overall lower threshold for implementation of ICU transfer. Our conclusion is limited by our study cohort's overall inpatient mortality rate, which is sufficiently low to preclude further assessment of the relationship of adverse outcomes with ICU transfer rate in our study groups. Therefore, clinical significance of our primary outcome findings, as well as the workload factors that impact ICU transfers initiated by hospitalist and teaching services, require further examination.

Despite a hypothesized increase in hospital LOS caused by additional discontinuity of hospitalist care in the admitter‐rounder model, adoption of the admitter‐rounder model was not associated with an increased hospital LOS. We suspect this finding may represent the presence of action(s) proximal to the admission process, on the part of either admission and/or rounding hospitalists, which decrease hospital LOS to a degree offsetting the expected LOS increase generated by provider discontinuity. Examples of such actions include more efficient testing or consultation, or improved detection of diagnostic errors.

Adoption of the admitter‐rounder model by the hospital medicine service was also associated with decreased hospital readmission rates compared to the time‐matched teaching service. We suspect that assignment of daily discharge and admission service activity to separate hospitalists in the admitter‐rounder model may allow more opportunity for rounder hospitalists to engage in activity protective against readmissions, such as greater direct engagement with postdischarge resources, or improved hospitalist availability for multidisciplinary inpatient efforts focused on discharge planning.

Adoption of the admitter‐rounder model was found to be associated with a median 29‐minute increase in ED LOS compared to the time‐matched teaching service. As a floor team member's physical presence in the ED was not required for ED‐floor transfer during the study period, increased physical availability of admitting hospitalists in the admitter‐rounder model may allow for increased opportunity for a hospitalist to disrupt ED‐specific workflows related to patient transfer (eg, disruption of transportation service activity by an earlier bedside visit from the admitting hospitalist). Hospitalists in the general model were allowed to leave after performing their daily duties, whereas admitting hospitalists in the admitter‐rounder model were assigned to stay for a timed shift, regardless of the completion of admissions; the difference in duty assignment may be associated with different hospitalist behaviors during the admission process. Improved ease for ED staff to contact hospitalist staff in the admitter‐rounder model may have led ED staff to prioritize other tasks more demanding of their continuous engagement at the expense of initiating admissions, thereby paradoxically delaying admissions to hospital medicine.

Other studies exist that attempt to describe changes in admission service structure, particularly with regard to housestaff admission activity in relation to changes in resident work hours. Many of these studies vary with regard to implementation of separate physician teams for day and night coverage, or are focused on a specific medical condition, thereby limiting their applicability to a hospital medicine service free of work‐hour restrictions and engaged in care of a wide variety of medical conditions.[18, 19, 20] In contrast, our study is an attempt to examine, in isolation, outcomes associated with adoption of an admitter‐rounder model of care as a specific discontinuity risk during the admission process, within the context of a stable system of night coverage in place for all medical teams engaged in admission activity of undifferentiated medical patients.

Limitations of our study include the inability to ascertain causality of observed outcomes, due to our observational study design. Our study was of a single hospital, which may limit applicability of our results to other hospital environments. However, the admission models examined in our study are common among hospital medicine groups. Clinically relevant outcome metrics, such as mortality and unexpected transfer to the operating room, were measured but of too low incidence to allow for further meaningful analysis. The clinical consequences and workflow practices that correlate with our study's findings likely require case review and time‐motion analyses, respectively, to further delineate the relevance of our findings; these analyses were outside of the scope of our study, and further investigation is required. In summary, our observations suggest that adoption by hospitalist services of an admitter‐rounder model of care for admissions is associated with a decreased rate of hospital readmission 30 days after discharge, with no effect on median hospital LOS, a statistically nonsignificant trend toward more ICU transfers in the first 24 hours of a patient's hospital stay, and a slight increase in median ED LOS.

Hospital admission represents a time period during which patients are at risk for poor clinical outcomes. Although some risk is directly generated by illness pathophysiology, some additive risk is generated by the emergency department (ED)inpatient service handover inherent in the admission process.[1] Increased risk of suboptimal outcomes can result from ED overcrowding, which has been associated with increased mortality, difficulty in patient disposition, and delays in provision of care.[2] Inpatient bed occupancy, as well as availability and organization of accepting inpatient service healthcare staff, can affect ED overcrowding as well.[3, 4]

The overwhelming majority of hospitalist groups accept a significant portion of their admissions via the ED.[5] Hospitalist services must balance their daily group workload between ongoing care and discharge of inpatients and the activity of admitting new patients to their service. Two major models of admission processing exist for hospitalist groups to accomplish these competing tasks. One model, called the general model, employs the use of individual hospitalists to simultaneously perform admission activity as well as ongoing ward‐based care for inpatients during their workday. In the general model, a hospitalist who admits patients on their first hospital day will generally continue to see them on their second hospital day. The other model, called the admitter‐rounder model, divides the hospitalist daily group workflow between hospitalists who are assigned to perform only admission activity (admitters), and hospitalists who are assigned to perform only ongoing care for patients who are already admitted (rounders). In the admitter‐rounder model, the admitter on a patient's first hospital day will generally not serve as the patient's rounder on subsequent hospital days.

Limited evidence exists to guide hospitalist groups on which model their service design should adopt. Conflicting evidence exists as to whether the fragmentation of care generated by an admitter‐rounder admission model is beneficial or harmful.[6, 7, 8, 9] Increased availability of attending inpatient physicians during the EDinpatient admission process has been associated with improved hospital mortality and decreased readmissions in hospital settings outside the United States, where attending availability may otherwise be limited.[10, 11, 12] Separation of admission and rounding activity within a hospitalist workforce may allow each group of hospitalists to provide more timely and effective care related to their respective tasks. Our division implemented a change from a general model to an admitter‐rounder model of care on January 2, 2012. We hypothesized that changing from a general admission model to an admitter‐rounder model of care would be associated with a decreased rate of transfer to the intensive care unit (ICU) 24 hours after floor arrival and shortened ED length of stay (LOS), due to improved availability of hospitalists during the admission process. Due to the introduction of discontinuity, we hypothesized that adoption of the admitter‐rounder model would be associated with a prolongation of hospital LOS and no overall effect on 30 day postdischarge readmission rate. We sought to examine the relationship between our division's service design change and our hypothesized variables of interest.

METHODS

RESULTS

DISCUSSION

Our observations were revealing for a statistically nonsignificant trend toward increased ICU transfers 24 hours after floor arrival after adoption of the admitter‐rounder model by the hospital medicine service. Despite prior publication of early transfer to the ICU being associated with adverse outcomes, including increased inpatient mortality, we observed no difference in mortality in our study groups.[13] We suspect that earlier transfer to the ICU in our study cohort may instead represent a protective action taken more frequently by admitting hospitalists in the admitter‐rounder model in response to provider discontinuity risks embedded in the admission process. Requests for transfer to the ICU at our institution require approval by the ICU team, and requests from attending hospitalists may be responded to differently from requests enacted by teaching team members, which as a factor also may account for some of the adjusted differences in transfer incidence. Taken together, increased availability of hospitalists during the admission process may result in earlier implementation of an overall lower threshold for implementation of ICU transfer. Our conclusion is limited by our study cohort's overall inpatient mortality rate, which is sufficiently low to preclude further assessment of the relationship of adverse outcomes with ICU transfer rate in our study groups. Therefore, clinical significance of our primary outcome findings, as well as the workload factors that impact ICU transfers initiated by hospitalist and teaching services, require further examination.

Despite a hypothesized increase in hospital LOS caused by additional discontinuity of hospitalist care in the admitter‐rounder model, adoption of the admitter‐rounder model was not associated with an increased hospital LOS. We suspect this finding may represent the presence of action(s) proximal to the admission process, on the part of either admission and/or rounding hospitalists, which decrease hospital LOS to a degree offsetting the expected LOS increase generated by provider discontinuity. Examples of such actions include more efficient testing or consultation, or improved detection of diagnostic errors.

Adoption of the admitter‐rounder model by the hospital medicine service was also associated with decreased hospital readmission rates compared to the time‐matched teaching service. We suspect that assignment of daily discharge and admission service activity to separate hospitalists in the admitter‐rounder model may allow more opportunity for rounder hospitalists to engage in activity protective against readmissions, such as greater direct engagement with postdischarge resources, or improved hospitalist availability for multidisciplinary inpatient efforts focused on discharge planning.

Adoption of the admitter‐rounder model was found to be associated with a median 29‐minute increase in ED LOS compared to the time‐matched teaching service. As a floor team member's physical presence in the ED was not required for ED‐floor transfer during the study period, increased physical availability of admitting hospitalists in the admitter‐rounder model may allow for increased opportunity for a hospitalist to disrupt ED‐specific workflows related to patient transfer (eg, disruption of transportation service activity by an earlier bedside visit from the admitting hospitalist). Hospitalists in the general model were allowed to leave after performing their daily duties, whereas admitting hospitalists in the admitter‐rounder model were assigned to stay for a timed shift, regardless of the completion of admissions; the difference in duty assignment may be associated with different hospitalist behaviors during the admission process. Improved ease for ED staff to contact hospitalist staff in the admitter‐rounder model may have led ED staff to prioritize other tasks more demanding of their continuous engagement at the expense of initiating admissions, thereby paradoxically delaying admissions to hospital medicine.

Other studies exist that attempt to describe changes in admission service structure, particularly with regard to housestaff admission activity in relation to changes in resident work hours. Many of these studies vary with regard to implementation of separate physician teams for day and night coverage, or are focused on a specific medical condition, thereby limiting their applicability to a hospital medicine service free of work‐hour restrictions and engaged in care of a wide variety of medical conditions.[18, 19, 20] In contrast, our study is an attempt to examine, in isolation, outcomes associated with adoption of an admitter‐rounder model of care as a specific discontinuity risk during the admission process, within the context of a stable system of night coverage in place for all medical teams engaged in admission activity of undifferentiated medical patients.

Limitations of our study include the inability to ascertain causality of observed outcomes, due to our observational study design. Our study was of a single hospital, which may limit applicability of our results to other hospital environments. However, the admission models examined in our study are common among hospital medicine groups. Clinically relevant outcome metrics, such as mortality and unexpected transfer to the operating room, were measured but of too low incidence to allow for further meaningful analysis. The clinical consequences and workflow practices that correlate with our study's findings likely require case review and time‐motion analyses, respectively, to further delineate the relevance of our findings; these analyses were outside of the scope of our study, and further investigation is required. In summary, our observations suggest that adoption by hospitalist services of an admitter‐rounder model of care for admissions is associated with a decreased rate of hospital readmission 30 days after discharge, with no effect on median hospital LOS, a statistically nonsignificant trend toward more ICU transfers in the first 24 hours of a patient's hospital stay, and a slight increase in median ED LOS.