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Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].
The Earlier, the Better
Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.
In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.
But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.
It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.
Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.
Write “Probable Discharge Tomorrow” Orders
Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.
Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.
Prepare the Day Prior
Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:
On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).
Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.
On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.
I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.
Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.
The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:
“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”
Start Rounds Earlier
This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.
In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.
But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.
It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.
Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.
Write “Probable Discharge Tomorrow” Orders
Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.
Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.
Prepare the Day Prior
Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:
On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).
Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.
On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.
I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.
Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.
The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:
“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”
Start Rounds Earlier
This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.
In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.
But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.
It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.
Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.
Write “Probable Discharge Tomorrow” Orders
Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.
Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.
Prepare the Day Prior
Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:
On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).
Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.
On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.
I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.
Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.
The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:
“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”
Start Rounds Earlier
This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
A New Narrative for Hospitalists
The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.
Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.
As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5
Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.
These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.
Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.
Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10
We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.
Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.
The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.
Acknowledgements
The authors acknowledge Andrew Auerbach, MD, and John Choe, MD, MPH, for their comments on this article.
- .Dismantling Rube Goldberg: Cutting through chaos to achieve coordinated care.J Hosp Med.2009;4(4):259–260.
- Transitions of care.J Hosp Med.2006;1(suppl 1):95.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
- ,,,.Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.J Hosp Med.2007;2(5):314–323.
- ,,,.Effect of discharge summary availability during post‐discharge visits on hospital readmission.J Gen Intern Med.2002;17(3):186–192.
- ,.Care transitions for hospitalized patients.Med Clin North Am.2008;92(2):315–324, viii.
- ,,,,.Impact of fragmentation of hospitalist care on length of stay and postdischarge issues. Abstract presented at: Society of Hospital Medicine 2008 Annual Meeting; April 2008; San Diego, CA.
- ,,,,.A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours.J Am Coll Surg.2005;200(4):538–545.
- .The checklist.New Yorker. December 10, 2007.
- ,,, et al.Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.J Hosp Med.2006;1(6):354–360.
- ,.The hospitalist's story.JAMA.2006;296(17):2067–2068.
- .Satisfaction?JAMA.2005;293(18):2193.
The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.
Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.
As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5
Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.
These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.
Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.
Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10
We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.
Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.
The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.
Acknowledgements
The authors acknowledge Andrew Auerbach, MD, and John Choe, MD, MPH, for their comments on this article.
The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.
Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.
As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5
Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.
These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.
Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.
Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10
We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.
Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.
The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.
Acknowledgements
The authors acknowledge Andrew Auerbach, MD, and John Choe, MD, MPH, for their comments on this article.
- .Dismantling Rube Goldberg: Cutting through chaos to achieve coordinated care.J Hosp Med.2009;4(4):259–260.
- Transitions of care.J Hosp Med.2006;1(suppl 1):95.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
- ,,,.Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.J Hosp Med.2007;2(5):314–323.
- ,,,.Effect of discharge summary availability during post‐discharge visits on hospital readmission.J Gen Intern Med.2002;17(3):186–192.
- ,.Care transitions for hospitalized patients.Med Clin North Am.2008;92(2):315–324, viii.
- ,,,,.Impact of fragmentation of hospitalist care on length of stay and postdischarge issues. Abstract presented at: Society of Hospital Medicine 2008 Annual Meeting; April 2008; San Diego, CA.
- ,,,,.A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours.J Am Coll Surg.2005;200(4):538–545.
- .The checklist.New Yorker. December 10, 2007.
- ,,, et al.Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.J Hosp Med.2006;1(6):354–360.
- ,.The hospitalist's story.JAMA.2006;296(17):2067–2068.
- .Satisfaction?JAMA.2005;293(18):2193.
- .Dismantling Rube Goldberg: Cutting through chaos to achieve coordinated care.J Hosp Med.2009;4(4):259–260.
- Transitions of care.J Hosp Med.2006;1(suppl 1):95.
- ,,,,,.Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care.JAMA.2007;297(8):831–841.
- ,,,.Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.J Hosp Med.2007;2(5):314–323.
- ,,,.Effect of discharge summary availability during post‐discharge visits on hospital readmission.J Gen Intern Med.2002;17(3):186–192.
- ,.Care transitions for hospitalized patients.Med Clin North Am.2008;92(2):315–324, viii.
- ,,,,.Impact of fragmentation of hospitalist care on length of stay and postdischarge issues. Abstract presented at: Society of Hospital Medicine 2008 Annual Meeting; April 2008; San Diego, CA.
- ,,,,.A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours.J Am Coll Surg.2005;200(4):538–545.
- .The checklist.New Yorker. December 10, 2007.
- ,,, et al.Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.J Hosp Med.2006;1(6):354–360.
- ,.The hospitalist's story.JAMA.2006;296(17):2067–2068.
- .Satisfaction?JAMA.2005;293(18):2193.