Medicolegal Issues

Where Does Hospital Medicine Begin and End?


It is clear to most of us in hospital medicine that the lines are rapidly blurring between the ED, and the floor, and the ICUs. Some of this has been brought about by the transitional units and the ability to place the patient in the most appropriate area with the correct level of monitoring equipment and nurse-to-patient ratio. Some of this has come about with the increased presence of hospitalists and intensivists in-house to complement the already ever-present ED physicians.

But now there is a movement afoot to both increase the use of observation units (OUs) and to change the physician oversight. Once thought to be an extension of the ED, OUs are now part of the hospitalists’ domain as these patients are thought to be more inpatient-light rather than long-term ED patients. And this makes sense when you realize that hospitalists are better suited to managing patients over time rather than ED physicians who favor shorter term relationships; you’re either admitted or “treated and streeted.”

Management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized patient.

This is further pushed toward the hospitalists’ realm as some OUs continue to treat patients for up to 48 hours (how can you be in a hospital bed for two days and still not be an inpatient?) and helped by the hospitalist’s 24/7 availability.

Having hospitalists serve as the medical directors for the OUs also makes sense because it gets these patients “out of the ED” from a logistic standpoint and shifts the responsibility to the hospitalist, freeing up the ED physicians to better do their primary job. This is just another in a list of examples of how hospitalists can improve ED throughput.

Further, now that governmental payers require closer on-site management of patients in OUs, this makes it virtually impossible for the outpatient-based primary care physicians to have a significant role.

According to The Advisory Board, Washington, D.C., and others, diseases such as CHF readily treated by hospitalists are well-suited to management in OUs. I thought I’d use CHF as an example of how a well-constructed OU might function. Obviously, there are clear classifications and criteria for those patients who are eligible to have their heart failure managed in an OU. And recent data have shown that appropriate management of CHF in OUs can lead to a lower admission rate, better use of resources, and better outcomes.

The OU setting can deliver a more extended course of therapy than traditionally available in the ED or a physician’s office for patients who may not need an acute hospitalization, but who are decompensating. With the best outcomes, management of CHF in an OU can prevent a hospitalization, delay a revisit to the ED, and improve the quality of the patient’s life by decreasing their symptoms and allowing them more time away form the hospital setting.

Not all patients who present to the ED with worsening CHF are candidates for OU management. Some clearly must be admitted. According to the American Heart Association/American College of Cardiology Guidelines the admission criteria for managing a CHF patient in an OU are:

  • Adequate systemic perfusion;
  • B-type natriuretic peptide < 100pg/mL;
  • CXR consistent with CHF; and
  • Demonstration of hemodynamic stability as evidenced by one of the following:
    • Heart rate >50 or <130;
    • Systolic blood pressure >90 and <175; or
    • Oxygen saturation >90%.

As more physicians become aware of the benefits of OU care for these patients, there has been a >9% increase in the number of OU patients in both 2003 and 2004, according to Medicare data. And the increased use is even more dramatic for CHF patients.

As one looks at the elements to design and staff a functioning OU, it is apparent this falls clearly in the hospitalist’s capabilities. The idea is to develop more than just a place to stay longer in the ED, but to create an evidence-based, cost-effective management solution for difficult patients. Key components would include:

  • Criteria for admission and exclusion based on risk stratification models;
  • Protocols for treatment using evidence-based practice guidelines;
  • Clear discharge process supported by patient education materials and discharge criteria; and
  • Performance standards and an ongoing data collection and quality improvement process.

CHF is an expensive condition to manage, fraught with frequent episodes of decompensation and admission. This takes an economic toll on the system and results in a poorer quality of life for those patients burdened with the disease. Because many physician offices are not set up to handle patients with increasing symptoms related to CHF, the ED becomes the treatment center of last resort. Thoughtful management of those patients correctly suited to OU care can lead to more directed treatment and avoid hospitalizations that are expensive to the system and unnecessary for the patient.

All data point to an increased prevalence of OUs as more hospitals develop them and more patients are treated in OUs. In addition, professional societies are establishing guidelines and criteria for the appropriate use of OUs for certain ED patients. At the same time, management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized (and near hospitalized) patient.

Once again the hospitalist is at the center of new initiatives that are a win-win-win. OUs can minimize the patient’s time away from home, improve their functional capacity, relieve congestion in the ED, allow the ED physicians to concentrate on true ED patients, uncrowd the hospital and the ED and improve throughput, and save the system money. And hospitalists with a plan can make this happen.

Not bad for a specialty that is still the new kid on the block. TH

Dr. Wellikson has been CEO of SHM since 2000.

Recommended Reading

The Doctor Is In
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The Newtonian Hospitalist
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The Hepatoadrenal Syndrome, HSS to Treat CHF, Treatment for Atrial Fib, and More
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Pediatric Hospital Medicine
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TRENDWATCH: The Specialization of Hospital Medicine
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The Pull is Strong
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Evidence Based Medicine for The Hospitalist
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Moving Out
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Tours of Duty
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10 Commandments for Hospitalists
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