Nishimura, Rick A. MD; Linderbaum, Jane A. MS, FNP; Naessens, James M. MPH; Spurrier, Barbara; Koch, Mark B.; Gaines, Kim A. RN, MS
Hospitals affiliated with academic medical centers provide the skill and expertise to care for the most complex and sickest patients. Residency programs have played a critical role in supporting these hospitals, supplying interns and residents who have the time, motivation, and expertise to provide tertiary care. The clinical experience of taking care of these critically ill patients has always been an essential part of the training of young physicians.1
Academic medical centers now face many challenges in the inpatient setting. Hospitals have had to adapt to more acute patient conditions, shorter allowable lengths of stay, and large reductions in reimbursements for the care they provide. The requirement for documentation of services is increasing, consuming time and diverting effort from direct patient care and residents’ education. Residents’ support is less available for hospital-based patient care because the emphasis is shifting to outpatient care2,3 and, overall, internal medicine programs are downsizing.2 The Accreditation Council for Graduate Medical Education (ACGME) has recently implemented new restrictions on residents’ work hours that have a profound impact on the ability of physicians in training to provide continuous care to hospitalized patients.4
Academic medical centers may not be able to meet these challenges merely by redeploying residents or increasing the size of a residency program. Academic centers need to reengineer systems of care without eroding the educational component of training programs.1,4
At Mayo Clinic, we developed a new model for the care of patients with cardiovascular disease that could meet accreditation demands in the hospital setting without staffing by internal medicine residents. This new service consists of a team of cardiovascular attending physicians, cardiovascular fellows, nurse practitioners and physicians assistants (midlevel providers), and registered nurse liaisons. This reengineering of our inpatient services was designed to address the new challenges confronting academic medical centers while maintaining optimal patient care. We report on the design of the new service and results of patients’ satisfaction, patients’ outcomes, and physicians’ satisfaction.
Traditional Cardiovascular Hospital Service at Mayo Clinic
Historically, the hospital practice of the Division of Cardiovascular Diseases at Mayo Clinic in Rochester, Minnesota, involved traditional resident teaching services. Each of these services consisted of four first-year internal medicine residents, one senior internal medicine resident, and one cardiovascular attending physician. Rounds began at 8:30 am with presentation of all the new cases to the cardiovascular attending physician. This physician then saw each new patient during rounds while teaching residents the key components of the history, the physical examination, and the plan of care. The attending physician was then responsible for continuing rounds to see the remaining patients on the service. Typically, the attending physician wrote admission notes and subsequent notes during the rounds. The usual census of this service was 15 to 20 patients. Rounds normally lasted four to five hours, with a break for lunch. Teaching occurred at the bedside, with occasional didactic lectures. The cardiovascular attending physician ended rounds in the early afternoon. New inpatients usually were evaluated and admitted by the internal medicine resident on call after rounds, starting at 2 p.m. and continuing until 7 a.m. the next day. The entire inpatient cardiovascular practice, excluding patients admitted to a coronary intensive care unit, was managed by four of these teaching services. Cardiovascular fellows were not involved with inpatient care at our institution, except for responsibilities with the coronary intensive care unit and a consultative service.
This traditional system worked well in the 1970s and 1980s. However, the admission rate and census of the cardiovascular hospital services gradually increased in the 1990s. By 1995, admissions could be up to eight a day for each service. The census could include 25 to 30 patients at a time. The increasing workload, greater severity of disease, and increasing requirements for documentation decreased attending physicians’ satisfaction. The residents’ heavy workload resulted in a corresponding decrease in residents’ satisfaction, and there was the perception that residents’ education was undermined by the need to accomplish clinical work. In addition, the high admission rate for the residents did not meet the workload guidelines required by the Residency Review Committee. The internal medicine residency program also began to shift its emphasis onto outpatient care, decreasing the number of residents available for the cardiovascular inpatient services.
Department of Medicine Task Force for Inpatient Care
In 1997, the Department of Medicine at Mayo Clinic formed a task force to address the challenges facing the inpatient services. At that time, the number of residents required in the inpatient setting was based on the workload demand of the large number of patients admitted to cardiovascular services. Mandates of the Residency Review Committee were not being met, including (1) residents should spend a greater amount of time in the outpatient setting, (2) residents should spend at least a half day per week in the continuity clinic, and (3) at least 50% of residents’ inpatient time should be spent on general medicine services.
The task force determined that a new model was required to provide patient care in the inpatient setting. Residents could no longer be used purely to provide care for patients. To support an educational environment for internal medicine residents and decrease the number of months spent on the cardiovascular inpatient service, the task force recommended that a new patient care service be established without the use of residents. This would allow for an admission cap (maximum number of admissions) to be placed on the remaining teaching services, allowing more time for educational endeavors. In addition, the new patient care service would consist of a patient care team model, characterized by collaborative decision making and shared ownership. Finally, because of financial pressures, the new patient care service would provide care in an efficient and cost-effective manner, with rapid deployment of physician consultation and subspecialty services.
Structure of the New Patient Care Service
In January 1998, the new patient care service was implemented to function without the involvement of internal medicine residents. Three of the resident teaching services, called Cardiology I, II, and III, continued in their traditional format, and the patient care service was called Cardiology IV. The major purposes of Cardiology IV were to redistribute workload from the resident teaching services, enhance the educational experience of the other services, and allow the other services to meet requirements of the Residency Review Committee. The admission rate for each resident teaching service was capped at five patients per day, allowing for the incorporation of bedside teaching rounds and didactic lectures.
Cardiology IV, consisting of cardiovascular attending physicians, cardiovascular fellows, and midlevel practitioners, all supported by nursing, now covers the remaining workload. Midlevel practitioners, an essential part of the team, provide direct patient care similar to that formerly provided by internal medicine residents. By performing history taking and physical examinations on the patient at admission, the midlevel practitioners streamline the process and documentation for the attending physicians. In addition, the midlevel practitioners take in-house call at night and address problems that arise, insulating the attending physicians from the 24/7 duty of patient care. Further, a new service role was created—a registered nurse liaison—to streamline daily operations and the flow of information among team members, patients, and families. The registered nurse liaison, a bedside nurse rotating into the role, is involved with rounds, facilitating and sequencing tests ordered by the physician, dictating dismissal summaries, and interacting directly with primary nursing colleagues at the bedside, providers on the service, patients, and families. Also, on the new service, cardiovascular fellows are involved directly in patient care, assuming the primary care of a portion of the patients directly under the supervision of the attending physician.
Cardiology IV is designed to enhance the flow of patient care for all cardiovascular services. The mornings and early afternoons of the traditional resident teaching services are used primarily for rounds and teaching, so few admission workups occur and major care decisions on these services are not made until the following day. Cardiology IV admits and treats patients specifically from 7 am to 2 pm. Each patient admitted on the service is seen by a member of the team within a half hour of admission and by the cardiovascular attending physician within one hour of admission. Because many cardiovascular patients have acute problems requiring urgent diagnostic or therapeutic interventions, Cardiology IV provides for testing and treatment on the day of admission, and the attending physician can meet directly with the patient and family on their arrival at the hospital, which rarely occurred with the old model.
With the implementation of Cardiology IV, support systems were instituted to enhance efficiency. Transcription services were provided for the first time to Cardiology IV so that patient assessment and documentation could follow in rapid order. The entire Cardiology IV team collaborates to meet the documentation requirements without redundancy. The nurse liaison and bedside nurse ensure that the patient or family complete the information forms, and they complete the nursing history and assessment of the patient, which helps the service complete the medical history, social history, family history, and review of systems. The cardiovascular fellow or midlevel practitioner obtains a complete history and cardiovascular physical examination. The cardiovascular attending physician examines the patient, adds appropriate comments on the history and physical examination, and provides a plan of care.
To evaluate the impact of the new cardiovascular patient care service, we measured patients’ satisfaction and outcomes and physicians’ satisfaction.
All patients dismissed in 1998 who were admitted to any of the four cardiology services were considered for evaluation. Patients transferred to other medical or surgical services during the hospitalization were excluded. In compliance with Minnesota law, all patients refusing retrospective review of their medical records for research purposes were also excluded. Analysis of data was approved by the Mayo Foundation Institutional Review Board.
Measurement of Patients’ and Physicians’ Satisfaction
Patients’ satisfaction was assessed by retrospectively examining responses to a questionnaire routinely used by our institution to document and track the satisfaction of patients on the Department of Internal Medicine inpatient services. This questionnaire focuses primarily on the interaction of the patient and the care-giving team. The one-page questionnaire is sent by mail to randomly selected patients approximately two to three months after their dismissal. Approximately 200 questionnaires per quarter are sent at random to patients dismissed from the cardiology inpatient services (total 800 per year), and the overall response rate is 60%. We report the results of all surveys from 1997 and 1998 to determine the impact of the Cardiology IV service, which was implemented in 1998.
Physicians’ satisfaction was documented for both the attending physicians and the internal medicine residents before and after Cardiology IV was implemented. The attending physicians routinely filled out a one-page questionnaire for the Division of Cardiovascular Diseases after completing every hospital rotation. The internal medicine residents also routinely filled out a two-page questionnaire for the Internal Medicine Training Program, focusing on their satisfaction with patient mix, core lectures, teaching of the physical examination, and teaching of evidence-based medicine. Each area was scored from 1 (lowest) to 5 (highest). The response rate on these surveys was 100%.
Standard hospital dismissal information was collected on all patients through the use of our institutional decision-support system. This system tracks characteristics, including the patient's diagnosis-related group, length of stay, in-hospital mortality, and 30-day readmission rate. The characteristics of hospitalizations on Cardiology IV were compared with those of admissions on the traditional resident teaching services. A χ2 analysis was used for nominal data, and a t test or Wilcoxon rank sum test for ordinal and continuous variables. Univariate analyses on patients’ outcomes were based on Wilcoxon rank sum test for length of stay, χ2 test for mortality, and log-rank tests for time to readmission.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes processed through disease staging were used to evaluate comorbid conditions and severity.5 From disease staging, we obtained the four summary severity scales of expected probability of death, resource demand scale, length of stay scale,6 and number of body systems with stage 2 or 3 conditions. We also determined measures of disease-specific severity by calculating the number of cardiovascular disease categories at stage 1+, stage 2+, or stage 3+ and measures of severe comorbid conditions by calculating the number of noncardiovascular disease categories.
Because this was a retrospective, observational analysis, regression models were developed to attempt to adjust for differences between patients admitted to the services. Stepwise regression models were developed separately to evaluate differences in the natural log of length of stay, costs, and charges, with the patient characteristics, hospitalization characteristics, and severity and comorbidity measures used as possible confounding factors. Log-transformed outcomes were used to account for the skewed nature of the economic data. The same method was applied to assess readmission rates between treatment groups by using logistic regression techniques. All variables significant at p < .05 were included as covariates in the adjusted assessment of the new Cardiology IV service compared with the traditional teaching services. For models with log-transformed dependent variables, a smearing retransformation was used to estimate the absolute difference in length of stay, costs, and charges between cardiology services.7 Each dismissal was considered an independent observation for all analyses. All analyses were performed with SAS version 8.2 (1999).
Patients’ and Physicians’ Satisfaction
Patients’ satisfaction was no different when patients on Cardiology IV were compared with those on traditional services. For “willingness to recommend,” 86% of the responding patients on the resident teaching services and 90% of those on Cardiology IV gave the highest ratings. For “overall care,” 59% of the responding patients on the resident teaching services and 60% of those on Cardiology IV gave “excellent” ratings. Both cardiovascular attending physicians (total n = 52) and internal medicine residents (total n = 45) were more satisfied with the hospital rotations after the institution of the Cardiology IV service (see Figures 1 and 2).
Univariate assessment demonstrated no significant differences in hospital mortality (p > .10) or rate of 30-day readmissions between groups (p > .10). Patients on Cardiology IV had significantly shorter lengths of stay compared with patients on the resident teaching services (2.9 days versus 3.8 days; p < .01). The average length of stay was 3.8 days for all cardiology services in 1997 before implementation of Cardiology IV. These outcomes were unchanged when adjusted for baseline characteristics of the patients in the two groups. Overall, the cost per case was 19% lower on Cardiology IV than on the resident teaching services.
The severity of cardiovascular problems did not appear to be different between patients on Cardiology IV and those on the resident teaching services. The patients on the resident teaching services had a higher prevalence of comorbid conditions, including stage 3 comorbidities, resulting in higher overall expected mortality and complexity scales. However, the patients on Cardiology IV had a higher mean resource demand scale and also had a higher diagnosis-related group (DRG) case-mix weight.
Patient age, sex, geographic origin, cardiovascular severity measures, comorbidity measures, and average DRG weight were all significantly related to log length of stay. After adjustment for these covariates, there was a highly significant difference (p < .001) in log length of stay, with patients on Cardiology IV staying an average of 0.9 day less than the adjusted 3.8-day length of stay on the traditional services. Similar results were seen in the adjusted economic analyses (transformed and nontransformed models), which showed lower total costs under the Cardiology IV model of care (p < .001) after adjustment for covariates, including DRG weight. No significant difference (p = .72) was observed in readmission rates between services after adjustment for significant covariates. The number of deaths was insufficient to justify development of an adjusted regression model for this clinical endpoint.
The major purpose of reorganizing the cardiovascular inpatient services at Mayo Clinic was to free residents from inpatient care responsibilities. Reallocating residents’ hours has allowed them more outpatient contact time and more experience on general medicine services. At the same time, formation of the Cardiology IV patient care service capped the number of new admissions a resident in cardiology would be responsible for each day. The reduction of the large number of patients admitted and cared for by the residents and the coverage of urgent admissions in the morning hours have improved residents’ education on these services, with time for bedside teaching and didactic sessions during the morning rounds. Also, the patient mix has been enhanced for the resident teaching services. During the daytime hours, for instance, admissions for predetermined therapy with limited educational value (e.g., patients who required hospitalization for hydration before angiography or anticoagulation before interventions) are now more efficiently taken care of by Cardiology IV, leaving the more complex patients for the resident teaching services.
We did not measure the satisfaction of the cardiology fellows in this study because there was no prior inpatient service for comparison. We do know, however, that the fellows who had been on this service and subsequently graduated believed this type of experience prepared them well for a busy private practice with hospitalized patients. The work hours of the fellows were only during the daytime hours and on weekdays, well below the 80-hour maximum workweek.
Cardiology IV has had other benefits for both patient care and institutional resources. The major outcome of this service has been facilitation of patient evaluation and management during the morning and early afternoon hours, which had not been accomplished with the traditional resident teaching services. On those services, the morning and early afternoon were reserved for rounds and teaching, so most patients could not be evaluated by the internal medicine resident until the middle or late afternoon, and the attending physician would see the patient the following day. Patients admitted to our cardiovascular services frequently require procedures such as stress testing, cardiac catheterization, and electrophysiologic testing. These tests require the approval of a staff cardiologist and, thus, could not be performed until the day after admission. With the implementation of Cardiology IV, patients are evaluated by the staff physician and begin their workup a full day ahead of what was possible in the past.
Rapid patient turnaround and shortened lengths of stay increase the potential for patient and family dissatisfaction because time for personal interaction and patient education is reduced. However, the fact that our findings showed patients’ satisfaction was maintained demonstrates that, in Cardiology IV, this potential problem was offset by the ability to have the patient and family seen within an hour after admission by all team members—the nurse, fellow or midlevel practitioner, and attending physician.
Cardiology IV has resulted in a direct decrease in both length of stay and cost per patient. Although a full financial analysis is beyond the scope of this study, the savings from decreased cost in a fixed reimbursement system by Cardiology IV have offset the increased resources required for staffing with midlevel practitioners.
Cardiology IV applies a care-team approach, which was not a part of the former traditional resident teaching service. Twice daily sit-down rounds were instituted with the entire team, including cardiac rehabilitation and nursing, to discuss complete care of the patient. The current model takes advantage of the expertise of nurse practitioners and physician's assistants, and studies show these providers deliver an effective level of care for outpatients8,9 and in subspecialized inpatient units.10–12 The role of the nurse practitioners and physician's assistants on this service is similar to that of the internal medicine residents because they can admit patients and provide day-to-day follow-up care. At the same time, a staff cardiologist sees the patient within one hour of admission, so that the primary decision making process always involves a fully trained cardiologist. One of the major advantages of the stable pool of nurse practitioners and physician's assistants in Cardiology IV is to provide consistency and continuity for orienting physicians to the service. These midlevel practitioners are on the service full-time and have been invaluable in implementing new initiatives, which was not possible on the fragmented resident teaching services. The addition of a registered nurse liaison has increased interaction between the team and bedside nursing, greatly enhancing the efficiency and outcomes of care.
This new patient care service has continued to be successful at Mayo Clinic and is being replicated on other hospital services. By providing patient care without the need for residents in an academic institution, the patient care service model protects the education function of the conventional teaching services. This new service provides more efficient patient care with outcomes comparable to those of conventional resident teaching services and maintains patients’ satisfaction. The overall satisfaction of residents and staff physicians has been enhanced by this service. The service also has established a framework to meet further external challenges. In the face of new ACGME requirements to decrease residents’ work hours, we can meet these requirements by further transferring the workload and responsibility for patient care from the resident teaching services to a patient-care model like Cardiology IV.