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Emergency Medicine News:
doi: 10.1097/01.EEM.0000294645.21995.ff
Quality Matters

Hospitalists and ED Patient Flow

Welch, Shari J. MD

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Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.

Hospitalist programs are a hospital innovation that has positively affected ED patient flow. As you think about patient flow through your department, be aware that one of the things you could do to most improve the flow of patients through the ED is actually on the inpatient side. Be an advocate for hospitalist services!

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Labeled hospitalists in 1996 (N Engl J Med 1996;335:514), these physicians are defined as hospital-based internists whose primary focus is the general medical care of inpatients. Their activities include patient care, teaching, research, and leadership at the hospital level. Hospitalists often provide critical care coverage for ICUs, staff rapid response teams, and provide house coverage and consultations to specialists. They numbered approximately 8,000 in 2004, but are expected to exceed 20,000 by 2010, roughly the number of cardiologists practicing today. (Amer J Med 1999;106:441.)

Market penetration varies from five percent to 100 percent depending on the medical community. Their development as a specialty parallels our own. Hospitalist programs initially took hold in community hospitals before becoming entrenched at academic centers, just as the first groups of emergency physicians were community hospital physicians who gave up their practices to pioneer the full-time practice of emergency medicine. The incentives may have been similar as time and patient volume demands identified a new kind of hospital-based practice. The “customers” for a hospitalist are similar to those of the emergency physician, including administrators, medical staff, nurses, patients, and hospital staff. Both also need to know how to staff and when to double-cover, how to avoid burnout, how to achieve highest productivity, and how to deal with indigent care and shift scheduling. In many ways, hospitalists are the cousins of emergency physicians.

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Changes in Primary Care

Why did hospitalists evolve? A number of factors saw the need for their development, including major changes in primary care over the years. The number of patients hospitalized at any one time for a private practice primary care physician declined over the latter half of the 20th century, going from 40 percent of a practice to less than 10 percent. For this physician, it was inefficient and cost-ineffective to care for only one or two inpatients at a time. Medicare also ended house call payments, and PROs discouraged primary care physicians from inpatient management.

These forces aligned to reveal a need for a physician who stayed at the hospital to care for inpatients. The complexity of health care for inpatients increased, making many primary care physicians uncomfortable with caring for them. A shortage of primary care physicians drove the primary care doctor back to the office, and the burden of the uninsured, the liability of the hospitalized patient, and hospital demands kept him away. As silos of care at the hospital were identified, including labor and delivery, mental health, surgery, cardiology, and subspecialty care, it became clear that one further silo was needed along with the physicians to care for them: medical inpatients and hospitalists.

Hospitalists evolved with no specific directive or government funding in response to a need for more efficient inpatient care. With the acuity of patients increasing and pressures mounting to reduce length of stay, physicians focused on the care of inpatients could yield substantial savings for hospitals and insurers. Multiple studies have, in fact, confirmed that hospitalists enhance the efficiency of hospital care by reducing lengths of stay. (JAMA 2002;287:487.) For the data junkies in the crowd, hospitalist services are consistently associated with a 17 percent reduction in length of stay, which translates into a 13 percent reduction in costs and a savings of at least $800 per admission. (Ann Intern Med 2002;137:866.)

So far the data suggest no sacrifice in the quality of care given by hospitalists. In fact, hospitals which use hospitalists have demonstrated better use of resources, higher patient satisfaction, and better outcomes. (JAMA 1998;279:1560.) The most compelling data in support of hospitalists involve lowered mortality rates in facilities that implement hospitalist programs, a finding of several research groups. (Am J of Med 2004;117:446.)

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Financial Savings

For the administrator, the financial case for hospitalists may be the most convincing. Besides the savings associated with decreased lengths of stay, operating performance translates into an even sunnier fiscal picture when hospitalist programs are introduced. More than 250 hospitals with hospitalist programs saw higher occupancy rates, faster bed turnaround, and higher return on assets. The facilities were matched for percentage of elderly and unemployment rate. (See table: Research by Hospitalists.)

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To emergency physicians, what does the presence of a hospitalist service mean? Hospitalists are usually internists, and can fill the on-call list for the ED. In many communities, hospitalists take all admitted patients who have no identifiable primary care physician, and are contracted by many physician groups to cover their admitted patients. Because hospitalists are on site, their callback times are short, expediting the time from when the decision to admit is made to the time the patient is able to go upstairs. Once hospitalists assume the care of the patient, the emergency physician can focus on the next patient in the queue.

Hospitalists also know the hospital side of the health care continuum and can finesse the bed situation and positively influence the flow of patients. Hospitalists control the discharge side of the health care continuum, and by making that process more efficient they help the incoming streams of patients. In some more progressive communities, hospitalists manage nursing homes and chronic care facilities. Those who incorporate good bed management systems and programs to incorporate innovations like day-ahead discharge planning, staggered discharges, and good management of extended care facility admissions have positively affected hospital-wide patient flow.

Other little sung advantages of hospitalist services involve feedback to the medical staff. Primary care physicians often complain that they are not kept in the loop when their patients come to the ED. Though increasingly difficult to provide in-depth real-time data-sharing from the ED, many institutions fax a copy of the admission note to the primary care physician. When this is followed by a phone call from the hospitalist prior to discharge, the communication loop is completed. Hospitalists are easier to standardize because they are typically a smaller group, and they also are easier to indoctrinate in information technology and protocols. Hospitalists add value in other ways, too, some of which include leading improvement efforts, co-managing surgical and ICU patients, providing house emergency coverage, staffing medical emergency response teams, teaching, and providing observation coverage. These services function well even in teaching hospitals with residents.

Hospitalist programs will be more and more difficult to start because of a shortage of practitioners. In February 2006, the average new graduate intent on a career in hospitalist medicine had five to 10 job offers. (Today's Hospitalist 2006;2:19.) Those institutions with existing programs have the advantage because most new graduates would rather join an existing group than a start-up. Hospitalist positions are more lucrative than general internal medicine practice positions.

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Salaries for Hospitalists

The average non-academic hospitalist will enjoy a starting salary of $165,000 to $180,000, or $20,000 to $30,000 more per year than their office-based counterparts. But it is typically not the money that draws the hospitalist to a position. Today's hospital-based practitioners want tools that make their lives and medical practices easier. Some of the perks considered important by new hires included wireless access to patient information, voice-activated transcription, Blackberries, and good parking. Some other items of interest when job searching include a good mentoring arrangement, merit-based bonuses, partnership tracks, and good specialty consultants. (This sounds a lot like what the new emergency physician would like, doesn't it?)

For hospitalists struggling to establish new hospitalist programs, alternative models might include the use of locum tenens physicians to start or expand a program. Taking an existing program within a system and expanding it to other facilities using less conventional staffing schemes may be easier than trying to start a new program at each hospital. The use of nurse practitioners, physician assistants, and other midlevel providers is another way to grow a program. Shorter shifts (just one shift a day to start) may be a way to launch a program with sparse staffing. Still, all should be mindful of the possibility of burnout, which is an issue for hospitalists.

The future of emergency physicians is sure to be intimately entwined with hospitalists'. In fact, some progressive groups are staffing the emergency department and hospitalist service. When hospitalists and emergency physicians are on the same team, some interesting dynamics can occur. The groups are mindful of each other's problem spots. For instance, one group of hospitalists and emergency physicians informally negotiate certain local standards together. The hospitalists agreed to expedite soft chest pain admissions (which were lingering in the ED) in exchange for the thorough work-up of abdominal pain patients (which have proved problematic for the hospitalist). Such local arrangements with this kind of give-and-take can help a facility with patient flow and offer a new paradigm for physician cooperation.

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Hospitalists: An Emerging Specialty

* Represented by the Society of Hospital Medicine.

* 8,000 hospitalists currently working.

* Experts predict 20,000 in next decade, on par with the number of cardiologists.

* Market penetration varies from 5% to 100%

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Measuring Hospitalist Practice

* Shorter length of stay

* Use fewer resources

* Produce better outcomes

* Improve patient satisfaction

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© 2006 Lippincott Williams & Wilkins, Inc.

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