11/17/2013
Hospitalist Roles
ACP Meeting
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Christopher Gamble, MD, FACP
Associate Medical Director Hospitalist Program
IU Health Ball Memorial Hospital
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Leader of the Medical Team
 Multi-disciplinary Rounds
 Documenting, Rounding,
Communicating,
Facilitating, Consulting
 Co-Management
Education
 Medical Student
 Resident
November 15, 2013
Leader of the Medical Team
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Quality Improvement
 Core Measures
 Mortality, LOS, Pt
Satisfaction
 Readmissions
 Management
Transitions of Care
 Pre-operative Evaluation
 Transition Clinic
 LTAC
 SNF
Hospitalist Co-Management
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"We always cover the ears of the patient whenever we
need to ask the nurse how to do something."
Definition - shared responsibility, authority and
accountability for the care of a hospitalized patient
across clinical specialties
“While there are opportunities for hospitalists to add real
value as co-managers of surgical patients (e.g. in
optimizing the medical care of patients with significant
co-morbidities such as heart failure and diabetes, and
reducing post operative complications such as venous
thromboembolism), the general definition of comanagement is vague and varies markedly from one
hospital to another.”
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SHM – A White Paper on a Guide to Hospitalist/Orthopedic Surgery Co
Management
*ACP Cartoon Sept 2009
Co-Management
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Medicine
• Cardiology
• Oncology
• Hospice/Palliative Care
• Endocrinology
• Nephrology
• Neurology
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Surgical
• Orthopedics
• General Surgery
• Urology
• ENT
Co-Management
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The Classic Question for Physicians???
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11/17/2013
Co-Management
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The Classic Question for Physicians???
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Co-Management
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Who is admitting and who is consulting?
What the surgeon says:
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“I need your help managing the medical
issues”
Co-Management
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What the hospitalist hears:
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“I need you to do the discharge summary”
Benefits of Co-Management
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Increased prescribing of evidence-based treatments
Reduced time to surgery
Fewer transfers to an ICU for acute medical deterioration
Lower post-operative complications
Increased likelihood of discharge to home
Reduced length of stay
Improved nurse and surgeon satisfaction
Lower readmission rates
Arch Intern Med. 2010 February 22; 170(4): 363–368.
Comanagement of hospitalized surgical patients by medicine physicians in the United States
Gulshan Sharma, MD, MPH,1,2 Yong-Fang Kuo, PhD,1,2 Jean Freeman, PhD,1,2 Dong D. Zhang, PhD,1,2 and James S. Goodwin, MD1,2
Comanagement of geriatric patients with hip
fractures: a retrospective, controlled, cohort study.
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Implementation of a comanagement protocol for care of geriatric
patients with hip fracture:
 Admission to a geriatric primary care service
 Standardized perioperative assessment regimens
 Expeditious surgical treatment
 Continued primary geriatric care postoperatively
Results:
 Reductions in lengths of stay, ICU admissions, and hospital costs
per patient
Geriatr Orthop Surg Rehabil. 2013 Mar;4(1):10-5. doi: 10.1177/2151458513495238.
Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study.Della Rocca GJ, Moylan KC, Crist BD, Volgas DA,
Stannard JP, Mehr DR.Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA.
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Medical and surgical comgmt after elective hip and
knee arthroplasty: a randomized, controlled trial
Issues with Co-Management
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Inconsistent definition from hospital to hospital
Increases demand for hospitalists and with it a critical
and potentially destabilizing hospitalist manpower
shortage
INTERVENTIONS: A comgmt Hospitalist-Orthopedic Team compared with standard postoperative
care by orthopedic surgeons with medical consultation.
RESULTS:
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Facilitates surgeon/specialist disengagement
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Hospitalist career dissatisfaction and burnout
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Unclear delineation of responsibilities places patient at
risk for conflicting/contradictory orders
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J Hosp Med. 2008 Sep;3(5):398-402. doi: 10.1002/jhm.361.Just because you can, doesn't mean that you should: A call
for the rational application of hospitalist comanagement. Siegal EM.University of Wisconsin School of Medicine and Public
Health, Madison, WI, USA.
CONCLUSIONS:
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The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative
complication rates with no statistically significant difference in length of stay or cost. The nurses
and surgeons strongly preferred the comanagement hospitalist model. Additional research on the
clinical and economic impact of the hospitalist model in other surgical populations is warranted.
Ann Intern Med. 2004 Jul 6;141(1):28-38. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized,
controlled trial. Huddleston JM, Long KH, Naessens JM, Vanness D, Larson D, Trousdale R, Plevak M, Cabanela M, Ilstrup D, Wachter RM;
Hospitalist-Orthopedic Team Trial Investigators. Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
huddleston.jeanne@mayo.edu
Opportunity missed: medical consultation, resource use, and
quality of care of patients undergoing major surgery.
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Co-Management
METHODS: Observational cohort of patients undergoing surgery at a university-based hospital.
The outcomes included costs, hospital los, use of preventive therapies (such as perioperative
beta-blockers) and clinical outcomes.
RESULTS: Consulted patients were of a similar age, sex, and race, but more frequently had an
American Society of Anesthesiologists score of 4 or higher (34.2% vs 13.0%; P < .001), diabetes
mellitus (29.1% vs 16.1%; P < .001), vascular disease (35.0% vs 10.6%; P < .01), or chronic
renal failure (23.9% vs 5.6%; P < .001).
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Patients were just as likely to:
 Have a serum glucose level of less than 200 mg/dL (<11.1 mmol/L)
 Receive perioperative beta-blockers
 Receive venous thromboembolism prophylaxis.
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Consulted patients had a longer adjusted length of stay (12.98% longer; 95% confidence
interval, 1.61%-25.61%) and higher adjusted costs (24.36% higher; 95% confidence
interval, 13.54%-36.34%).
More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs.
49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points])
Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, -14.1
percentage points [CI, -22.7 to -5.3 percentage points])
Observed length of stay was not statistically different between treatment groups. However, when adjusted
for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days
vs. 5.6 days; difference, -0.5 day [CI, -0.8 to -0.1 day]).
Total costs did not differ between groups.
Orthopedic surgeons and nurses preferred the hospitalist model.
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The question isn’t if Hospitalists should or
should not provide surgical comanagement but with how, with what
patients, and with what goals?
CONCLUSIONS:
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Patients who had a consultation from a generalist did not receive different quality of care,
but had costs and length of stay similar to nonconsulted patients.
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Perioperative internal medicine consultation produces inconsistent effects on efficiency and
quality of care in surgical patients. Modifying the consultative model may represent an
opportunity to improve care.
Auerbach AD,Rasic, MA,Sehgal N,Ide B,Stone B,Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of
patients undergoing major surgery. Arch Intern Med. 2007; 167(21): 2338–2344.
Hospitalist Co-Management
Building Co-Management
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What is administration’s expectations?
One service at a time
 Ortho’s different from Gen Surg which is different than Urology
Define the population of patients that will benefit
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ASA Guidelines
Low, moderate, high risk
SHM – A White Paper on a Guide to Hospitalist/Orthopedic Surgery Co Management
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11/17/2013
ASA Classification
Hospitalist Co-Management
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Minimal evidence to support co-mgmt of uncomplicated surgical
patients
Moderate risk patients
 Mixed evidence on improving LOS and functional status
High Risk
 Most convincing evidence that hospitalists improve outcomes,
decrease complications
 Examples:
 Decompensated Heart Failure
 Acute COPD exacerbations
 Acute MI
 Acute CVA
 DKA
 Active Arrhythmias
http://my.clevelandclinic.org/services/Anesthesia/hic_ASA_Physical_Classification_System.aspx
Building Co-Management
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Put it in writing and stick to the script
 Miscommunication between providers increases risk to patient
 Define who manages what
Common Questions that need addressed:
 Who manages:
 DVT prophylaxis? Pain? Activity? Wound care?
 Post op complications?
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Building Co-Management
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Conflict resolution
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Who does the nurse call for Fever? Hypotension? Low UOP?
Medication Reconciliation – Admission and Discharge
Discharge Summary
Will there be a process for resolving issues or conflicts regarding the
design or operation of the co-management program?
Who will be responsible for providing authority when conflicts are
unable to be resolved?
Educate
 Hospitalists and Surgeons
 Nursing Staff
 Secretaries
 Administration
References
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Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J
Am Geriatr Soc. 2001 May;49(5):516–22.
Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for older patients with hip
fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006 March;20(3):172–8.
Phy MP, Vanness DJ, Melton LJ, III, et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch
Intern Med. 2005 April 11;165(7):796–801.
Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients. Results of an
interdisciplinary hospital care program. Clin Orthop Relat Res. 1992 January;(274):213–25.
Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee
arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004 July 6;141(1):28–38.
Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture Center on shortterm hip fracture outcomes. Arch Intern Med. 2009 October 12;169(18):1712–7
Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients. Results of an
interdisciplinary hospital care program. Clin Orthop Relat Res. 1992 January;(274):213–25.
Arch Intern Med. 2010 February 22; 170(4): 363–368. doi: 10.1001/archinternmed.2009.553 Comanagement of
hospitalized surgical patients by medicine physicians in the United States Gulshan Sharma, MD, MPH,1,2 YongFang Kuo, PhD,1,2 Jean Freeman, PhD,1,2 Dong D. Zhang, PhD,1,2 and James S. Goodwin, MD
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References
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Anaesth Intensive Care. 2013 Sep;41(5):569-72. Medical co-management of high risk surgical patients.
Story DA, Jones DA.
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil. 2013 Mar;4(1):10-5. doi: 10.1177/2151458513495238.
Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study.Della
Rocca GJ, Moylan KC, Crist BD, Volgas DA, Stannard JP, Mehr DR.Department of Orthopaedic Surgery, University
of Missouri, Columbia, MO, USA.
J Hosp Med. 2012 Oct;7(8):649-54. doi: 10.1002/jhm.1951. Epub 2012 Jul 12.Evolving practice of hospital
medicine and its impact on hospital throughput and efficiencies. Chadaga SR, Maher MP, Maller N,
Mancini D, Mascolo M, Sharma S, Anderson ML, Chu ES. Division of Hospital Medicine, Department of Medicine,
Denver Health Medical Center, Denver, Colorado 80204-4507, USA.
Arch Intern Med. 2010 Dec 13;170(22):2004-10. doi: 10.1001/archinternmed.2010.432. Comanagement of
surgical patients between neurosurgeons and hospitalists. Auerbach AD, Wachter RM, Cheng HQ, Maselli J,
McDermott M, Vittinghoff E, Berger MS. Division of Hospital Medicine, Department of Medicine, University of
California, San Francisco, CA 94143-0131, USA.
Ann Intern Med. 2004 Jul 6;141(1):28-38. Medical and surgical comanagement after elective hip and knee
arthroplasty: a randomized, controlled trial. Huddleston JM, Long KH, Naessens JM, Vanness D, Larson D,
Trousdale R, Plevak M, Cabanela M, Ilstrup D, Wachter RM; Hospitalist-Orthopedic Team Trial Investigators. Mayo
Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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