COMMENTARY

Can Hospitalists and ED Staff Drive Down Healthcare Costs?

Robert Glatter, MD; Sherri L. Sandel, DO

Disclosures

October 24, 2017

Robert Glatter, MD: With the advent and explosive growth of hospitalists as the primary mode to care for patients admitted to the hospital, the playing field for in-patient care has been transformed. On a positive note, implementation of the hospitalists model has led to reductions in length of stay, readmissions, and significant cost savings, based on multiple studies.

Beyond these milestones, improvements in quality of care as well as patient satisfaction are additional measurable benefits. This paradigm of care—that is, patients being cared for by hospitalists—also sheds light on a critical relationship between emergency department (ED) physicians and hospitalists as a result of potentially conflicting priorities as care providers.

While we share the goal of providing the best possible care for patients, we may also find ourselves working in opposition to one another due to conflicting priorities. That is, moving patients quickly through the ED and efficiently managing in-patient length of stay.

Here to discuss the pitfalls of this important relationship is Dr Sherri Sandel, director of hospitalist medicine and associate program director at Lenox Hill Hospital, Northwell Health. Welcome, Dr Sandel.

Sherri L. Sandel, DO: Thank you, Dr Glatter.

Dr Glatter: It's so nice to have you here because we've worked together for so long, and I wanted to have the opportunity to bring you in because you are the director of hospitalist medicine. I think you really add an incredible amount of information to this discussion.

Dr Sandel: It's great to be here. Thanks for inviting me.

Dr Glatter: I want to start off by talking about the relationship between hospitalists and ED physicians, because at times it can be contentious. But we have to work together and understand each other's role. Maybe, in a nutshell, you could summarize what you feel are the issues that currently exist, how you approach them, and what you feel are some future directions.

Dr Sandel: It's a very important thing to talk about because in the past we worked in silos. We know now that that model doesn't work and we have to communicate and collaborate. How do we create an environment and a change of culture where we can collaborate well? Why do we need to collaborate? The reasons you just said: We have different performance models that we have to respond to; how do we combine them and make it work fluently?

One of the things that we want to do is get the patients quickly through the ED, keep that flow going. That improves throughput and patient experience, and prevents a log jam. A lot of times the physicians on the other end, the hospitalists, don't want the patients to come up very quickly because they want more workup to be done in the ED. Changing that culture has been a big problem.

Dr Glatter: Do you feel that part of this change is having more shared meetings or collaboration, getting to know one another? Because that often heads off a lot of the issues—if we know each other. When we don't know each other, then we come at each other in a certain way.

Dr Sandel: Absolutely. I think that's the key: collaboration, communication, and sharing in our research, sharing in our grand rounds, understanding what our goals are and making them combined goals. I think you're absolutely right.

Dr Glatter: That brings us to the first topic: admissions and handoffs. That's a critical time, when we're ready to send a patient up. You guys may not be ready, but we have a metric to adhere to from the time of admission to the time they hit the floor. That shared metric is something we agree upon, but often it can be a source of stress.

Dr Sandel: Absolutely. Communication is going to be the issue; often physician-to-physician communication is not happening. For instance, a lot of times in the past, hospitalists would get worried if a patient would come up from the ED; the ED physician would see them, they look fine, and then they wouldn't get up to a room for an hour. When they got up to the room, they would crash on the floor. This is historical stress that people are worried about. In this day and age, we change the way we look at the patients, and we think about patient safety first. The ED physician will check on the patient, along with a nurse, and get vitals before the patient goes upstairs. That will be beneficial for the patient and for the hospitalist who then gets the patient when they come to the floor.

Dr Glatter: Exactly. Do you think that, other than a verbal discussion with the patient, hospitalists or a resident in our situation who is coming to see the patient has improved handoff and care, in general?

Dr Sandel: Absolutely. Residents are a great tie between the physicians, but if you don't have residents, a quick look just to see the patient, have a warm handoff between each other, makes a great difference.

Dr Glatter: With technology and the ability to FaceTime and videoconference, and even just take a video or a picture in general, do you think that might be something down the pipe that could help? Just a visual—obviously a picture is worth a thousand words, right?

Dr Sandel: Absolutely. We now have telemedicine. With telemedicine, you can hear a heartbeat, take a blood pressure, see everything you want. So I think you're right—that's a big thing for the future.

Dr Glatter: That's something the technologists are really looking at, because [in the past] we've just used telephones or even just texted or emailed, but now we can see a picture of that patient. In terms of the handoff itself, obviously the patient comes up, gets admitted. The hospitalist who's leaving shift might have to then transfer that patient's care to the oncoming hospitalist. Do you see that as a problematic time, in general?

Dr Sandel: The handoffs are always critical. When new hospitalists come, part of orientation is what is important in a handoff, and resident training as well. There should be a sick patient's verbal handoff and then there should be written handoff. The most important thing should be communicated: What's happening now, what are you foreseeing, what should be followed up?

Dr Glatter: Absolutely. From our standpoint, that transition of care, that end of shift and handoff, is a dangerous time, and we've always focused on, "Go to the bedside, see that patient." In the past, it may have been just a verbal signoff. A picture is worth a thousand words: When you see that patient, you get an idea of what really is transpiring. Plus, the family may be there and then you can get an idea of what further social issues are revolving around that care. They may not be able to go home. Someone tells you to just check an x-ray and discharge—maybe it's just not that simple.

Dr Sandel: You bring up a great point in that it should be patient centered. Being at the bedside together, if you're handing off to me, the family feels the security, the patient feels the security that everything's being communicated appropriately.

Dr Glatter: Is that something that you're doing now on the floors? You have both the hospitalists and the residents convening to say that this is the plan of care?

Dr Sandel: Yes; on critical patients we absolutely do—that's a necessity, yes. We instituted a few things. Every night, residents and physicians will say goodnight to their patients, and that's another way to signoff, double-check, and see their patients again.

Dr Glatter: That's nice; that adds good quality of care there.

Dr Sandel: Absolutely.

Dr Glatter: In terms of discharge in that patient, they go back to their primary care doc—that's always a problematic issue, because if you haven't been in contact, and if the doctor is unaware that the patient has even been admitted, then it's an issue. Do you try to stay in contact with the primary care doc?

Dr Sandel: Yes. Transitions of care is one of the biggest problems nationally with patients. It's a problem everywhere, because we all have separate medical records, and if you're not part of a system it makes it much harder. Everyone has to take the time and make the effort to communicate through the whole hospitalization and then at the end. Obviously, the trick is communicating not just with the primary care doctor but also with the patient. We often see medication reconciliation not done appropriately in patients going home and then coming back with adverse drug reactions or issues regarding that.

Dr Glatter: Do you do read-back before the patient leaves, or teach-back so that they have an understanding of the plan, their medications, and so forth?

Dr Sandel: Yes, and we've instituted pharmacy at our hospital to come in and talk about any new medication with the patients, look over what they were taking, what they should take, and what they shouldn't take. Often we go over these lists with the patients and they really don't have a great understanding.

Dr Glatter: Exactly; that's what we face. Sometimes a patient takes double the dose because they don't really understand. Some hospital systems are now having video instructions. I don't know if you're aware that certain services have instituted that, even within our hospital system, in our surgical services. They're finding some good outcomes with that in terms of reduced readmission rates and better patient understanding. Maybe that's something that could be explored.

Dr Sandel: More is better. Follow-up phone calls would be tremendous. Everything takes time and manpower, but just calling someone 24 hours later and saying, "Tell me everything you're taking, tell me what you're doing and what you're supposed to do tomorrow" would be a huge benefit.

Dr Glatter: I think it brings the smartphone into the picture again, because we have this incredible computer in our hands that can really help us. Really staying in touch with patients now can be as simple as using the smartphone when it has HIPAA protections involved and so forth.

Dr Sandel: Absolutely. That would be fantastic, and they have multiple programs that are HIPAA protected.

Dr Glatter: In fact, caregivers now, on some platforms, are actually helping the care for patients after discharge. Not just from subacute rehab settings but actually in the home settings using such technology, so that's helping us to help prevent such readmissions.

Dr Sandel: That should be our focus going forward: prevention of readmissions and, of course, making sure that what we've done with the patient gets translated going forward.

Dr Glatter: Do you have any thoughts about how technology could help us even further down the line, 10 or 20 years from now? Do you see any other trends?

Dr Sandel: Telemedicine is very interesting. I know we've started to touch on it, and it's a little cumbersome right now, but I see in the future that it's going to be something that, often, you won't even need to go and see your primary.

Dr Glatter: That brings us back to the idea of the human touch of medicine. People still want to have that conversation, that in-person visit, that old house call that existed.

Dr Sandel: There's definitely something to that.

Dr Glatter: I think that some of the technology is certainly nifty, but we always think about how patients feel.

Dr Sandel: The healing touch.

Dr Glatter: The screen doesn't necessary replace an in-person visit.

Dr Sandel: Going forward, we're going to have to figure out where that fits in—I agree.

Dr Glatter: That's very good. Thank you so much. I appreciate it.

Dr Sandel: Thanks for having me.

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