In the ED, the prompt and efficient treatment of unassigned patients can reduce backlogs and minimize hassles for emergency physicians. There is no need for the emergency physician to track down an on-call physician to admit the patient. The ED maintains a better work flow and makes better use of their resources, especially of physician and nursing time as well as space. Most hospitalists are familiar with pertinent laws (e.g., EMTALA) and insurance company policies, thereby spending less time investigating and resolving problems. The hospitals benefits through improved throughput.
“We have a high-volume ED with a large percentage of unassigned patients. In addition our hospital census is often 120% at midday and 90% at midnight. Efficient flow of patients though the ED at all hours is a critical issue at our hospital,” says Patrick Cawley, MD, Director of Hospitalist Services at the Medical University of South Carolina in Charleston. “We have been asked to lead throughput initiatives which have resulted in a dramatic reduction in backlogs and the movement of patients out of the ED either to a bed or possibly to an alternative setting.”
The members of the medical staff of a hospital are often the driving force for the creation of a hospital medicine program. Having hopitalists at their institution may mean that affiliated physicians do not have to assume the undesirable responsibilities of participating in an on-call schedule. Furthermore, since hospitalists typically do not have an office practice, community physicians still have the opportunity to care for the unassigned patients once they are discharged, thereby building their practice. Hospitals can refer the patients according to an equitable schedule approved by the medical staff. By addressing issues related to on-call physician coverage, a hospital can improve medical staff relations.
At Winchester Medical Center in Virginia, family practitioners in the area surrendered their admitting privileges, creating an onerous call schedule for generalist internists. The hospital hired four hospitalists to admit and treat all unassigned patients. Instead of taking call, the internists are part of a primary care roster and rotate responsibility for unassigned patients once they are discharged (6). It has been a win-win solution for the hospital and the medical staff.
Often the unassigned patients have significant discharge planning and placement problems, especially those that are uninsured. While these issues can be daunting to the office-based physicians, hospitalists usually have a more comprehensive knowledge of the resources of the hospital and the community to help solve these placement and post-discharge care issues.
In treating unassigned patients, hospitalists blend their clinical skills with knowledge of their hospital’s objectives, concerns, policies, and procedures. Since they are a relatively small, cohesive group within the institution, hospitalists are often familiar with practice guidelines, medical records documentation requirements, computerized physician order entry (CPOE) systems, quality initiatives, and utilization management requirements.
“The hospitalists’ responsibilities in our program must have a good citizenship component,” says Winthrop Whitcomb, MD, Director of the Inpatient Medicine Service at Merry Medical Center in Springfield, MA and co-founder of the Society of Hospital Medicine (SHM). “Each physician must serve on a committee, a project, or a program that serves the hospital. Hospitalists are often the leaders of hospital-wide initiatives directed at quality of care, utilization management, and throughput.”
Stakeholder Analysis
By treating unassigned patients, hospitalists provide value to a wide range of stakeholders involved in the inpatient care process. The benefits to these stakeholders are summarized in Table 1.
Assigning Value to Hospitalists’ Work
Hospitalists typically manage unassigned and uninsured patients as part of their regular job duties. It is important that the administrator or leader of the hospital medicine group have a budgetary understanding of how to “score” the services that the hospitalists provide to these patients.