“As a hospitalist, I am employed by the hospital and have more of a stake in overall quality and cost-effectiveness of care,” says Justin Psaila, MD, of St. Luke’s Hospital in Bethlehem, Pa. “Some of the private attendings are doing their own thing and just see guidelines as creating more work.”
“Hospitals are looking for more standardized approaches to medical care via guidelines and order sets, and hospitalists can deliver this,” says Alex Strachan, Jr., MD, medical director for the Hospitalist Program at St. Joseph Hospital in Eureka, Calif., and medical director of Team Health West Hospital Medicine Programs. “There is a tremendous amount of teamwork involved in guideline implementation and use, and hospitalists are natural team players.”
In addition to working with facilities to develop and implement guidelines, hospitalists can help increase buy-in from other clinicians. This may involve working with facility leadership to develop materials to promote the guidelines to stakeholders, such as letters to attending physicians that outline how the guidelines will work, where they can obtain copies, how they can obtain electronic versions (if available), the advantages of using these tools, what to do if they don’t follow a step in the guideline (e.g., document the patient’s refusal to receive a particular treatment), and who to contact if they have questions about the guideline.
Despite all of the positives about guidelines and the growing number of physicians who use and embrace them, there continues to be some resistance to guideline use. “Many physicians still are hesitant to use guidelines,” explains Dr. Simone. “They feel as if they will lose some creativity and that it may obligate them to go in a particular direction.”
Even when a facility’s hospitalists are on board with guidelines, attending physicians—who usually are in the majority—who resist can prevent the documents from having a positive impact. Dr. Strachan offers an example: “If you have 50-100 medical staff admitting, they will use the antibiotics that they are most comfortable with—regardless of cost, staff time involved in medication administration, and so on. If even half of these buy into a guideline addressing antibiotic use, it can streamline medication management, administration, and costs considerably.”
Some physicians worry that guidelines put them at risk for lawsuits. “One physician said, ‘You put my back to the wall if I don’t do these things,’” says Dr. Simone. “However, good guidelines don’t set you up; they protect you. If you don’t follow a step or recommendation, you just need to document why.”
Often, some basic revisions can help overcome objections to guideline use. As Dr. Simone explains, “We had an order set that was five pages in length, and physicians balked at using it. They said that it was too complicated. So we winnowed it down to two to three concise pages, and now they all use it.”
He cautions that if guidelines are too confusing, complex, or long, they seem overwhelming and are less likely to be used.
Birth of a Hospitalist Guideline
While there are many clinical practice guidelines in existence that address a range of clinical issues and conditions, hospitalists and other physicians are more likely to use a tool they have helped create. Arun Tewari, MD, program director of the Hospitalist Program, Ball Memorial Hospital Medical Consultants, Muncie, Ind., has experienced this first-hand and has been involved in guideline development at his facility for the past three years.
“We’re just starting to track data, but we’ve already realized a reduced length of stay for all the pathways we use, including stroke, CHF, COPD, pneumonia, chest pains, MI, and GI bleed,” he says. “To date, the numbers are only statistically significant for pneumonia. However, we expect to see significant results in the other areas over time.”