Sign-offs, change of service, handoffs, inter-shift communications. Whatever the euphemism used, these occurrences symbolize the stigmata of disruption in the continuity of care for the hospitalized patient. The medical literature is saturated with studies pointing to the universal fact that disruption in the continuity of care leads to medical errors, and this ultimately contributes to compromise in patient care and safety. The New England Journal of Medicine article demonstrating that mortality rates are higher on the weekends than on weekdays is just a hint of the negative consequences that result from the disruption of the continuity of care in hospital medicine.1
Disruptions in continuity of care have been viewed as a necessary evil by the medical community. There is an ever-present diametric pull between physician hourly workload and continuity of care. Is the full potential of the hospitalist model undermined by the disruption in continuity of care? As hospitalists, we are fully aware of the inherent benefits of being in-house in terms of delivering efficiency and quality of care. Unfortunately, the weakness inherent in the hospitalist model has been the fragmented delivery of care it provides—a problem that is primarily due to the multiple changes in physician care that set it apart from the continuity of care that a primary care physician model can deliver. In the traditional primary care physician model, a patient is under the care of the primary care physician during hospitalization, with 24/7 pager coverage and occasional weekend sign-ons and sign-offs.
Decatur (Ill.) Memorial Hospital (DMH) is a 350-bed hospital; our facility serves a community of 100,000 and acts as a tertiary center for the smaller medical facilities in the collar counties. All specialty services are represented, including invasive cardiology, interventional radiology, neuro-interventional radiology, cardiothoracic surgery, and neurosurgery. Currently DMH Hospitalist Services has four physicians (with the addition of two more hospitalists planned for July 2007), two physician assistants, and an office manager. DMH Hospitalist Services utilizes a one-week-on/one-week-off system. Because Decatur has no traffic congestion, all hospitalists live 10 to 15 minutes from the hospital by car.
DMH staff from left to right: Elaine Rynders, PA-C; David J. Yu, MD, FACP; Jennifer Augenbaugh; Nicoleta Speil, MD; Larry Holder, MD,FACP; James Neviackas, MD; and David Gose, PA-C
We in Hospitalist Services advocate a paradigm shift: Continuity-of-care disruptions should be minimized by eliminating the process entirely. We didn’t want to improve the sign-off process; instead, we eliminated it. We don’t use the traditional hospitalist model of shift work. Rather we have affected a marriage of the primary care physician model and the hospitalist model, utilizing the advantages of both models in a hybrid system.
In our model, we have eliminated the daily sign-off and sign-on process altogether. The only time there is a sign-off and sign-on is on a weekly basis, when the new service starts its weekly shift on Monday mornings. Instead of the 14 handoffs required in a week for a nocturnist shift model, there is only one physician sign-off and sign-on per patient per week. Because the number of handoffs has been reduced from 14 to one per week, the change of service sign-outs on Monday are performed face to face and at a deliberate pace, with sign-out averages of 15 patients sometimes taking a full hour or more. This luxurious pace is not possible with multiple handoffs per day.
For the patient admitted and discharged between Mondays, there is no disruption in continuity of care in terms of physicians. The hospitalist who accepts the patient on Monday morning will be on pager call for the patient until the next Monday morning when he or she signs off for the week—or until the patient is discharged, whichever comes first.