Responsibilities for new admissions and consults are divided into a 24-hour period, with the physician on call performing all the admissions and consults. During the next 24-hour period, the same hospitalist does not have any admission responsibilities. All new admissions are evaluated in real time by the admitting hospitalists; admissions between midnight and 7 a.m., however, can be evaluated in the morning at the discretion of the hospitalist in conjunction with the emergency department physician, who may write temporary holding orders. All critically ill patients are evaluated in real time.
We have found that there are some key advantages to our model. First, there is true continuity of care. As mentioned earlier, the admitting hospitalist will be the attending physician until the patient is discharged or until the following Monday morning when the relieving hospitalist accepts the patient.
Second, when the hospitalist is paged after hours, patient familiarity aids in the appropriate and efficient management of the patient, with reduction in unnecessary laboratory orders, redundant tests, and overcautious ICU transfers. “When our nurses call the hospitalist about their patients, especially in the evening and night shifts, the nurses are not wasting time and effort educating an on-call physician about the patient, but instead can focus on the acute medical issues at hand, knowing that the hospitalist intimately knows the patient’s background and current medical status,” says Chris Pope, RN, director of the Medical Nursing Unit at Decatur Memorial Hospital. “This gives confidence to our nursing staff that their interactions with the hospitalists will result in appropriate care delivered to the patient.”
Third, the hospitalist has a natural incentive to optimize patient care, knowing that a lackadaisical approach to patient care cannot be pawned to another physician at a later shift: The hospitalist has true ownership and attending status for the patient. I believe that the manner in which a hospitalist program’s infrastructure is set up plays a critical role in the hospitalists’ behavior. Just as collective farms in the communist system were far less efficient and more poorly run than privately owned farms in a capitalist system, hospitalist programs that have more of a collective approach to patient management may offer less motivation for the hospitalist.
Fourth, our relationships and ability to communicate with the patients and their families are strengthened because the confusion about exactly who is the hospitalist in charge of patient care has been eliminated with the removal of nocturnists and weekend coverage. We have found this to be one of the most rewarding aspects of this system because communication is the bedrock of any doctor-patient relationship and is especially important for the hospitalist, who must quickly develop a rapport with the patient. This success is reflected in the fact that our hospitalists have earned among them 20 Decatur Memorial Hospital Exceptional Service Recognition Awards from our patients in the last two years.
Fifth, the nurses and the primary care physician have a clear understanding of which hospitalist/attending is responsible for patient care. The nursing staff was initially shocked that there was no cross coverage, even on weekends and nights; the primary care physician, though, knows exactly which hospitalist is taking care of his or her patient, even after hours. In thinking about my time spent working at a major teaching hospital (a powerfully negative experience, by the way) I found there that, most of the time, I couldn’t get a clear answer from the internal medicine residents who were taking care of my patient. If I rounded early, the service had not picked up the patient from night float; and if I rounded in the afternoon, the service had signed out to the night float, and the night float had no medical knowledge of the patient. I made a personal commitment that this would not happen at DMH.