This model, devised at Johns Hopkins Bayview Medical Center in Baltimore, enabled communication between ED doctors and hospitalists, and reduced wait times by more than two hours when a bed was available.2 This triage and direct-admission protocol was not associated with increased mortality and resulted in improved patient and physician satisfaction. (See Figure 2 at right). Once the ED attending decides to admit a patient, direct communication is facilitated with a hospitalist. The approach includes monthly meetings between the department of medicine and the ED to continue to discuss improvements in admissions.
At Norwalk Hospital, the administration asked the hospitalist group to intervene in that throughput process. But Dr. Orlinick, also a clinical instructor of medicine at Yale University in New Haven, Conn., says they’ve hesitated out of sensitivity to their ED colleagues.
“We as a group have really struggled with that concept because [although] we feel like that is something we can do well, this is really within the purview of the emergency medicine docs,” says Dr. Orlinick. Adopting the Johns Hopkins model is a win-win solution where each specialty is providing its best skills to solve mutual issues. “What we can do well is look at the patients … on the floor[s], look at flow through the hospital systems in terms of getting testing; make sure that all that—and consults—happen in a timely manner, and that people leave the hospital when they’ve reached their goals of hospitalization,” he says. “It’s afterload as opposed to preload.”
Hospitalists see committee collaboration as important to solving the complex multidisciplinary systemic issues. Jasen W. Gundersen, MD, participates on a pneumonia task force with several hospitalists, a pulmonologist, and one of the heads of the ED. “We address the whole gamut from when patients come in to when they go through the hospital,” says Dr. Gundersen, head of the Hospital Medicine Division, University of Massachusetts Memorial Medical Center, Worcester. “We can learn from each other as we go through the process.”
Many of the ways hospitalists and ED physicians tackle systems-related issues are new to Dr. Glasheen’s institution because the hospital medicine program was begun in 2004. It is now common to see higher-level leadership from different specialties and areas all in the same room—talking about issues of capacity, for instance. There are also many more instances of hospitalists and ED physicians sitting on the same committees. Further, “It is relatively common for our ED to call our hospitalists to say, ‘Can you help see this patient? I’m not sure what to do,’ or, ‘I’ve got this situation with this patient, this needs to be done and I need help getting that done,’ ” Dr. Glasheen says. Even though he concedes that is more of a workaround as opposed to a solution for a faulty system, it still represents ED physicians and hospitalists co-managing that workaround.
The Future
Because he “sits on both sides of the fence” between emergency medicine and hospital medicine, Dr. Gundersen thinks it is especially important for hospitalists to train in all the different areas—including emergency medicine—when they are medical students and residents.
Emergency medicine physicians Dr. Hoekstra and Benjamin Honigman, MD, professor of surgery and head of the Division of Emergency Medicine at the University of Colorado School of Medicine, Denver, believe hospital medicine will be integral to that training. Dr. Glasheen, also the director of the longest-running internal medicine hospitalist-training program in the U.S., expects greater attention to hospitalist training. “My sense is that many hospitalists groups are in a growth phase and are trying to solve their own problems,” he says. Basically, their primary focus is staffing the hospital with good people and retaining them. He believes that once groups have been around for three to five years, they are more likely to take on bigger issues, such as hospital efficiency and capacity management.