He says his hospitalists fill a crucial gap that intensivists can’t: “We’re the only doctors who are here in the hospital 24 hours a day—besides the ER doctors.”
Dr. Hoffman believes it’s more important to focus on outcomes than to adhere to strict Leapfrog standards. His HM group, comprised of half family medicine-trained, half internal medicine-trained hospitalists, emphasizes teamwork, evidence-based protocols, and bonuses tied to quality outcomes and patient satisfaction.
In many smaller community hospitals, HM groups must do what works to simply provide coverage. Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in Cortland, N.Y, who also works as a hospitalist, says, “The people who are here around the clock are the hospitalists, so they also do the ICU management.” Last summer an intensivist who joined his hospitalist team provided ICU coverage five days a week.
Dr. Rohr believes hospitalists must acquire skills in mechanical ventilation and placement of central lines, and have high-level knowledge of infectious disease. For most ICU patients, however, this type of care is “basically internal medicine pushed to extremes,” he says.
Advantages and Disadvantages of Shared Responsibility
Under a co-managed ICU model, hospitalists can offer benefits beyond their direct time on the unit, says Hugo Quinny Cheng, MD, associate clinical professor in the Division of Hospital Medicine at the University of California at San Francisco. Dr. Cheng says his colleagues can provide more continuous care to patients because they rotate less frequently than do intensivists. In addition, hospitalists may have a broader view of hospital-wide systems and often can maximize ancillary services, such as physical therapy or nutrition, when it’s most appropriate for the patient, Dr. Sharpe adds.
One possible downside to a co-managed ICU, however, is confusion about responsibility. “In a critical care setting, ambiguity can lead to bad outcomes,” says Dr. Sharpe. To avoid this, make all ICU policies and procedures collaborative and involve all providers, including ancillary staff, in the process. “The clearer those guidelines and boundaries are, the easier it is for everyone,” he emphasizes.
For the most part, offering ICU rotations is a useful recruiting, hiring, and retention tool.
“Many hospitalists enjoy critical care and enjoy the opportunity to take care of very ill patients as part of their day-to-day practice, as long as they’re not in over their heads,” Dr. Sharpe says.
Preparation for the Future
Physicians have differing ideas about how intensivist-hospitalist relations will look in the future and what role hospitalists should play in the ICU. R. Neal Axon, MD, assistant professor in the departments of internal medicine and pediatrics at the Medical University of South Carolina in Charleston and a Team Hospitalist member, has worked in both academic and community settings. In the former, a pulmonary critical care specialist with a team of fellows, residents, and students ran the high-intensity ICU. In a local hospital where he worked as an attending, “there was no critical care team, per se. The hospitalists were the critical care team,” he says. “The difference in the care setting was pretty dramatic.”
Dr. Axon believes it might be a better long-term solution (in light of continuing critical care workforce shortages) to pursue formation of a fellowship program that combines advanced training in hospital medicine and critical care medicine.
Robert M. Wachter, MD, professor and chief of the Division of Hospital Medicine, associate chairman of the Department of Medicine, and Lynne and Marc Benioff Endowed Chair in Hospital Medicine at the University of California at San Francisco, and author of the “Wachter’s World” blog (www.the-hospitalist.org) says it’s a matter of whether hospitalists have enough intensive care training to work in the ICU.