“While the physician in the hospital is highly trained to deal with the unique clinical needs of that patient, it is also important that the team treating the patient has all relevant information from all clinicians who may have treated the patient prior to the acute episode,” he says.
“It is also critical that when the patient is discharged that there is as seamless transition back to the system that will continue to care for that patient. Those handoffs may or may not be working well.”
The handoff, to and from the hospital, is one of the most risk-fraught areas for patients. So what is gained from the specialized skills of hospitalists might be lost if transitions from the hospital are not done well, Dr. Wise explains. “The hospitalist concept, while adding a new level of expertise, also increases the fragmentation of care and, therefore, can lead to some increased risk,” he says. “That risk is mitigated by well-functioning systems that can both initiate and accept the transfers.”
The use and mastery of the electronic medical record is crucial to the successful handoff, he adds.
“Another issue that is often discussed is whether, as the number of [hospital]-employed physicians increase, that will impact the medical staff’s freedom to constructively challenge hospital administration or the board concerning issues of quality and safety,” Dr. Wise says. “While this remains a theoretical issue, as the number of medical staff members employed by the hospital increase, [it is important] that their voices on the issues of quality and safety of medical care remain unimpeded.”
He also says that the speed of the growth of the hospitalist field comes with a certain amount of risk.
“The current hospitalist system attempts to assure that seriously ill patients are being treated by physicians who are current and competent in the complicated, high-tech environment of the 21st-century hospital,” he explains. “It will take time to develop a number of the supporting systems. If the speed of growth is very rapid, it is possible that the supporting systems, both inside and outside of the hospital, will not be able to keep up. None of these possible problems are insurmountable, but all will take a significant amount of attention and resources to support this method to deliver care.”
—Robert Wise, MD, medical advisor, Division of Healthcare Quality Evaluation, The Joint Commission, Washington, D.C.
Orthopedic Surgery
Older orthopedic patients are at serious risk after surgery, but their chances are improved by the work of hospitalists, says Alexandra Page, MD, a member of the American Academy of Orthopaedic Surgeons’ National Health Care Systems Committee and a surgeon with Kaiser Permanente in La Jolla, Calif., who works with geriatric patients.
A major role of hospitalists in support of orthopedic surgeons is to help patients be “as tuned up as they can be prior to surgery,” she says.
For octogenarians, there is a 25% mortality rate in the year after a hip fracture. For a nonagenarian, the one-year mortality rate is 50%.
“That’s a real high risk, and we don’t even in orthopedics have a good sense of what those factors are that make them so high-risk,” says Dr. Page, adding that it is known that optimal levels of glycemic control can minimize perioperative complications like infection.
That makes it all the more important for hospitalists to get patients into the best shape possible. After the operation, hospitalists help control blood pressure and blood sugar, and take steps to minimize post-operative delirium.