Hospitalists at the University of Chicago Medical Center, like many of their colleagues, were being called increasingly often to consult on the care of surgical patients. Many of the calls were coming late in patients' hospital stays, after medical complications of surgery had developed.
Hospitalists Elizabeth Marlow, MD, and Chad Whelan, ACP Member, theorized that by seeing patients who were at high risk for surgical complications earlier in their stay, the hospitalist program could possibly reduce complications and length of stay without taking on the burden of full comanagement for all of the surgical patients.
In a pilot program with their orthopedics department, they reviewed the charts of patients scheduled for surgery, looking for several risk factors: age 75 or older, stage 3 kidney disease, diabetes, hypertension, congestive heart failure, and chronic anticoagulation. If a patient met any of the criteria, the surgeon was notified and a hospitalist consult was scheduled.
Dr. Marlow talked with ACP Hospitalist about the pilot.
Q: What motivated the development of this project?
A: We did the program with orthopedics because they were our highest-volume consultants, mostly with their joint replacement patients. We realized that we were getting called pretty frequently. Oftentimes we would get called a couple of days after whatever the concern was started. We thought if we could somehow work closer with [the orthopedists] to identify their patients beforehand that might benefit from our services, maybe we could improve their hospital course.
Q: How did you determine which patients should be seen?
A: It was clinical gestalt. [In] the papers that are out there, a lot of the variables that they have shown that are associated with complications after surgery are ones that you can't really intervene on, for example, low albumin. We came up with clinical criteria, for example, age greater than 75, chronic renal deficiency, hypertension, diabetes, other general medical issues, that could cause complications post-operatively.
Q: What medical problems did you typically encounter during the consults?
A: Oftentimes, it was medication reconciliation. We could help to clarify their outpatient medications—what medications, especially for anti-hypertensives, to resume post-operatively. Another area that we could help with was post-operative hyperglycemia—to start insulin management. But there were a lot of times that we saw the patients that we had identified and didn't really make any interventions. They actually ended up being quite stable post-op even if they had chronic renal disease and hypertension.
Q: How did the project affect hospitalist workload?
A: There really wasn't an increase in our workload per person. That was one of our motivations for the pilot. We also wanted to create more of a relationship with these surgeons so that we could generate more consults, not to make more work for ourselves, just to become involved with those patients. We felt that our volume was such that we wouldn't become overburdened.
Q: Did the project have an impact on patient outcomes?
A: We really didn't show anything with length of stay. That was the main outcome that we could look at and there really wasn't a difference. If you look at the outliers, maybe patients that were more medically complex, maybe we did shorten their length of stay, because we don't know what would have happened. It wasn't a randomized study. Hopefully, it would be some of the unmeasurable things [that we improved], like [patients being] discharged home on their appropriate medications.
Q: What difficulties did you encounter in implementation?
A: The system was hard only because of how it was constructed. We received a list from the surgeons of their surgical schedule. It took work to make sure that we got the list on time, and also patients were added to the [daily] list that weren't on the initial list. It was a lot of communication that was required to keep the system going.
Q: How does your system compare to typical comanagement?
A: If you have a hospitalist group that follows every single patient that's operated on by a certain group of specialists, the volume's so high. Are you going to get burnout? Are you going to get people who are unsatisfied with their jobs because they're not clinically diverse enough? I think automatic comanagement is also not ideal and that the answer is somewhere in between.
Q: What might that look like?
A: You need to have a better collaboration to be able to decide which patients benefit the most. It's having more of a blended system. I do think there's some gestalt on the surgical side, to say, “Hey, we really think we need a hospitalist involved.” To let that drive the system as well probably makes it better for both worlds.