Avoiding the pitfalls of hospital medicine

Ten tips from a seasoned hospitalist.

Having spent most of my career as a hospitalist in the private sector, long before the term “hospitalist” was in use, I learned from my own mistakes and, over time, developed the insight to avoid common missteps. Later, as an academic hospitalist, I saw residents making many of the same management errors I used to make. Here, in my experience, are 10 ways to avoid the most common pitfalls.

Earn your patients' respect

Despite our clinical skills and extensive medical education, we cannot be effective clinicians unless we garner the respect of our patients. This is achieved primarily by assuring the patient that we will do whatever is necessary to diagnose and manage his or her problem and by being open and honest about what we know and what remains uncertain. Keeping the patient and family informed, in terms they can understand, is an important key to patient satisfaction and makes our own work more efficient, effective and enjoyable. Since hospitalists are not primary care clinicians and are often unfamiliar to the patient and family, such interaction is especially important.

When in doubt, admit

Over the past decade or so, an army of admission advisors, hired to enforce strict admissions criteria from CMS and private insurers, has pressured hospitalists to adhere to guidelines. While we must comply in principle, our primary commitment should be to the welfare of our patients. If certain symptoms or findings are worrisome, it is always best to keep the patient in observation status until a clinical picture is clarified. Of course, proper documentation of your concerns and clinical findings is essential.

Don't hesitate to consult specialists

For a variety of reasons (pride, cost concerns, hesitancy to bother colleagues), hospitalists are sometimes reluctant to obtain consultations. This is especially common during training, when residents and fellows are keenly aware of each other's workload and when they are more likely to meet resistance from the consulting trainee. However, consultations benefit everyone: We learn from the consultant's input, the consultant learns from the case and can bill for his or her services, and the patient is reassured.

Do not seek or accept curbside consults

While the advice of specialists is almost always helpful, consults should be formally obtained, ensuring that the consultant actually sees the patient, reviews his or her chart, and leaves recommendations in the form of a consultation note. Of course, the consultant should also follow the patient until the problem is resolving and document visits in follow-up notes. Anything less is unacceptable, and recommendations received during casual conversation—even if recorded in your own note—would be pure hearsay in a court of law.

Do more ABGs

If there is one lab investigation that is underused by hospitalists and residents, it is the arterial blood gas (ABG) test. This simple and relatively inexpensive test should be obtained on any patient with altered mental status and on all patients with unstable vital signs or with clinical signs of toxicity. Too often, a normal bedside oxygen saturation is accepted as evidence that the patient's respiratory status is stable, though it offers no insight into the patient's ventilation or acid-base status. Abnormal ABGs often prompt movement to the ICU before clinical signs of organ failure become evident.

Don't ignore lab results that don't fit your diagnosis

We hospitalists pride ourselves on our diagnostic skills but too often get locked into a diagnosis and management plan soon after admission. While we should not be sidetracked by the occasional lab error, a persistent unexpected finding should prompt investigation and a willingness to reconsider or expand our initial diagnosis. As discussed above, consultants can be very helpful in sorting through the confusion. We are taught to “treat the patient, not the lab results,” but ignoring an unexplained (and inconvenient) abnormality can place the patient's welfare at risk.

Err on the side of aggressive management

The initial signs of some fatal conditions (sepsis, pulmonary embolus, myocardial infarction) can be subtle; the only evidence of a developing clinical catastrophe may be minor changes in vital signs, patient confusion or suspicious lab findings. When in doubt, it is best to initiate aggressive management, including transfer to the ICU, until the diagnosis is clear. Of course, you should obtain appropriate cultures before initiating broad-spectrum antibiotics and review any contraindications for specific therapies, such as anticoagulation. You should obtain consultations, if warranted, as well. If cultures and imaging are negative, the aggressive management can be discontinued, but if you wait too long to begin such treatment, a preventable death might occur.

Don't neglect pregnancy testing

Since most hospitalized patients arrive through emergency departments, pregnancy testing is often documented by the time of admission. However, a number of patients are transferred from clinics, physician offices or outside facilities where such testing is not automatic. Any woman of childbearing age who has not had some form of sterilization surgery should have a pregnancy test on admission, regardless of her sexual history. The various medications and imaging we use can pose significant risk to a fetus and a simple pregnancy test can prevent unnecessary complications and lawsuits.

Make every effort to prevent delirium

Delirium is a common complication of hospitalization, especially in elderly patients, and it may significantly prolong the hospital stay. While not all cases are preventable, narcotics and benzodiazepines are common culprits and these drugs should be used with caution, if at all. Other measures that help reduce delirium incidence are natural day-night lighting, the continuous presence of family or friends, the removal of unnecessary lines and catheters, and regular assisted activity. Fall precautions (without the use of restraints) should be initiated, and the possible presence of infection should be investigated, as minor infections (even when not clinically evident) are a common cause of mental confusion in elderly patients.

Don't abandon your patient at discharge

While concerted, multidisciplinary efforts to avoid readmissions have become commonplace in our hospitals, hospitalists can do their part by ensuring good communication with the patient's primary care clinician and by making themselves available to patients and clinicians in the short term. Though routinely giving out your email address or cell phone number is not generally necessary, special situations might warrant such a gesture. In my experience, such generosity is rarely abused.