Hospitalist: Long hospital stays are often due to poor planning

Being a hospitalist, I often see patients sitting in the hospital for days at length for no reason other than poor planning.

Sometimes I feel that physicians who are involved in patient care are oblivious of each other. Everyone is in their own domain rather than working as a team. An increased length of stay in the hospital not only increases the cost of health care but also adds to the risk of medical complications like infections and medical errors.

There are several factors which contribute to an increase in patient length of stay:

  • Lack of a leadership role by physicians involved in patient care
  • Delay from the time ER admits a patient to 1:1 contact by the admitting physician
  • Lack of proper follow up. For example, the patient is ready to be discharged but there is no confirmed follow up for labs. Some of these patients are doing nothing but waiting for labs which will not change management. These patients can be discharged with responsible follow ups
  • Some patients need transfer to rehabilitation centers. However, if they have Medicare as their primary insurance, then they can not be transferred as per Medicare rules.  They need to stay 3 days in the hospital before they are eligible for discharge
  • Unfortunately, a few physicians may keep their patients in the hospital for monetary gains
  • Lack of nocturnal hospitalist
  • Lack of support staff for procedures and tests over the weekends

Consider a patient with chest pain and was admitted at 5pm. He is not seen until the next morning by the admitting physician. He was ruled out for myocardial infarction but has an abnormal nuclear stress test and this requires a cardiac catheterization. In the meantime, a CT of the chest with contrast is performed to rule out pulmonary embolus. This comes out negative; however, the patient develops contrast nephropathy and acute renal failure. He also develops Foley catheter related urinary tract infection.

This is a typical patient may end up with an army of consultants: an admitting doctor who is either a hospitalist or an internist, a cardiologist for chest pain, a nephrologist for renal failure and an infectious disease consultant for the urinary tract infection.
The cardiologist would write in progress notes that he will perform cardiac catheterization when the patient’s kidney function improves, and the infectious disease consultant would like to wait until urinary tract infection resolves. On the other hand, the nephrologist could have already cleared the patient for cardiac catheterization but this has not been conveyed to the rest of the team. The hospitalist writes his daily notes but never takes the time to call and inquire about the plan. Now comes the weekend, where no procedures could be done.

By now 6 to 7 days have already passed, but since no one has reviewed each other’s notes, all is at a stand still. No single physician is ready to take a leadership role and everybody is just going with the flow.

A leadership role in patient care plays a significant part in appropriate patient management. Most of the time, we rely on the other person to take the initiative. When I once called a specialist who saw the patient at 9am to ask his opinion about starting plasmapheresis on a patient of thrombotic thrombocytopenia, the answer was, “I was thinking about it but I will ask the surgeon to put the line in the morning, as it is already too late in the day (7pm).”

The problem with this statement is, 1) this is a medical emergency which require immediate care; 2) if he was really thinking about it why was it not conveyed on time; and, 3) this is delay in care which increases the risk of developing various fatal complications.
I often witness a physician that comes up with a plan that is not communicated properly to the rest of the team. A lead physician needs to formulate a plan, communicate with other physicians in the team and decide what needs to be done in the hospital and what could be done outside the hospital. Considering the position a hospitalist is in, they should take that leadership role as they are eventually responsible to review not just one area but all aspects of patient care.

Hospitalists are known to rely on too many consultants. Every time a patient is admitted, there could be 3 or more consultants asked to see the patient. I respect the need for specialists and their expert opinion. I do rely on their recommendations, especially in this day and age of medico-legal medicine. But on the other hand, all kidney failures do not require a nephrologist, every anemia does not require a hematologist and requesting an oncology referral without a tissue biopsy results is waste of their time.

So what are the solutions for these problems?

  1. As we are moving towards the era of electronic medical records (EMR), a physician should be able to task other physicians, just as they can do it in the office utilizing EMRs, We can debate if these tasks should be part of medical records or not. This could substitute physician’s hesitation to call other physicians and allow all members of the team to review the proposed tasks for the day.  Whenever a physician opens the chart of a patient they should not be able to close the chart or sign out their orders or progress note unless those tasks have been reviewed or answered.
  2. There should be training workshops for physicians regarding the importance of a leadership role in patient care.
  3. We should hire full time discharge planners who can assist in scheduling  follow up visits with outpatient doctors and arrange for desired labs. These planners should be given access to add notes in EMR so concerned parties can review their work flow. (We could argue that case managers should do this job, but most of the times they are consumed with utilization review or with nursing home discharges; they do not have time to keep track of these things). These discharge planners need to be certified in a curriculum which provide them complete comprehension of these task and needs of patient and physicians.
  4. We should have more services available over the weekends for patients.
  5. Eliminate the Medicare 3-day rule regarding transfer to rehabilitation centers.
  6. Review the time between ER encounter to patient-admitting physician contact.
  7. Utilization of a nocturnal hospitalist in all hospitalist programs.

S. Irfan Ali is a hospitalist who blogs at Human Factor in Medicine and Life.

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  • Donald Green MD

    If the hospitalist is going to admit the patient, then they should be in charge. It is true, however, with multiple shifts the hand off could be less than ideal. Developing a system where more providers with divided responsibilities are put between the patient and their personal physician predictably dilutes out coordination and someone taking hold of what is done to the patient.

    Who knows, maybe taking care of your patient yourself at the time of their most intensive needs may have a comeback.

    It seems the true human element of direct conversation with all those taking part in treatment of the patient has taken a beating. This is what should be restored, not more rules for people not to follow.

  • J.T. Wenting

    OTOH there are scores who are sent home way too early and end up suffering (or dead) as a result.

  • http://drpauldorio.com Paul Dorio

    Good insight. Great topic! I agree that direct conversation doc to doc is essential. It is the lack of continuity of care that seems to be the big chink in the hospitalist chain. With frequent, i.e. shift-change, patient sign-outs and hand-offs, it is hard to see how the hospitalist could fulfill the role of Lead Physician. But, I agree that the hospitalist is in the best position to BE the Lead. Perhaps if one hospitalist were assigned to the same patient during the whole of that patient’s inpatient stay, with one additional individual covering at night, then the role of Lead would be effective.

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