call to action, we challenge emergency physicians and hospitalists to work together to develop .... in advance of) ED care, hospitalist to PCP/nursing facility at.
REVIEW
Emergency Medicine and Hospital Medicine: A Call for Collaboration Charles V. Pollack Jr., MA, MD, FACEP, FAAEM, FAHA,a Alpesh Amin, MD, MBA, FACP, SFHM,b David A. Talan, MD, FACEP, FIDSAc,d a Department of Emergency Medicine, Pennsylvania Hospital, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; bDepartment of Medicine, Hospitalist Program, University of California, Irvine, Irvine, California; c Department of Emergency Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, California; d Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California.
ABSTRACT BACKGROUND: In the United States, emergency physicians and hospitalists are increasingly responsible for managing hospitalized patients. These specialists share a common practice space and similar shift work schedules. Together they govern decisions about use of the most expensive care setting in medicine—the hospital. DISCUSSION: Unfortunately, in most institutions there is little collaboration between emergency physicians and hospitalists, resulting in missed opportunities to improve the quality of care and reduce its cost. In this call to action, we challenge emergency physicians and hospitalists to work together to develop protocols for consistent, evidence-based, and expeditious care of patients admitted from the ED; to collaborate in the care of ED patients who can safely be discharged home; to pursue joint quality, hospital leadership, and cost-effectiveness projects; to work in partnership to assure adequate staffing of hospital-based specialists; and to cooperate in the professional, front-line assessment of clinically and fiscally driven policies aimed at assessing the appropriateness of hospital admissions and readmissions. SUMMARY: Hospital care is increasingly driven by emergency physicians and hospitalists. We envision a vital role for ongoing collaboration between them in achieving the goals of patient care, education, and quality and safety outcomes. © 2012 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2012) 125, 826.e1-826.e6 KEYWORDS: Emergency medicine; Hospital medicine; Hospitalist; Quality; Reimbursement; Clinical protocols
INTRODUCTION Increasingly, emergency physicians and hospitalists are managing patients who are hospitalized in the United States (US). Currently there are approximately 30,000 emergency physicians and approximately 30,000 hospitalists in the United States, comprising two of the largest specialties behind primary care. In 2006, emergency departments (EDs) were the portal of admission for 50.2% of all nonobstetric admissions in the United States, an increase from 36.0% in 1996.1 An increasing proportion of medical service inpatients are admitted to hospitalists, who are now
This article will be co-published in the August 2012 issue of The Journal of Emergency Medicine. Reprint Address: Charles V. Pollack Jr., MD, Department of Emergency Medicine, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107.
0002-9343/$ -see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2011.12.005
present in 70% of US hospitals.2 The odds of a Medicare patient receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006.3 Emergency physicians also consult hospitalists on patients being considered for hospital admission, but who are subsequently discharged home with outpatient care plans. Hospitalists are also increasingly assuming responsibility for the care of intensive care and surgical patients.4 Emergency physicians and hospitalists share a common practice space and similar shift work schedules. They are often the only attending physicians present in the hospital after hours and, increasingly, at all times of the day. Together they govern decisions about use of the most expensive care setting in contemporary practice—the hospital. Despite these shared characteristics and joint responsibilities of emerging importance, in many hospitals there is little collaboration between emergency physicians and hos-
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wasted time in completing patient work-ups. Within some pitalists, beyond brief encounters discussing individual paEDs, hospitalists expedite admissions or facilitate safe and tients. These specialists do not routinely work together timely ED discharge of patients, just as they coordinate care globally, missing opportunities to examine evidence, deof inpatients to expedite their safe discharge. Emergency velop protocols for hospital admission, design referral prophysicians can start treatment plans early in an admitted grams for outpatient services that may allow avoidance of patient’s care (e.g., by ordering admission, conduct quality rerelevant studies, starting antibiotviews of co-managed patients, and ics) to improve the efficiency of assess ways to enhance communiCLINICAL SIGNIFICANCE inpatient care. cation on throughput, patient Improved decision-making handoffs, medication reconcilia● Why is this topic important? about the need for hospital admistion, and feedback regarding a paEmergency physicians and hospitalsion also enhances ED capacity. tient’s subsequent course. Given ists are responsible for utilization of Hospitalization is the most expenthe growing importance of shared many expensive hospital resources. sive medical decision made in the patient care between emergency ● What does this study attempt to show? context of ED care. Critically physicians and hospitalists, we beevaluating need for hospitalization lieve that improved collaboration In this call to action, emergency phyand identifying outpatient alternais both paramount and overdue. sicians and hospitalists are challenged tive plans for care can substanAn apt analogy would be the proto work together to develop protocols tially reduce costs. Hospitalists are cess by which tumor boards bring for consistent, evidence-based, and exthe link to the community’s pritogether medical oncologists, surpeditious care of patients admitted mary care network and can be of gical oncologists, pathologists, from the emergency department. tremendous assistance in identifyand radiation oncologists to deter● What are the key findings? ing effective outpatient care plans mine the best course for patients as alternatives to admission. Hosthey co-manage. In this article, we Too often there is little ongoing colpitalists are often knowledgeable identify areas of mutual interest, laboration between emergency physiabout outpatient care strategies and opportunities and actions that cians and hospitalists. There are multiple not typically utilized by emerwill improve patient care. general and disease-specific opportunigency physicians, such as periphties to improve transitions of care beerally inserted central catheter tween the two services across an evidence DISCUSSION (PICC) lines, outpatient parenteral basis. There are also many areas in which antibiotic therapy, and transfers to Shared Interests improved cooperation in administrative, skilled nursing facilities and hosImproved Efficiency, Optimizatraining, and financial issues would impice settings. Collaboration on the tion of Hospital Use, and Avoidprove the hospital work environment and, management of patients in clinical ance of Hospital Readmissions. ultimately, clinical care. decision units allows a short-term Boarding time for patients awaitED care plan to help further deter● How is patient care impacted? ing hospital admission is a primine need for hospital care. Hospital care is increasingly driven mary indicator of ED and hospital Avoidance of unnecessary admisefficiency. Median time from the by emergency physicians and hospitalsions will be increasingly imporadmission decision to ED deparists. We envision a vital role for ongoing tant as the CMS and other payers ture is one of the voluntary core collaboration between them in achievcontinue to focus on both 1-day quality measures of the Centers ing the goals of patient care, education, admissions and “inappropriate” for Medicare and Medicaid Serand quality and safety outcomes. admissions. vices (CMS). Prolonged boarding CMS and other payers are ties up ED resources, leads to demoving to a reimbursement model lays in care for new and existing that reinforces coordinated care, such as through bundled patients, and results in increased patient elopement, ambupayments. Hospitals will be penalized for same-diagnosis lance diversion, and decreased surge capacity. It has been readmissions within a specific time period; the most widely associated with increased hospital length of stay, adverse 5,6 deployed penalties to date are for readmission for heart events, errors, and lost revenue. Effective strategies to failure, myocardial infarction, or pneumonia within 30 days reduce boarding time largely rely on enhanced teamwork of hospital discharge. The first way to avoid hospital readand communication between ED and admitting staff control mission is to avoid an index hospital admission; many of non-ED hospital use. Increasingly, hospitalists govern strategies apply to both. Enhanced emergency physician and hospital capacity by their management of hospital admishospitalist coordination of effective outpatient management sions, inter-unit transfers, and discharges. Coordinated inprovides an alternative to hospital readmission for patients volvement of the hospitalist earlier in the management of ED-boarded patients can help ensure safer care and avoid who return to the ED. Protocolization and consistency in
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hospitalist discharges back to primary care physicians or rehabilitation facilities that maximize necessary patient and caregiver support, medication adherence, and appropriate follow-up will be instrumental in reducing avoidable admissions and readmissions. Quality and Safety Goals. Many established hospital quality and safety goals can be promoted through better emergency physician and hospitalist collaboration. The Joint Commission’s National Patient Safety Goals emphasize improved staff communication (e.g., through transitions of care from emergency physicians to hospitalist), and medication safety (e.g., developing systems for medication reconciliation). In addition to ED boarding time, core quality measures developed by The Joint Commission and CMS include many items for which shared responsibility exists between emergency physicians and hospitalists, such as management of community-acquired pneumonia, acute myocardial infarction, congestive heart failure, and stroke. Hospitalists increasingly manage intensive care unit (ICU) patients and, like emergency physicians, utilize procedural sedation, perform bedside ultrasound and invasive procedures, and manage mechanically ventilated patients. Coordination of efforts between specialists would help to establish best practice protocols, identify common equipment needs, and develop improved credentialing and safety monitoring processes. Transitions of Care/Communications Issues. In addition to the emergency physician– hospitalist patient transition at the time of admission, patients benefit from clear communication across other information interfaces, including primary care physician (PCP)/nursing facility to ED during (or in advance of) ED care, hospitalist to PCP/nursing facility at the conclusion of inpatient care, and communication to facilitate care coordination outside the hospital. Systematic transfer of information across these interfaces is critical to good continuity of care and reduces the likelihood of nearterm rehospitalization. Emergency physicians and hospitalists should work more closely together with information services and hospital administration to maximize the efficiency of such information transfers, to identify and strengthen weak links in the communication chain, and improve patient care across the continuum. Risk Stratification. Several clinical risk-stratification tools are used in the management of acutely ill patients, which may better inform the need for inpatient care and monitoring. Examples of validated scoring systems include the Thrombolysis in Myocardial Infarction Risk Score for Non-ST-SegmentElevation Acute Coronary Syndrome; the Pneumonia Severity Index (PSI), CURB-65, and SMART-COP scores for pneumonia; and various assessments for the likelihood of venous thromboembolism.7-11 The ED-to-hospital transition affords many opportunities for developing consensus on risk assessment and patient disposition protocols. These scoring systems offer a consistent platform across which communication be-
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tween emergency physicians and hospitalists about a patient’s need for hospital admission and the level of care required can be improved. Future of Bundled Payments/Diagnosis-Related Group Payments. As the payment mechanism for inpatient stays shifts from case rates and per diem payments to a bundled or diagnosis-related group payment model, inpatient services will need to work together to optimize resource use and throughput to protect revenue. Improved collaboration between emergency physicians and hospitalists is critical to achieving this success and providing optimal, evidencebased care in a manner that facilitates efficiency and improves the payer’s bottom line. Regulatory/Public Reporting Requirements. As public reporting of hospital data becomes more widespread and sophisticated, and patients, payers, and competing hospitals analyze them, the motivation for change in basic processes— such as the transition from the ED to the hospital—will increase. Organizations are already competing for better reporting of performance measures, while internally linking employee and provider incentive payments to achieving better scorecards. Examples of such parameters include the core measures for myocardial infarction, heart failure, pneumonia, and post-operative venous thromboembolism. Many times one specialty acting alone cannot meet all the requirements for a specific disease target. Core measures for community-acquired pneumonia are illustrative, because the timing of blood cultures and initial antibiotic therapy is largely the responsibility of emergency physicians, whereas ensuring that smoking cessation education and pneumococcal or influenza vaccine are given are in the domain of hospitalists. Staffing Support/Hospital Administration Comprehension of Mission. Staffing support for hospital-based specialties such as Emergency and Hospital Medicine is similar in that most have moved to a shift-based scheduling model, as used in nurse staffing. Over the years, Emergency and Hospital Medicine have developed their own guidelines for staffing, but as needs increase to meet aggressive quality, service, and outcomes goals, engagement of hospital administration is important. Further, hospitalists are often teamed with nurse practitioners, case managers, pharmacists, social workers, and nurses to meet the needs of throughput, quality, and error reduction. Multidisciplinary staffing must also be factored into the support requirements for Emergency and Hospital Medicine groups.
Opportunities Organized Collaboration. As hospital-based physicians, it is reasonable to expect emergency physicians and hospitalists to collaborate effectively and in an ongoing manner. There is much to be gained from regularly scheduled group interactions, with discussion of specific issues—such as “the pneumonia pathway,” “how to facilitate work-ups from
826.e4 the clinical decision unit,” “deployment of resources in sepsis patients”—for which both groups can be prepared in advance. It is also useful to regularly review difficult cases or circumstances encountered by the two services. Such regular collaboration fosters improved communication and promotes personal investment in making the system work better. Training Opportunities. Several opportunities exist for training to help practitioners better understand each other’s needs. Once in practice, hospitalists have a disproportionate experience in being contacted about patients presorted by emergency physicians thought to require hospital admission, but may be deficient in their experience evaluating the full spectrum of patients and factors that may affect disposition decisions. Internal Medicine residency rotations in the ED facilitate learning how to decide which patients should be admitted and which can be managed as outpatients, and how to start management of patients early in the ED. Emergency Medicine residents are spending time on ward medicine and ICU rotations, gaining an understanding of hospitalists’ many duties, ongoing management of patients, discharge planning, and quality-of-care issues. They also benefit from learning—from the inpatient perspective— common deficiencies in ED management of hospitalized patients and novel options for outpatient disposition. Some combined Emergency Medicine-Internal Medicine residency programs exist, which present natural opportunities for training of “super-hospitalists,” who work in both capacities and further promote coordination of services within centers. In teaching hospitals, joint educational sessions such as grand rounds and morbidity-and-mortality conferences between Emergency and Hospital Medicine groups foster an improved working relationship that optimizes the quality and efficiency of patient management. Opportunities exist for joint development of skills in leadership, teaching, research, and quality.12 Diagnosis-Specific Opportunities to Deliver EvidenceBased Care. Although the number and types of patients crossing the Emergency Medicine-Hospital Medicine interface continue to increase, there are some specific diagnoses for which guidelines help guide collaboration. We would expect that tighter adherence to guidelines would result in better patient outcomes, shorter lengths of stay, and fewer avoidable readmissions. Non-ST-Segment Elevation Acute Coronary Syndrome. Unlike ST-segment elevation myocardial infarction, which is typically managed briefly by emergency physicians and then by cardiologists, the more common non-ST-segmentelevation acute coronary syndrome is now often managed after admission by hospitalists, whether or not the patient undergoes catheterization while an inpatient. Published guidelines call for a number of diagnostic and therapeutic actions that readily lend themselves to inclusion in a protocol initiated in the ED and continued by hospitalists.13
The American Journal of Medicine, Vol 125, No 8, August 2012 Previous work has validated the success of quality-focused, guidelines-supported acute coronary syndrome care across this transition.14 Heart Failure. Many measures have been demonstrated to improve symptoms, decrease length of stay, and reduce the likelihood of costly short-term readmission for this increasingly common diagnosis.15 Initiation of “triple therapy” (diuretics, beta-adrenergic blockers, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker agents) is essential to quality heart failure care and can be driven by an Emergency and Hospital Medicine protocol, which, when followed, can be expected to improve both clinical and economic outcomes. Community-Acquired Pneumonia. Risk-stratification and disposition strategies for patients with community-acquired pneumonia are perhaps the best studied of any infectious disease diagnosis. The Agency for Healthcare Research and Quality-funded Pneumonia Patient Outcomes Research Team group developed and validated the PSI, a risk-stratification scoring system to identify patients with low 30-day mortality risk who may be safe to discharge for outpatient care or, alternatively, are higher risk and may require hospitalization.8 PSI use has been demonstrated to reduce pneumonia hospital admission rates safely. A simpler score used for this purpose is called CURB-65.9 SMART-COP and the Infectious Diseases Society of America guidelines are other tools developed to discriminate among higher-risk patients and guide the decision for ICU admission.10,16 Common awareness and consistent use of these schemes has the potential to ensure efficiencies in management and more optimal hospital resource utilization. Skin and Skin Structure Infections. With greater coordination among emergency and hospitalist physicians, and wound care resources, many more hospitalized patients with skin and soft tissue, and bone infections, could be treated effectively as outpatients. A long-acting antibiotic regimen could be initiated in the ED with arranged 24-48-h followup, with patients subsequently assessed for transition to oral antibiotics. For patients requiring a longer course of parenteral therapy, PICC and outpatient parenteral antibiotic therapy can be initiated from the ED.17-19 Sepsis. Quality standards for management of sepsis and septic shock are being promoted in hospitals. This movement is related to the dramatic mortality reduction demonstrated in a randomized trial comparing early goal-directed therapy (EGDT) to standard resuscitation.20 EGDT includes central venous and arterial pressure monitoring to guide fluid resuscitation and pressor use; its unique feature is sequential therapeutic interventions, including anemia-correcting blood transfusion, dobutamine, and mechanical ventilation, to increase sub-threshold central venous oxygen saturation (or, more recently, lactate clearance).21 Quality standards also include time posts for severe sepsis recogni-
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tion and administration of appropriate antimicrobials. Because these standards are being applied to both ED-presenting and in-hospital-onset sepsis patients, development of a common management protocol represents an important opportunity for Emergency and Hospital Medicine collaboration. Although successful ED-based strategies have been described, EGDT can be labor intensive and may be difficult to institute in busy EDs.22 Hospitalists can assist with expedited ICU transfer. Another model proposes an on-call sepsis management team.23 Emergency physicians and hospitalists should develop team-based management strategies for these and other critically ill patients. Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD). COPD is a common ED presentation that often results in admission and significantly contributes to readmissions. Emergency physicians and hospitalists should jointly develop pathways for COPD management so that appropriate therapy is started in the ED and seamlessly continued in the hospital. Hospitalist adoption of therapeutic strategies at discharge to lessen the risk of near-term exacerbation and ED re-visit should also be encouraged. Transient Ischemic Attack (TIA). TIA is a diagnosis that in the not-too-distant past was an automatic admission to Neurology. Now these patients are often managed by hospitalists and do not always require an inpatient Neurology consultation.24 Emergency physicians and hospitalists can jointly develop pathways for TIA that allow expeditious disposition. The logistics of prompt scheduling of, for example, Holter monitoring, echocardiograms, computed tomographic scanning, and carotid Doppler studies lend themselves to protocolization. Avoidance of admission may be achieved for many patients with a well-defined pathway initiated in the ED and continued by the Hospital Medicine service. Pain Management and Palliative Care. Pain is the most common reason patients present to EDs.25 Patients who require hospital admission for intractable pain are particularly challenging for both emergency physicians and hospitalists. An attitude of suspicion, lack of objective knowledge about underlying medical or surgical problems, and suboptimal transitions between ED and hospital and between hospital and continuing care combine to present formidable obstacles for effective pain management in the acute care setting. A consistent approach to analgesia by emergency physicians and hospitalists aimed both at improved understanding of patient needs and expectations for pain relief, and at patient education regarding pain, can improve outcomes and satisfaction.26 Likewise, patients who might best be managed with a palliative or hospice-based approach are often encountered at the emergency physician-hospitalist interface.27,28 Improved pain management strategies, early involvement of case managers, and protocol-driven, smooth transitions from hospital to hospice, or even from ED to hospice, would
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help decrease the inordinate expense of end-of-life care and reduce the frustration experienced by providers, patients, and caregivers in those difficult times.29 Hospitalists are often more familiar with hospice services than are emergency physicians, and closer collaboration for the development of a consistent approach to palliative care would be beneficial to all. Prophylaxis for Venous Thromboembolism. Venous thromboembolism (VTE) prevention is a national quality issue endorsed by The Joint Commission, Surgeon General, and many professional organizations. Well under one-half of hospitalized patients in the United States currently receive appropriate VTE prevention.30 Emergency physicians and hospitalists should work closely together to help ensure VTE prevention processes occur within the hospital setting, not only to promote better clinical outcomes, but also to avoid payment penalties and adverse public-reporting issues. This may lead to initiation of prophylaxis by emergency physicians, especially when ED boarding times delay initiation of routine inpatient orders. When evidence-based prophylaxis is not provided, patients with “preventable” VTE complications are readmitted to the hospital, thus leading to un-reimbursed “never events.”
CONCLUSION Hospitals today face unprecedented fiscal threats, given the increasing numbers of uninsured patients, unfunded federal and regulatory mandates, and scrutiny of health care quality that impacts both compensation and consumer choice. At the center of most hospitals’ efforts to manage these challenges is the interface between the ED and the hospitalist service. We propose that emergency physicians and hospitalists work together to develop protocols for consistent, evidence-based, and expeditious care of patients admitted from the ED; to collaborate in the care of ED patients who can safely be discharged home; to pursue joint quality, hospital leadership, and cost-effectiveness projects; to work in partnership to assure adequate staffing of hospital-based specialists; and to cooperate in the professional, front-line assessment of clinically and fiscally driven policies aimed at assessing the appropriateness of hospital admissions and readmissions. Care in the hospital of the future will be largely determined by emergency physicians and hospitalists. We envision a vital role for ongoing collaboration between them in achieving the goals of patient care, education, and quality and safety outcomes.
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