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In this month’s What's New in the Patient Safety World column “Surgeon On-Call Shifts” we noted how the length of a surgeon’s on-call shift can impact patient outcomes and costs of care. It turns out that shifts of hospitalists, likewise, are important in influencing patient outcomes.
A recent study showed that patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization (Goodwin 2019). Goodwin and colleagues note that discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient’s hospital stay and hypothesized that poor continuity of care during hospitalization may be associated with poor patient outcomes. They then did a retrospective study, using a formula with a weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days,
In the lowest quartile for continuity, hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days, compared to 67% to 100% in the highest quartile for continuity. Compared to those in the lowest quartile, admitted patients cared for by hospitalists in the highest quartile had lower 30-day mortality after discharge (adjusted odds ratio 0.88), lower readmission rates (adjusted odds ratio 0.94), higher rates of discharge to the home (adjusted odds ratio 1.08), and lower 30-day post-discharge costs (−$223). The findings were consistent in several sensitivity analyses.
Hospitalists offer several important contributions to patient care. Since they are in the hospital, they are particularly good at steering patients through the complex world of testing and consults, thus promoting more efficient care and shorter lengths of stay. They also are more readily available to attend promptly to changing patient conditions and to interact with families of hospitalized patients. But, at the same time, several studies have shown care by hospitalists compared with care by primary care physicians is associated with higher readmission rates, higher costs after discharge and lower rates of discharge home (we discussed one of those papers by Kuo and Goodwin (Kuo 2011) in our September 2011 What's New in the Patient Safety World column “Shiftwork and Patient Safety”).
Handoffs are critical when inpatient hospital care is rendered by someone other than the physician who will be primarily managing the patient after discharge. A good hospitalist keeps the PCP (or other physician who will have primary responsibility after discharge) apprised of the patient’s status not just at discharge, but throughout the course of the hospitalization. We’ve also noted the critical importance of communicating tests pending at discharge so that significant test results do not “fall through the cracks”. Also, in our December 20, 2016 Patient Safety Tip of the Week “End of Rotation Transitions and Mortality” we speculated that an increase in mortality was noted for patients hospitalized around the end of rotation for medical housestaff might also be seen with similar transitions for hospitalists.
Note that it’s not just continuity
through shift assignments that may impact patient outcomes. How patients are
assigned to hospitalists may also play a role. A recent study looked at the
impact of geographic cohorting on hospitalist activity (Kara
2019). By geographic cohorting we mean assigning hospitalists to patients
on one or two units. The researchers hypothesized that geographic cohorting
would increase direct patient interactions, a positive phenomenon, but would
also increase interruptions, a negative phenomenon. They then did a time-motion
study study that proved them to be right. Geographic cohorting was associated
with longer durations of patient visits. Interruptions were pervasive. Morning
interruption rates were comparable between the two groups, but the highest
interruption rate of once every eight minutes in the afternoon was noted in the
geographic cohorting group (compared to once every 17 minutes in the
non-geographic cohorting group). However, they also found changes in workload
might have a significant impact. Increasing patient loads were associated with
shorter visits, but geographic cohorting, increasing patient loads, and increasing
numbers of units visited were associated with increased indirect care time.
Geographic cohorting hospitalists were observed spending 56% of the day in
computer interactions vs 39% for non-geographic cohorting hospitalists. The
percentage of time spent multitasking was 18% for geographic cohorting
hospitalists and 14% for non-geographic cohorting hospitalists.
We also discussed the impact of hospitalist workload on patient care and costs in our May 2014 What's New in the Patient Safety World column “Hospitalist Workload Impact on Care and Cost”.
Kuo Y-F, Goodwin JS. Association of Hospitalist Care with Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study. Ann Intern Med 2011; 155: 152-159
Kara A, Flanagan ME, Gruber R, et al, A Time Motion Study Evaluating the Impact of Geographic Cohorting of Hospitalists. J Hosp Med 2019; Published Online First November 20, 2019
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