Co-managing patients is an attractive concept: you draw upon the special knowledge, expertise and skill sets of more than one physician to provide the optimal care for your patients. Theoretically, such a synergistic approach should produce a result that is greater than sum of the parts – that two physicians are more likely to ensure the patient gets all the evidence-based care that is appropriate. But, in reality, is that what occurs? Sometimes co-management leads to a false sense of security that someone will remember all aspects of care.
On the outpatient side there are lots of examples where co-management by a primary care physician and a specialist results in less optimal care than that provided by either alone. We’ve seen the diabetic patient whose LDL elevation goes unaddressed because both the PCP and the endocrinologist assume the other is addressing it. Or the CHF patient whose blood pressure is still above target because the cardiologist and the PCP each assume the other is managing the blood pressure.
On the inpatient side, the co-management is most often done by a surgeon and a hospitalist or geriatrician. Nursing staff may be confused about whom to call for problems. The lab or radiology may not know whom to contact with critical or unexpected values. Patients and families frequently become confused about who their doctor really is and whom to go to when they have questions.
The hospitalist might be addressing medical issues such as glycemia management but might have a different glucose target than the surgeon who is concerned about surgical site infections. DVT prophylaxis approaches may differ between internists and surgeons but the rationales used by each need to be discussed with each other and then one should be assigned the responsibility of managing the DVT prophylaxis.
Whenever responsibility becomes “shared” we know there are certain dangers we may encounter. Two weeks ago, in our Patient Safety Tip of the Week “Slipping Through the Cracks”, we noted that appropriate timely follow-up to alerts about potentially significant radiology findings was twice as likely not to occur when dual alerts (i.e. alerts to more than one physician) were sent out.
Similarly, another point we have made over and over – double checks are very weak safety interventions. From all industries we know that the error rate when a supervisor checks someone else’s work may be 10% or higher. Note also that we don’t know what influence the double check has on the error rates of the original person. It is quite conceivable that the original person may make more errors if they feel that their errors will be intercepted by a second reviewer. In our May 2008 What’s New in the Patient Safety World column “UK NPSA Alert on Heparin Flushes” a study did acknowledge the controversy regarding double checks but notes that the literature supports a medication error reduction of about 30% when using a double check system.
Note that the second reviewer need not be a person. We have certainly seen in some technology solutions that staff become so confident in the computer’s ability to capture errors that their own vigilance may wane. There certainly have been numerous cases where a nurse administers too high a dose of a medication because the barcoding/bedside medication verification system “confirmed” that it was the correct patient, the correct medication, and the correct dose (i.e. the dose that had been ordered).
So there are lots of examples where dangers exist when two physicians are managing the same patient. But there are also lots of examples where co-management has been successful. A study from the University of Rochester in the most recent issue of Archives of Internal Medicine (Friedman et al 2009) looked at outcomes in a geriatric fracture center in a community teaching hospital where patients are co-managed by a geriatrician and an orthopedic surgeon. Compared with similar patients managed at a similar center without co-management, outcomes with co-management showed shorter times to surgery, fewer postoperative infections, fewer total complications and shorter lengths of stay. There were also fewer cases of delirium and restraint use in the co-managed group. Note that the co-managed model also relied heavily on care protocols and standardized order sets and focused heavily on measures to help avoid delirium or use of medications known to affect mental status. Involvement of geriatricians or hospitalists in orthopedic programs has also been of benefit in other studies done in the US (Pinzur et al 2009) and the UK (NHS 2009), including improvements not only in hospital efficiencies but also in patient satisfaction.
So co-management, if done correctly, does provide the opportunity to improve outcomes in many cases. Interestingly, whereas logic would predict the biggest impact of co-management would occur in patients with the most complex medical problems, some have anecdotally seen the biggest impact in those patients who were less sick (Butterfield 2009).
If you are going to co-manage patients, there are several recommendations we have for you:
· Make sure there is a true need for the “co-manager” (eg. if you just need someone to write orders while the surgeon is in the OR, a physician extender is a more logical choice but if you have a complicated patient with diabetes, CHF and chronic kidney disease the expertise of a hospitalist or geriatrician may be invaluable)
· Clearly define roles up front (who will manage what aspects of care)
· Define those roles in writing so the nursing staff (and others) know who to call for each problem
· Establish key goals (eg. glucose targets) to ensure you are all on the same page
· Clarify who will speak to family regarding what aspects of care
· Clarify who will communicate with those physicians who will be providing care after discharge
· Make sure your CPOE/clinical decision support system directs alerts to the appropriate physician and be very wary about “dual” alerts
· Make sure the lab (or radiology or other department) know whom to contact with critical values
· If you are co-managing perioperative patients, try to involve the hospitalist or geriatrician preoperatively, not just postoperatively
· Standardized order sets and standardized protocols are still valuable tools even for co-managed patients (eg. so both physicians don’t assume the other will write the order to discontinue the urinary catheter!)
· Co-management is particularly likely to be helpful in patients at risk for post-op delirium (see our Patient Safety Tips of the Week for October 21, 2008 “Preventing Delirium”, October 14, 2009 “Managing Delirium”, February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”, and March 31, 2009 “Screening Patients for Risk of Delirium”)
Co-management can improve the quality of patient care and outcomes. But, like most other things in healthcare, it has the potential for unintended consequences. You need to be wary of these upfront and design your systems to help avoid them.
Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a Comanaged Geriatric Fracture Center on Short-term Hip Fracture Outcomes. Arch Intern Med. 2009;169(18):1712-1717.
Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist–Orthopedic Co-management of High-risk Patients Undergoing Lower Extremity Reconstruction Surgery. ORTHOPEDICS 2009; 32: 495 July 2009
NHS Institute Orthopaedic Programme Improves Quality Of Care In 12 Weeks, UK
Medical News Today. 15 Oct 2009
Butterfield S. Surgical comanagement done right. ACP Hospitalist 2009; March 2009