By: Lauren Doctoroff, MD
Much has been written about the loss of the perspective of the primary care doctor for hospitalized patients and the impact on their hospitalization. However, few have reflected on the challenges posed by the 7 on/7 off hospitalist schedule for complicated long-stay patients.
I have been a hospitalist for more than 10 years, and, for the past 3, I have been responsible for a complex patient strategy for my hospital. Having looked at the charts of hundreds of patients with long and complicated hospital stays, it is clear that there is an incompatibility between the on again/off again hospitalist schedule and the needs of these patients.
With frequently changing providers, patients suffer not only from their own medical fluctuations, but also the changing plans of their providers. These are not the patients awaiting guardianship or insurance to allow for an adequate discharge plan. These are the patients who have ping-ponged between the floor and the ICU. Or who have spent 15 days on the surgical service before being transferred to medicine for new atrial fibrillation. Or who have opiate use disorder, and are on hospital day 12 for treatment of an epidural abscess with complicated pain management needs, and another 6 weeks of IV antibiotics.
What does this phenomenon look like? I may hand off a patient whom I think will be ready for discharge in 2 days after one more dialysis treatment following a 27-day hospitalization for acute hypoxic respiratory failure complicated by new renal failure. But the next hospitalist assuming his care may require more time to acquaint himself with the case. Or work up the worsened anemia. Or want to wait for him to wean off of oxygen. So that planned discharge is pushed out another 3 or 4 days. Added to this challenge is the possibility that a patient whom you know will not be discharged during your stint may end up with a less clear plan at the end of the week than another as you spend more time tying up loose ends for the patients with clearer, easier to answer questions.
This is not a challenge only for general medical patients, but also for patients with prolonged heart failure or cirrhosis hospitalizations.
As more long-stay patients are hospitalized at academic urban medical centers1, this challenge is more acute for academic hospitalists but to some extent affects all hospitalists and accordingly, all patients. Even though overall length of stay has decreased nationwide, trends among outlier patients are far less well-researched. In our hospital, despite an initiative to reduce length of stay, we have successfully reduced length of stay for patients with short lengths of stay but have not yet had an impact on our long-stay patients. This phenomenon may be buried in the overall length of stay data.
What can be done to ameliorate this problem?
Developing a dedicated ward with designated staff who work for longer stretches is one option. Staffing with NP/PAs to provide more continuity is another. Providing just weekend coverage to allow staff to work more weekdays in a row may help. The continuing trial in Chicago examining the effect of a single physician, akin to a traditional primary care doctor but with a smaller panel and a practice breadth across all sites for a high-risk group of patients, may provide further insight into the benefit of physician continuity.2 All of these solutions would require significant changes in the law of the land in the hospitalist world – the 7 on/7 off schedule.
In the likely event that this wholesale change is not within the realm of possibility for your hospital or your group, then greatly augmenting and enhancing the transitions for patients with prolonged complicated hospital stays may help. Enhanced handoffs may include in-person transition from one provider to another or enhanced standardized documentation with an opportunity for open discussion.
Discharge plans for these patients often require a multidisciplinary approach. Determining if there is a better way to document and propagate the other aspects of the plan with case management, social work and other ancillary providers may also improve care continuity. This enhanced handoff may describe your standard handoff, but for many hospitalists, in-person detailed handoff is not routine.
Hospitals – and increasingly hospitalists – are increasingly assessed by the value we provide. 25% of the current value-based purchasing for hospitals relates to the cost of care. Thus, our work to efficiently care for this complex group of patients with prolonged hospitalizations is key to the value proposition for hospitalists. This need may require some hospitalist groups and hospitalists to significantly change their scheduling and care model.
- Doctoroff L, Hsu DJ, Mukamal KJ. Trends in Prolonged Hospitalizations in the United States from 2001 to 2012: A Longitudinal Cohort Study. Am. J. Med. Apr 2017;130(4):483 e481-483 e487.
- Meltzer DO, Ruhnke GW. Redesigning Care For Patients At Increased Hospitalization Risk: The Comprehensive Care Physician Model. Health Aff. (Millwood). May 1, 2014 2014;33(5):770-777.
As a hospitalist NP, the continuity issue would be the same. One exception might be if you have a model where an advanced practice clinicians works a traditional 5-day a week schedule. Most HM groups work on a block model including the APCs.
We all find that long-stay patients to be a big challenge, sometimes they seem to undergo one complication after another. I think other block scheduled groups have tried to have long stay patients stay with the same set of duo-teamed providers whether they are physicians or APCs.