HOSPITALISTS IN 2010 EVOLUTION OR REVOLUTION

1. HOSPITALISTS IN 2010EVOLUTION OR REVOLUTION? Bilal Ahmed MD, FACP Associate Professor of Medicine Colleen T. Fogarty MD, MSc Assistant Professor of Medicine Ravi Bhati MD Assistant Professor of Medicine

2. Hospital Medicine has changed

3. HOSPITAL IN USA Almshouses of 19th century. Early 20th century: Charitable roots had to supported by a revenue stream �No Money, No Mission� Hospitals employed Nurses, Pharmacists, Anesthesiologists etc, but NO physicians PCPs �brought in business�

4. How we differ Physicians of record Outpatient MDs called in consultants for advice. Natural to American patients and Physicians, but distinctly unusual GPs not expected to come to hospitals. Specialist Wards

5. AMERICAN HOSPITAL CIRCA 1960-90 PCPs in Doctor�s lounge at 7:30 AM Hospital rounds till mid morning Returning at the end of the day Worked well: Patients/Physicians liked it 8-10 patients in hospital. Pace of hospitalization was leisurely

6. So what happened? 1983: Medicare moved to DRGs Hospitals wanted to shorten stays Physicians disconnected with DRG payments. Clash of interests. Technology allowed workups to be done as outpatient PCP�s average census dropped to 1-3 Patients in the hospital were extremely sick

7. So what happened? Meanwhile patients being cared for in the hospital were had not gone away Tremendous fragmentation PCPs less comfortable with clinical organizational aspect of Hospitals A new concept was born: Generalist who spends all day in Hospitals

8. Predictable Specialists focusing on organ systems and technologies. Specialties born due to new environments: ER, Intensive Care (Site Defined Specialties) HOPITALISTS are Evolutionary, not Revolutionary

9. The Present Inpatient/Outpatient discontinuity offset by continuity within the Hospital Hospitalists become experts at coordinating care in the hospital and provide a high level of access Re Branding: Not �experts� at getting people out of the hospital, but responsible for quality of care

10. SHM ProjectionsNumber of Hospitalists

11. New Horizons Limitation of Housestaff work hours Surgical Co-management Academic Teaching Committees Palliative Care Surgical/Neuro/Obstetrical/Pediatric/GI Hospitalists.

12. A Difficult Challenge for Hospital Medicine is the Transition of Care of Patients

13. VOLTAGE DROP

14. Transitions within the Healthcare Environment Let�s look at visual representation of transitions within the healthcare environment. Patients can transition from the emergency department to the hospital. They can transition between areas of the hospital, such as from the floor to the OR or ICU They can be discharged to different sites of care, such as to SNF, home or LTC They often follow up with primary care providers and specialists As providers, we tend to view health care delivery within sites of care, such as these (highlight 3 examples) Patients, however, experience episodes of illness across sites of care, such as these (highlight 2 examples) This shifts our perspective and allows us to understand transitional care.Let�s look at visual representation of transitions within the healthcare environment. Patients can transition from the emergency department to the hospital. They can transition between areas of the hospital, such as from the floor to the OR or ICU They can be discharged to different sites of care, such as to SNF, home or LTC They often follow up with primary care providers and specialists As providers, we tend to view health care delivery within sites of care, such as these (highlight 3 examples) Patients, however, experience episodes of illness across sites of care, such as these (highlight 2 examples) This shifts our perspective and allows us to understand transitional care.

15. A CASE IN POINT

16. Case Presentation-- History Ms. S is a 65 year old Spanish-speaking Cuban immigrant who presented for outpatient acute primary care visit at an inner city Square Community Health Center for evaluation of coughing and sore throat and URI symptoms. Medications: Tamoxifen, Omeprazole, Proventil HFA 2 puff q 4 hours prn, Acetaminophen prn N.K.D.A. Social history: Remote smoking history; no alcohol Born in Cuba; emigrated Cuba in her early 20�s Disabled due to congenital cardiac disease Family history: Divorced, Three adult daughters, 9 Grandchildren This slide has the Slide Design template �content� applied. The first level bullet has been set up with a �null� character to make it appear unbulleted and still allow automatic bullets for subsequent levels. The second through fifth levels have bullets: from the left margin, tab once (or click the �increase indent� button) and the second level bullet will appear; further tabbing increases the indent and produces the corresponding bullet.This slide has the Slide Design template �content� applied. The first level bullet has been set up with a �null� character to make it appear unbulleted and still allow automatic bullets for subsequent levels. The second through fifth levels have bullets: from the left margin, tab once (or click the �increase indent� button) and the second level bullet will appear; further tabbing increases the indent and produces the corresponding bullet.

17. Case Presentation-- History Past medical history significant for: Breast cancer--infiltrating ductal carcinoma; s/p mastectomy/radiation; Node negative 1995 Colonic polyps 1996, 11/28/2008; 7/09 Colon cancer 2008 Asthma Past surgical history : Endocardial cushion defect repair, 1989 Mastectomy Partial colectomy

18. Case Presentation-- History She was found to be wheezy, Oxygen sat % 95, Peak Flow 150-130-120 Given her history of asthma, was treated with ipratropium/albuterol nebulizer with good response. She was treated for outpatient asthma exacerbation with close follow-up. The day after her initial presentation, she was substantially better. The following week, although she had reported improvement with office nebulizer and finished prednisone and antibiotic, she was worse. She reports not feeling well and a "noise in throat.� Thought she might have felt heart racing.

19. Follow up visit, one week later� BP 101/68, HR 92, Wt 140.2 Oxygen saturation 93% General :�mildly ill appearing, alert and oriented.� Neck:�supple, no thyromegaly.� Heart:�RRR, normal S1S2, , II/VI systolic murmur at her baseline.� Lungs: minimal wheezing Peak Flow 160/180/180 Abdomen:�not tender.� Breasts:�L mastectomy scar present.� .

20. Follow up visit, one week later� I doubted the asthma was worse, but gave her a trial Duoneb. Repeat O2 sat 95, Repeat Peak Flow 190/170/160 Lungs exam after treatment: fine crackles at the very base of lungs, bilaterally. No wheeze or rhonchi.� Extremities:�perhaps a subtle trace edema.� Further history obtained:

21. Follow up visit, one week later� Admits to "walking here very slowly" today from home; further inquiry suggests increasing fatigue/decreasing ex tolerance. Denies edema. No F/C, cough. No n/v/d. When asked directly, she admitted to decreasing exercise tolerance and fatigue. Hx of endocardial cushion defect repair and some MR; review of 10.08 cardiology visit showed stable echo and clinical status. Pt denies any prior CHF dx or sx. EKG sinus @ 90 bpm. with Left axis deviation and LVH; no acute findings.� 

22. Next steps? Urgent, same-day visit at HH cardiology. Echocardiogram: worsening Mitral regurg mild aortic stenosis valve area of 1.6 cm2. Intervention: furosemide 20 mg bid transesophageal echocardiogram on Tuesday

23. Outpatient cardiology Echocardiogram showed worsening Mitral regurgitation and mild aortic stenosis with a valve area of 1.6 cm2. She was started on furosemide 20 mg bid and booked for a transesophageal echocardiogram on 6/15/2010.

24. Outpatient Cardiology Monday, patient appeared at cardiology office acutely dyspneic with palpitations and was found to be in rapid atrial fibrillation. She was sent to the emergency department and admitted for management of atrial fibrillation and acute congestive heart failure in the setting of an impaired mitral valve.

25. Inpatient Hospital course Admitted to Highland Hospital for correction of Acute Congestive heart Failure and management of Atrial Fibrillation. Goal was to stabilize patient and discharge her to home prior to surgical valve correction.

26. HOSPITALIST PERSPECTIVE RAVI BHATI MD Communication between the PCP and the Hospitalist caring for the patient is Critical Equally important is the communication between the members of the hospital staff. Talk about the case on W7 when the BA didn�t notify me of room change and I tried to pronounce a live person dead. It has been few months since the incident but it remains as one of the most memorable moments of my life. � I had an elderly patient (in her 90�s) who, after a prolonged hospital stay, �many active medical issues and several phone calls to the family, was made hospice. One day I saw the patient late evening and she looked �like she was going to pass away any moment. The following morning I get a call from the floor BA that the patient had expired and if I can come and pronounce her dead. I was not surprised about this and told the BA that I will be there in a few minutes. Unfortunately I was never told that my patient was moved to another room. � I walked in the room where I thought my patient was and saw an elderly women laying in bed � her face was turned away from the door so I didn�t see her. There were several family members in the room sitting next to her bed, they had just arrived to see the patient and didn�t want to wake her because she had a rough night. Not knowing she was a different patient, I grabbed a chair and sat next to the family and told them that the patient had died few hrs ago � they were all somewhat shocked (which surprised me a little) but admitted that she was too sick and knew this was coming; meanwhile the patient is sleeping soundly (not even snoring) and couldn�t hear our conversation about her death because she has hearing-difficulties at baseline. We talked about her life for about 15 minutes and the fact how she was a fighter and fought a cancer and many other medical conditions (unfortunately for me, this patient also had many of the same medical conditions). � I politely ask the family to step out so that I can pronounce her dead, they did. I grabbed and turned the patient and all of the sudden I see TWO LARGE EYES glaring at me in a surprise. I almost fainted. . . . few seconds later It hit me like a brick and I knew I had a mess in my hand. Lucky for me, family and the patient had good sense of humor and they all laughed when I told them what happened (of course I was just sweating, not laughing much at the time) . . . . while I was walking out the room the patient called and told me �can I make a request, can you please come to pronounce me dead the NEXT TIME I DIE�, she had a smirk on her face when she said this. I told her �madam I am never coming close to you ever again� . . . . � J Lucky for me it ended well but could�ve ended in a bad way. . . . Talk about the case on W7 when the BA didn�t notify me of room change and I tried to pronounce a live person dead. It has been few months since the incident but it remains as one of the most memorable moments of my life. � I had an elderly patient (in her 90�s) who, after a prolonged hospital stay, �many active medical issues and several phone calls to the family, was made hospice. One day I saw the patient late evening and she looked �like she was going to pass away any moment. The following morning I get a call from the floor BA that the patient had expired and if I can come and pronounce her dead. I was not surprised about this and told the BA that I will be there in a few minutes. Unfortunately I was never told that my patient was moved to another room. � I walked in the room where I thought my patient was and saw an elderly women laying in bed � her face was turned away from the door so I didn�t see her. There were several family members in the room sitting next to her bed, they had just arrived to see the patient and didn�t want to wake her because she had a rough night. Not knowing she was a different patient, I grabbed a chair and sat next to the family and told them that the patient had died few hrs ago � they were all somewhat shocked (which surprised me a little) but admitted that she was too sick and knew this was coming; meanwhile the patient is sleeping soundly (not even snoring) and couldn�t hear our conversation about her death because she has hearing-difficulties at baseline. We talked about her life for about 15 minutes and the fact how she was a fighter and fought a cancer and many other medical conditions (unfortunately for me, this patient also had many of the same medical conditions). � I politely ask the family to step out so that I can pronounce her dead, they did. I grabbed and turned the patient and all of the sudden I see TWO LARGE EYES glaring at me in a surprise. I almost fainted. . . . few seconds later It hit me like a brick and I knew I had a mess in my hand. Lucky for me, family and the patient had good sense of humor and they all laughed when I told them what happened (of course I was just sweating, not laughing much at the time) . . . . while I was walking out the room the patient called and told me �can I make a request, can you please come to pronounce me dead the NEXT TIME I DIE�, she had a smirk on her face when she said this. I told her �madam I am never coming close to you ever again� . . . . � J Lucky for me it ended well but could�ve ended in a bad way. . . .

31. It was challenging to keep the patient, who wanted to go home, in the hospital especially given the fact that she got conflicting recommendations My work as hospital-based-physician allowed me to be able make multiple daily visits to speak with the patient & her family, better coordinate care between various subspecialties and help get the patient to surgery on the same admission Hospital utilization team were also pressuring us to discharge Ms. S after reviewing the recommendations by the surgical team 31

32. Breakout session In groups of 3-5, discuss the following: What are the barriers for good continuity across the outpatient-inpatient setting? How do these barriers make me feel as a clinician? How can I as a (hospitalist/specialist/primary care clinician) contribute to lessening these barriers?

33. Discharge Scenario: Incidentaloma 65 year old man with chest pain CAD work up is negative Lung nodule on CXR: �compare to previous CXR, or evaluate with CT� Prior to D/C: A PCP follow-up visit was arranged Medications prescriptions given Patient educated about nodule Discharged on day hospital day 2

34. Clinical Scenario (cont) A discharge summary is sent to PCP with CXR finding and recommendations Patient misses the follow up appointment Nine months later the patient visits PCP

35. Discharge Scenario: New Medication A 43 year old diabetic woman is hospitalized with Pneumonia ACE inhibitor started for HTN A discharge summary is done The patient is sent home The D/C summary is not available during the follow-up visit, patient does not bring information PCP does not check renal function Two months later the patient is hospitalized with hyperkalemia and ARF

36. �IMPATIENT� WARFARIN DOSING C.R. 78 year old admitted with a history of Left leg swelling and dyspnea after driving up from Florida in his motor home. MEDS: ASA 81 mg, Lisinopril, Duonebs, Glucophage PHYSICAL EXAM: HR: 82/min, BP 150/80, O2 sat 91% on 2l NC. Heart: 2/6 SEM Extremities: Left calf swelling and tenderness.

37. IMPATIENT WARFARIN DOSING Doppler confirmed a DVT Started on Warfarin 5 mg at bedtime and Enoxaparin.INR checked daily: Day 0: 0.9, Day 1: 1.1, Day 3: 1.7 Coumadin Dose increased to 7.5 mg/day and patient discharged on Enoxaparin and Warfarin Next INR draw as outpatient scheduled after 3 days. Discharge instructions not clear as to who would manage anticoagulation and adjust the Coumadin dose

38. IMPATIENT WARFARIN DOSING The patient developed an acute left thigh & calf hematoma on day #7 and was admitted to Highland. INR on admission was 13.2 and Hct. 22 mg %. PRBC transfusion given, anticoagulation stopped and vitamin K 5 mg IV administered. Greenfield filter placed by IR

39. Discharge Scenario: Amended Result A 62 year old man is admitted with abdominal pain A CT done and reviewed with attending radiologist and hospitalist together A diagnosis of constipation is made: patient is treated and discharged Two months later irate patient contacts hospitalist demanding to know why he was not told of diagnosis of renal cell cancer CT was revised after initial read to include probable renal cell carcinoma in report, with no communication to hospitalist

40. COMMUNICATION COMMUNICATION COMMUNICATION WHAT WORKS AND WHAT DOES NOT?

41. Physician Transitions of Care Improvements ANY communication to PCP improves outcomes! Make a call to the PCP Dictate DC summary on day of DC Hand the patient the DC summary to take to PCP E-mail Fax

42. The Handoff: What�s the Big Deal? Hospitalists = Care Discontinuity = Potential miscommunications Loss of information: �voltage drop� Confusion over responsibilities Potential patient dissatisfaction Communication important to physicians and patients There is increased risk, medically & legally, with poor communication

43. Transfer Information at �High-Risk� On Admission Meds Code Status Other patient preferences On Discharge Meds Testing (completed, pending and planned) New diagnosis

44. Physician Directed Improvements: Barriers Limited time PCP & hospitalist Varied communications preferences Phone: Phone tree Fax: Propensity to get lost. E-mail: HIPPA concerns Little pressure to improve (to date)

45. RECOMMENDATIONS PCP�S: Continue to be a part of a continuum of care. Medicine reconciliation on admission Most PCP�s do not want daily calls. Imperative to have discharge summaries available on the day of discharge Hospitalist need to make every effort to contact PCP�s on discharge Discharge summary focus has to be transfer of information rather than billing. Test results, Diagnosis, Discharge meds, pending tests, follow up plans Focused, intensive patient education