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Hospitalist-only unit frees time, improves care

By Rochelle Nataloni

From the October ACP Hospitalist, copyright © 2008 by the American College of Physicians

Where: St. Mary’s Health Center in St. Louis, Mo.

The issue: Maximizing efficiency and time spent with patients by creating a hospitalist-only unit.

Background

Philip Vaidyan, FACP, director of hospital medicine at St. Mary’s Health Center, was wasting a lot of time and energy tracking down his physicians, who were spread across various units of the 582-bed hospital. “Before this pilot project began, I would have an admission in one corner of the hospital, a discharge in another, and (a third) discharge in another nursing unit,” Dr. Vaidyan said. To resolve the problem, Dr. Vaidyan and Nancy Yurchak, RN, BSN, implemented a pilot in June to test a 20-bed, 8,400-square-foot, hospitalist-only unit, with five hospitalists and 24 RNs. Unit staff comprised existing hospital employees, and the unit is self-sufficient, with its own office and computers.

How it works

Primary care doctors who choose not to manage their inpatients are admitted to the hospitalist-only unit. Patients who require telemetry or higher level care are not eligible. Ms. Yurchak rounds daily prior to the hospitalists, then speaks with them during their rounds about noteworthy patient issues. Hospitalists also confer with nurses at the start of each shift, and nurses leaving a shift give face-to-face hand-offs about their patients to incoming nurses.

The challenges

The number of beds in the unit is currently limited to 20, so it can fill up fast. Two other designated units in the hospital accept overflow patients, who can then switch when a hospitalist unit bed opens up. Construction is underway to add 10 additional beds to the unit by mid-January 2009. Weekends can be especially challenging, with three hospitalists covering for the usual five, and other staff operating as a skeleton crew, too.

Results

Each hospitalist is saving about one hour per day in not having to run all over the hospital to do discharges and admissions in various units. He or she also receives two-thirds fewer pages per day, since the hospitalists are physically closer to the nurses.

Press-Ganey surveys showed a 13% rise in patients’ likelihood of recommending the hospital, and a 16% rise in overall rating of care, from June to July—percent increases that repeated from July to August. By the end of August, 100% of patients in the hospitalist unit said they would recommend the hospital.

The number of patients discharged by 2 p.m. has doubled to about 50% since inauguration of the hospitalist unit, thanks mostly to better communication among staff.

More efficiency means more time, so doctor training has improved. Hospitalists engage in bedside “teaching moments” for residents, students, nurses and patients.

Lessons learned

Encourage strategic partnerships between physicians and nurses. “Physician and nurse co-management results in improved communication, which improves patient care,” Dr. Vaidyan said.

Welcome hospital administrators into the process. At St. Mary’s, administrators attend meetings every six weeks to review the progress of the hospitalist pilot program. Their presence enables the team to quickly address problems, said Ms. Yurchak.

How patients benefit

Because they spend less time running between units of the hospital, hospitalists and nurses have more time to spend with patients. “Every nurse, doctor and department that plays a role in the care of these patients is now effectively communicating and listening to our patients,” Ms. Yurchak said.

Next steps

Currently, the hospitalists lead multi-disciplinary conferences twice a week which center on patient care plans. These will increase to five times a week by December. Also, if patient satisfaction scores continue to indicate the hospitalist unit is a positive development, the unit will become a model for all of the Health Center’s nursing units. “The institution will set about identifying team leaders—nursing directors and physicians— who want to be engaged more intensely, and we will have comanagement teams ultimately running all of our nursing units,” said Morey Gardner, ACP Member, St. Mary’s chief of medicine.

Words of wisdom

The patient is always the main reason for any changes made, Dr. Gardner said. “All of our initiatives have to ultimately result in improved patient care and improved patient experience.”

Rochelle Nataloni is a freelance writer in Sewell, N.J.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated