acp meeting 1 acp meeting christopher gamble, md, facp associate medical director hospitalist...
TRANSCRIPT
11172013
1
ACP Meeting
Christopher Gamble MD FACP Associate Medical Director Hospitalist Program
IU Health Ball Memorial Hospital
November 15 2013
Hospitalist Roles
Leader of the Medical Team Multi-disciplinary Rounds Documenting Rounding
Communicating Facilitating Consulting
Co-Management
Education Medical Student Resident
Quality Improvement Core Measures Mortality LOS Pt
Satisfaction Readmissions Management
Transitions of Care Pre-operative Evaluation Transition Clinic LTAC SNF
Leader of the Medical Team
We always cover the ears of the patient whenever we need to ask the nurse how to do something
ACP Cartoon Sept 2009
Hospitalist Co-Management
Definition - shared responsibility authority and accountability for the care of a hospitalized patient across clinical specialties
ldquoWhile there are opportunities for hospitalists to add real value as co-managers of surgical patients (eg in optimizing the medical care of patients with significant co-morbidities such as heart failure and diabetes and reducing post operative complications such as venous thromboembolism) the general definition of co-management is vague and varies markedly from one hospital to anotherrdquo
SHM ndash A White Paper on a Guide to HospitalistOrthopedic Surgery Co
Management
Co-Management
Medicine bull Cardiology bull Oncology bull HospicePalliative Care bull Endocrinology bull Nephrology bull Neurology
Surgical
bull Orthopedics
bull General Surgery
bull Urology
bull ENT
Co-Management
The Classic Question for Physicians
11172013
2
Co-Management
The Classic Question for Physicians
Who is admitting and who is consulting
Co-Management
What the surgeon says
ldquoI need your help managing the medical issuesrdquo
Co-Management
What the hospitalist hears
ldquoI need you to do the discharge summaryrdquo
Benefits of Co-Management
Increased prescribing of evidence-based treatments
Reduced time to surgery
Fewer transfers to an ICU for acute medical deterioration
Lower post-operative complications
Increased likelihood of discharge to home
Reduced length of stay
Improved nurse and surgeon satisfaction
Lower readmission rates
Arch Intern Med 2010 February 22 170(4) 363ndash368
Comanagement of hospitalized surgical patients by medicine physicians in the United States
Gulshan Sharma MD MPH12 Yong-Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD12
Comanagement of geriatric patients with hip fractures a retrospective controlled cohort study
Implementation of a comanagement protocol for care of geriatric patients with hip fracture
Admission to a geriatric primary care service
Standardized perioperative assessment regimens
Expeditious surgical treatment
Continued primary geriatric care postoperatively
Results
Reductions in lengths of stay ICU admissions and hospital costs per patient
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238
Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella Rocca GJ Moylan KC Crist BD Volgas DA
Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
11172013
3
Issues with Co-Management
Inconsistent definition from hospital to hospital
Increases demand for hospitalists and with it a critical and potentially destabilizing hospitalist manpower shortage
Facilitates surgeonspecialist disengagement
Hospitalist career dissatisfaction and burnout
Unclear delineation of responsibilities places patient at risk for conflictingcontradictory orders
J Hosp Med 2008 Sep3(5)398-402 doi 101002jhm361Just because you can doesnt mean that you should A call
for the rational application of hospitalist comanagement Siegal EMUniversity of Wisconsin School of Medicine and Public
Health Madison WI USA
Medical and surgical comgmt after elective hip and knee arthroplasty a randomized controlled trial
INTERVENTIONS A comgmt Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation
RESULTS
More patients in the hospitalist group were discharged from the hospital with no complications (616 vs 498 difference 118 percentage points [95 CI 28 to 207 percentage points])
Fewer minor complications were observed among hospitalist patients (302 vs 443 difference -141 percentage points [CI -227 to -53 percentage points])
Observed length of stay was not statistically different between treatment groups However when adjusted for discharge delays mean length of stay for patients in the hospitalist model of care was shorter (51 days vs 56 days difference -05 day [CI -08 to -01 day])
Total costs did not differ between groups Orthopedic surgeons and nurses preferred the hospitalist model
CONCLUSIONS The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative
complication rates with no statistically significant difference in length of stay or cost The nurses and surgeons strongly preferred the comanagement hospitalist model Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA huddlestonjeannemayoedu
Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery
METHODS Observational cohort of patients undergoing surgery at a university-based hospital
The outcomes included costs hospital los use of preventive therapies (such as perioperative beta-blockers) and clinical outcomes
RESULTS Consulted patients were of a similar age sex and race but more frequently had an American Society of Anesthesiologists score of 4 or higher (342 vs 130 P lt 001) diabetes mellitus (291 vs 161 P lt 001) vascular disease (350 vs 106 P lt 01) or chronic renal failure (239 vs 56 P lt 001) Patients were just as likely to
Have a serum glucose level of less than 200 mgdL (lt111 mmolL) Receive perioperative beta-blockers Receive venous thromboembolism prophylaxis
Consulted patients had a longer adjusted length of stay (1298 longer 95 confidence interval 161-2561) and higher adjusted costs (2436 higher 95 confidence interval 1354-3634)
CONCLUSIONS Patients who had a consultation from a generalist did not receive different quality of care
but had costs and length of stay similar to nonconsulted patients Perioperative internal medicine consultation produces inconsistent effects on efficiency and
quality of care in surgical patients Modifying the consultative model may represent an opportunity to improve care
Auerbach ADRasic MASehgal NIde BStone BMaselli J Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery Arch Intern Med 2007 167(21) 2338ndash2344
Co-Management
The question isnrsquot if Hospitalists should or should not provide surgical co-management but with how with what patients and with what goals
Hospitalist Co-Management
SHM ndash A White Paper on a Guide to HospitalistOrthopedic Surgery Co Management
Building Co-Management
What is administrationrsquos expectations
One service at a time
Orthorsquos different from Gen Surg which is different than Urology
Define the population of patients that will benefit
ASA Guidelines
Low moderate high risk
11172013
4
ASA Classification
httpmyclevelandclinicorgservicesAnesthesiahic_ASA_Physical_Classification_Systemaspx
Hospitalist Co-Management Minimal evidence to support co-mgmt of uncomplicated surgical
patients
Moderate risk patients Mixed evidence on improving LOS and functional status
High Risk Most convincing evidence that hospitalists improve outcomes
decrease complications Examples
Decompensated Heart Failure Acute COPD exacerbations Acute MI Acute CVA DKA Active Arrhythmias
Building Co-Management
Put it in writing and stick to the script
Miscommunication between providers increases risk to patient
Define who manages what
Common Questions that need addressed
Who manages
DVT prophylaxis Pain Activity Wound care
Post op complications Who does the nurse call for Fever Hypotension Low UOP
Medication Reconciliation ndash Admission and Discharge
Discharge Summary
Building Co-Management
Conflict resolution
Will there be a process for resolving issues or conflicts regarding the design or operation of the co-management program
Who will be responsible for providing authority when conflicts are unable to be resolved
Educate
Hospitalists and Surgeons
Nursing Staff
Secretaries
Administration
References
Marcantonio ER Flacker JM Wright RJ Resnick NM Reducing delirium after hip fracture a randomized trial J Am Geriatr Soc 2001 May49(5)516ndash22
Fisher AA Davis MW Rubenach SE Sivakumaran S Smith PN Budge MM Outcomes for older patients with hip fractures the impact of orthopedic and geriatric medicine cocare J Orthop Trauma 2006 March20(3)172ndash8
Phy MP Vanness DJ Melton LJ III et al Effects of a hospitalist model on elderly patients with hip fracture Arch Intern Med 2005 April 11165(7)796ndash801
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an
interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Huddleston JM Long KH Naessens JM et al Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Ann Intern Med 2004 July 6141(1)28ndash38
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 October 12169(18)1712ndash7
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Arch Intern Med 2010 February 22 170(4) 363ndash368 doi 101001archinternmed2009553 Comanagement of hospitalized surgical patients by medicine physicians in the United States Gulshan Sharma MD MPH12 Yong-
Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD
11172013
5
References
Anaesth Intensive Care 2013 Sep41(5)569-72 Medical co-management of high risk surgical patients Story DA Jones DA
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238 Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella
Rocca GJ Moylan KC Crist BD Volgas DA Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
J Hosp Med 2012 Oct7(8)649-54 doi 101002jhm1951 Epub 2012 Jul 12Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies Chadaga SR Maher MP Maller N Mancini D Mascolo M Sharma S Anderson ML Chu ES Division of Hospital Medicine Department of Medicine Denver Health Medical Center Denver Colorado 80204-4507 USA
Arch Intern Med 2010 Dec 13170(22)2004-10 doi 101001archinternmed2010432 Comanagement of surgical patients between neurosurgeons and hospitalists Auerbach AD Wachter RM Cheng HQ Maselli J McDermott M Vittinghoff E Berger MS Division of Hospital Medicine Department of Medicine University of California San Francisco CA 94143-0131 USA
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA
11172013
2
Co-Management
The Classic Question for Physicians
Who is admitting and who is consulting
Co-Management
What the surgeon says
ldquoI need your help managing the medical issuesrdquo
Co-Management
What the hospitalist hears
ldquoI need you to do the discharge summaryrdquo
Benefits of Co-Management
Increased prescribing of evidence-based treatments
Reduced time to surgery
Fewer transfers to an ICU for acute medical deterioration
Lower post-operative complications
Increased likelihood of discharge to home
Reduced length of stay
Improved nurse and surgeon satisfaction
Lower readmission rates
Arch Intern Med 2010 February 22 170(4) 363ndash368
Comanagement of hospitalized surgical patients by medicine physicians in the United States
Gulshan Sharma MD MPH12 Yong-Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD12
Comanagement of geriatric patients with hip fractures a retrospective controlled cohort study
Implementation of a comanagement protocol for care of geriatric patients with hip fracture
Admission to a geriatric primary care service
Standardized perioperative assessment regimens
Expeditious surgical treatment
Continued primary geriatric care postoperatively
Results
Reductions in lengths of stay ICU admissions and hospital costs per patient
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238
Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella Rocca GJ Moylan KC Crist BD Volgas DA
Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
11172013
3
Issues with Co-Management
Inconsistent definition from hospital to hospital
Increases demand for hospitalists and with it a critical and potentially destabilizing hospitalist manpower shortage
Facilitates surgeonspecialist disengagement
Hospitalist career dissatisfaction and burnout
Unclear delineation of responsibilities places patient at risk for conflictingcontradictory orders
J Hosp Med 2008 Sep3(5)398-402 doi 101002jhm361Just because you can doesnt mean that you should A call
for the rational application of hospitalist comanagement Siegal EMUniversity of Wisconsin School of Medicine and Public
Health Madison WI USA
Medical and surgical comgmt after elective hip and knee arthroplasty a randomized controlled trial
INTERVENTIONS A comgmt Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation
RESULTS
More patients in the hospitalist group were discharged from the hospital with no complications (616 vs 498 difference 118 percentage points [95 CI 28 to 207 percentage points])
Fewer minor complications were observed among hospitalist patients (302 vs 443 difference -141 percentage points [CI -227 to -53 percentage points])
Observed length of stay was not statistically different between treatment groups However when adjusted for discharge delays mean length of stay for patients in the hospitalist model of care was shorter (51 days vs 56 days difference -05 day [CI -08 to -01 day])
Total costs did not differ between groups Orthopedic surgeons and nurses preferred the hospitalist model
CONCLUSIONS The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative
complication rates with no statistically significant difference in length of stay or cost The nurses and surgeons strongly preferred the comanagement hospitalist model Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA huddlestonjeannemayoedu
Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery
METHODS Observational cohort of patients undergoing surgery at a university-based hospital
The outcomes included costs hospital los use of preventive therapies (such as perioperative beta-blockers) and clinical outcomes
RESULTS Consulted patients were of a similar age sex and race but more frequently had an American Society of Anesthesiologists score of 4 or higher (342 vs 130 P lt 001) diabetes mellitus (291 vs 161 P lt 001) vascular disease (350 vs 106 P lt 01) or chronic renal failure (239 vs 56 P lt 001) Patients were just as likely to
Have a serum glucose level of less than 200 mgdL (lt111 mmolL) Receive perioperative beta-blockers Receive venous thromboembolism prophylaxis
Consulted patients had a longer adjusted length of stay (1298 longer 95 confidence interval 161-2561) and higher adjusted costs (2436 higher 95 confidence interval 1354-3634)
CONCLUSIONS Patients who had a consultation from a generalist did not receive different quality of care
but had costs and length of stay similar to nonconsulted patients Perioperative internal medicine consultation produces inconsistent effects on efficiency and
quality of care in surgical patients Modifying the consultative model may represent an opportunity to improve care
Auerbach ADRasic MASehgal NIde BStone BMaselli J Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery Arch Intern Med 2007 167(21) 2338ndash2344
Co-Management
The question isnrsquot if Hospitalists should or should not provide surgical co-management but with how with what patients and with what goals
Hospitalist Co-Management
SHM ndash A White Paper on a Guide to HospitalistOrthopedic Surgery Co Management
Building Co-Management
What is administrationrsquos expectations
One service at a time
Orthorsquos different from Gen Surg which is different than Urology
Define the population of patients that will benefit
ASA Guidelines
Low moderate high risk
11172013
4
ASA Classification
httpmyclevelandclinicorgservicesAnesthesiahic_ASA_Physical_Classification_Systemaspx
Hospitalist Co-Management Minimal evidence to support co-mgmt of uncomplicated surgical
patients
Moderate risk patients Mixed evidence on improving LOS and functional status
High Risk Most convincing evidence that hospitalists improve outcomes
decrease complications Examples
Decompensated Heart Failure Acute COPD exacerbations Acute MI Acute CVA DKA Active Arrhythmias
Building Co-Management
Put it in writing and stick to the script
Miscommunication between providers increases risk to patient
Define who manages what
Common Questions that need addressed
Who manages
DVT prophylaxis Pain Activity Wound care
Post op complications Who does the nurse call for Fever Hypotension Low UOP
Medication Reconciliation ndash Admission and Discharge
Discharge Summary
Building Co-Management
Conflict resolution
Will there be a process for resolving issues or conflicts regarding the design or operation of the co-management program
Who will be responsible for providing authority when conflicts are unable to be resolved
Educate
Hospitalists and Surgeons
Nursing Staff
Secretaries
Administration
References
Marcantonio ER Flacker JM Wright RJ Resnick NM Reducing delirium after hip fracture a randomized trial J Am Geriatr Soc 2001 May49(5)516ndash22
Fisher AA Davis MW Rubenach SE Sivakumaran S Smith PN Budge MM Outcomes for older patients with hip fractures the impact of orthopedic and geriatric medicine cocare J Orthop Trauma 2006 March20(3)172ndash8
Phy MP Vanness DJ Melton LJ III et al Effects of a hospitalist model on elderly patients with hip fracture Arch Intern Med 2005 April 11165(7)796ndash801
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an
interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Huddleston JM Long KH Naessens JM et al Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Ann Intern Med 2004 July 6141(1)28ndash38
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 October 12169(18)1712ndash7
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Arch Intern Med 2010 February 22 170(4) 363ndash368 doi 101001archinternmed2009553 Comanagement of hospitalized surgical patients by medicine physicians in the United States Gulshan Sharma MD MPH12 Yong-
Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD
11172013
5
References
Anaesth Intensive Care 2013 Sep41(5)569-72 Medical co-management of high risk surgical patients Story DA Jones DA
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238 Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella
Rocca GJ Moylan KC Crist BD Volgas DA Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
J Hosp Med 2012 Oct7(8)649-54 doi 101002jhm1951 Epub 2012 Jul 12Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies Chadaga SR Maher MP Maller N Mancini D Mascolo M Sharma S Anderson ML Chu ES Division of Hospital Medicine Department of Medicine Denver Health Medical Center Denver Colorado 80204-4507 USA
Arch Intern Med 2010 Dec 13170(22)2004-10 doi 101001archinternmed2010432 Comanagement of surgical patients between neurosurgeons and hospitalists Auerbach AD Wachter RM Cheng HQ Maselli J McDermott M Vittinghoff E Berger MS Division of Hospital Medicine Department of Medicine University of California San Francisco CA 94143-0131 USA
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA
11172013
3
Issues with Co-Management
Inconsistent definition from hospital to hospital
Increases demand for hospitalists and with it a critical and potentially destabilizing hospitalist manpower shortage
Facilitates surgeonspecialist disengagement
Hospitalist career dissatisfaction and burnout
Unclear delineation of responsibilities places patient at risk for conflictingcontradictory orders
J Hosp Med 2008 Sep3(5)398-402 doi 101002jhm361Just because you can doesnt mean that you should A call
for the rational application of hospitalist comanagement Siegal EMUniversity of Wisconsin School of Medicine and Public
Health Madison WI USA
Medical and surgical comgmt after elective hip and knee arthroplasty a randomized controlled trial
INTERVENTIONS A comgmt Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation
RESULTS
More patients in the hospitalist group were discharged from the hospital with no complications (616 vs 498 difference 118 percentage points [95 CI 28 to 207 percentage points])
Fewer minor complications were observed among hospitalist patients (302 vs 443 difference -141 percentage points [CI -227 to -53 percentage points])
Observed length of stay was not statistically different between treatment groups However when adjusted for discharge delays mean length of stay for patients in the hospitalist model of care was shorter (51 days vs 56 days difference -05 day [CI -08 to -01 day])
Total costs did not differ between groups Orthopedic surgeons and nurses preferred the hospitalist model
CONCLUSIONS The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative
complication rates with no statistically significant difference in length of stay or cost The nurses and surgeons strongly preferred the comanagement hospitalist model Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA huddlestonjeannemayoedu
Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery
METHODS Observational cohort of patients undergoing surgery at a university-based hospital
The outcomes included costs hospital los use of preventive therapies (such as perioperative beta-blockers) and clinical outcomes
RESULTS Consulted patients were of a similar age sex and race but more frequently had an American Society of Anesthesiologists score of 4 or higher (342 vs 130 P lt 001) diabetes mellitus (291 vs 161 P lt 001) vascular disease (350 vs 106 P lt 01) or chronic renal failure (239 vs 56 P lt 001) Patients were just as likely to
Have a serum glucose level of less than 200 mgdL (lt111 mmolL) Receive perioperative beta-blockers Receive venous thromboembolism prophylaxis
Consulted patients had a longer adjusted length of stay (1298 longer 95 confidence interval 161-2561) and higher adjusted costs (2436 higher 95 confidence interval 1354-3634)
CONCLUSIONS Patients who had a consultation from a generalist did not receive different quality of care
but had costs and length of stay similar to nonconsulted patients Perioperative internal medicine consultation produces inconsistent effects on efficiency and
quality of care in surgical patients Modifying the consultative model may represent an opportunity to improve care
Auerbach ADRasic MASehgal NIde BStone BMaselli J Opportunity missed medical consultation resource use and quality of care of patients undergoing major surgery Arch Intern Med 2007 167(21) 2338ndash2344
Co-Management
The question isnrsquot if Hospitalists should or should not provide surgical co-management but with how with what patients and with what goals
Hospitalist Co-Management
SHM ndash A White Paper on a Guide to HospitalistOrthopedic Surgery Co Management
Building Co-Management
What is administrationrsquos expectations
One service at a time
Orthorsquos different from Gen Surg which is different than Urology
Define the population of patients that will benefit
ASA Guidelines
Low moderate high risk
11172013
4
ASA Classification
httpmyclevelandclinicorgservicesAnesthesiahic_ASA_Physical_Classification_Systemaspx
Hospitalist Co-Management Minimal evidence to support co-mgmt of uncomplicated surgical
patients
Moderate risk patients Mixed evidence on improving LOS and functional status
High Risk Most convincing evidence that hospitalists improve outcomes
decrease complications Examples
Decompensated Heart Failure Acute COPD exacerbations Acute MI Acute CVA DKA Active Arrhythmias
Building Co-Management
Put it in writing and stick to the script
Miscommunication between providers increases risk to patient
Define who manages what
Common Questions that need addressed
Who manages
DVT prophylaxis Pain Activity Wound care
Post op complications Who does the nurse call for Fever Hypotension Low UOP
Medication Reconciliation ndash Admission and Discharge
Discharge Summary
Building Co-Management
Conflict resolution
Will there be a process for resolving issues or conflicts regarding the design or operation of the co-management program
Who will be responsible for providing authority when conflicts are unable to be resolved
Educate
Hospitalists and Surgeons
Nursing Staff
Secretaries
Administration
References
Marcantonio ER Flacker JM Wright RJ Resnick NM Reducing delirium after hip fracture a randomized trial J Am Geriatr Soc 2001 May49(5)516ndash22
Fisher AA Davis MW Rubenach SE Sivakumaran S Smith PN Budge MM Outcomes for older patients with hip fractures the impact of orthopedic and geriatric medicine cocare J Orthop Trauma 2006 March20(3)172ndash8
Phy MP Vanness DJ Melton LJ III et al Effects of a hospitalist model on elderly patients with hip fracture Arch Intern Med 2005 April 11165(7)796ndash801
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an
interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Huddleston JM Long KH Naessens JM et al Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Ann Intern Med 2004 July 6141(1)28ndash38
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 October 12169(18)1712ndash7
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Arch Intern Med 2010 February 22 170(4) 363ndash368 doi 101001archinternmed2009553 Comanagement of hospitalized surgical patients by medicine physicians in the United States Gulshan Sharma MD MPH12 Yong-
Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD
11172013
5
References
Anaesth Intensive Care 2013 Sep41(5)569-72 Medical co-management of high risk surgical patients Story DA Jones DA
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238 Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella
Rocca GJ Moylan KC Crist BD Volgas DA Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
J Hosp Med 2012 Oct7(8)649-54 doi 101002jhm1951 Epub 2012 Jul 12Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies Chadaga SR Maher MP Maller N Mancini D Mascolo M Sharma S Anderson ML Chu ES Division of Hospital Medicine Department of Medicine Denver Health Medical Center Denver Colorado 80204-4507 USA
Arch Intern Med 2010 Dec 13170(22)2004-10 doi 101001archinternmed2010432 Comanagement of surgical patients between neurosurgeons and hospitalists Auerbach AD Wachter RM Cheng HQ Maselli J McDermott M Vittinghoff E Berger MS Division of Hospital Medicine Department of Medicine University of California San Francisco CA 94143-0131 USA
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA
11172013
4
ASA Classification
httpmyclevelandclinicorgservicesAnesthesiahic_ASA_Physical_Classification_Systemaspx
Hospitalist Co-Management Minimal evidence to support co-mgmt of uncomplicated surgical
patients
Moderate risk patients Mixed evidence on improving LOS and functional status
High Risk Most convincing evidence that hospitalists improve outcomes
decrease complications Examples
Decompensated Heart Failure Acute COPD exacerbations Acute MI Acute CVA DKA Active Arrhythmias
Building Co-Management
Put it in writing and stick to the script
Miscommunication between providers increases risk to patient
Define who manages what
Common Questions that need addressed
Who manages
DVT prophylaxis Pain Activity Wound care
Post op complications Who does the nurse call for Fever Hypotension Low UOP
Medication Reconciliation ndash Admission and Discharge
Discharge Summary
Building Co-Management
Conflict resolution
Will there be a process for resolving issues or conflicts regarding the design or operation of the co-management program
Who will be responsible for providing authority when conflicts are unable to be resolved
Educate
Hospitalists and Surgeons
Nursing Staff
Secretaries
Administration
References
Marcantonio ER Flacker JM Wright RJ Resnick NM Reducing delirium after hip fracture a randomized trial J Am Geriatr Soc 2001 May49(5)516ndash22
Fisher AA Davis MW Rubenach SE Sivakumaran S Smith PN Budge MM Outcomes for older patients with hip fractures the impact of orthopedic and geriatric medicine cocare J Orthop Trauma 2006 March20(3)172ndash8
Phy MP Vanness DJ Melton LJ III et al Effects of a hospitalist model on elderly patients with hip fracture Arch Intern Med 2005 April 11165(7)796ndash801
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an
interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Huddleston JM Long KH Naessens JM et al Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Ann Intern Med 2004 July 6141(1)28ndash38
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 October 12169(18)1712ndash7
Zuckerman JD Sakales SR Fabian DR Frankel VH Hip fractures in geriatric patients Results of an interdisciplinary hospital care program Clin Orthop Relat Res 1992 January(274)213ndash25
Arch Intern Med 2010 February 22 170(4) 363ndash368 doi 101001archinternmed2009553 Comanagement of hospitalized surgical patients by medicine physicians in the United States Gulshan Sharma MD MPH12 Yong-
Fang Kuo PhD12 Jean Freeman PhD12 Dong D Zhang PhD12 and James S Goodwin MD
11172013
5
References
Anaesth Intensive Care 2013 Sep41(5)569-72 Medical co-management of high risk surgical patients Story DA Jones DA
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238 Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella
Rocca GJ Moylan KC Crist BD Volgas DA Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
J Hosp Med 2012 Oct7(8)649-54 doi 101002jhm1951 Epub 2012 Jul 12Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies Chadaga SR Maher MP Maller N Mancini D Mascolo M Sharma S Anderson ML Chu ES Division of Hospital Medicine Department of Medicine Denver Health Medical Center Denver Colorado 80204-4507 USA
Arch Intern Med 2010 Dec 13170(22)2004-10 doi 101001archinternmed2010432 Comanagement of surgical patients between neurosurgeons and hospitalists Auerbach AD Wachter RM Cheng HQ Maselli J McDermott M Vittinghoff E Berger MS Division of Hospital Medicine Department of Medicine University of California San Francisco CA 94143-0131 USA
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA
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References
Anaesth Intensive Care 2013 Sep41(5)569-72 Medical co-management of high risk surgical patients Story DA Jones DA
SHM White Paper on Hospitalist Co-Mgmt
Geriatr Orthop Surg Rehabil 2013 Mar4(1)10-5 doi 1011772151458513495238 Comanagement of geriatric patients with hip fractures a retrospective controlled cohort studyDella
Rocca GJ Moylan KC Crist BD Volgas DA Stannard JP Mehr DRDepartment of Orthopaedic Surgery University of Missouri Columbia MO USA
J Hosp Med 2012 Oct7(8)649-54 doi 101002jhm1951 Epub 2012 Jul 12Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies Chadaga SR Maher MP Maller N Mancini D Mascolo M Sharma S Anderson ML Chu ES Division of Hospital Medicine Department of Medicine Denver Health Medical Center Denver Colorado 80204-4507 USA
Arch Intern Med 2010 Dec 13170(22)2004-10 doi 101001archinternmed2010432 Comanagement of surgical patients between neurosurgeons and hospitalists Auerbach AD Wachter RM Cheng HQ Maselli J McDermott M Vittinghoff E Berger MS Division of Hospital Medicine Department of Medicine University of California San Francisco CA 94143-0131 USA
Ann Intern Med 2004 Jul 6141(1)28-38 Medical and surgical comanagement after elective hip and knee arthroplasty a randomized controlled trial Huddleston JM Long KH Naessens JM Vanness D Larson D Trousdale R Plevak M Cabanela M Ilstrup D Wachter RM Hospitalist-Orthopedic Team Trial Investigators Mayo Clinic College of Medicine Rochester Minnesota 55905 USA