Hospitalist Care Extends into Surgical Specialties

Starting in August of this year, Stanford hired six surgical co-management hospitalists to provide inpatient medical care for patients in neurosurgery, CT surgery and orthopaedic surgery. Stanford created this peri-operative team of physicians to manage the medical care of a growing number of surgical patients who have complex medical problems that could be better managed by doctors who specialize in internal medicine.

"With hospitalists at the bedside, patients are being managed by specialists who know inpatient medicine, specialists who can optimize the surgical experience and make sure patients are getting the care they need at night, during the day and on holidays," says Neera Ahuja, MD, clinical associate professor of medicine and director of the hospitalist program at Stanford. "It's 24/7 care."

Surgical co-management hospitalists practice peri-operative medicine – working with patients before and after surgery – to enhance patient care, reduce complications and improve patient satisfaction.

"In neurosurgery we are utilizing hospitalists to improve medical management of our patients, such as tighter plasma glucose control, better management of hypertension and optimizing treatment of systemic medical issues," says Gary Steinberg, MD, the Bernard and Ronni Lacroute-William Randolph Hearst Professor of Neurosurgery and the Neurosciences. "Having these hospitalists available 24/7 enhances overall patient care, facilitates earlier patient discharge, decreases readmissions and improves patient satisfaction."

A day in the life of a surgical hospitalist

Guruman Kalra, MD, is one of two new hospitalists hired to co-manage surgical patients in orthopaedic surgery. He spends his days alongside fellow hospitalist Manny Lam, MD, working directly with surgeons and nursing staff to co-manage surgical patients. Both physicians are on staff everyday during the week. They trade weekend days and nighttime phone coverage.

"We help manage patients' medical issues before and after surgery to help prevent complications, reduce costs and increase patient satisfaction," Kalra says. Before hospitalists became a mainstay on the surgical floors, patients were cared for by the house staff and surgical attending physicians. Yet with an aging population, many more surgical patients are entering the hospital with a number of chronic medical problems.

"Hospitalists are providing care to patients for complex medical problems that surgeons are not necessarily well trained to handle," Kalra adds. "We supplement their care. We are on the floor and can attend to their patients right away if they are in surgery or in clinic."

The same pressures that make it hard for physicians to come into the hospital in the morning to see patients have also made it virtually impossible for surgeons to spend time with patients outside the OR. "Who's taking care of these incredibly sick cardiovascular patients, or the 90-year-old with a broken hip or a neurosurgery patient with metabolic consequences as a result of having increased pressure on the brain?" says Mark Cullen, MD, chief of general medical disciplines at Stanford.

"I think the benefit to patients, the hospital and to those surgical services will be extraordinary," Cullen adds. "You have a small group of highly disciplined members of your own faculty for whom taking care of people while they are acutely sick is their specialty. I think they'll substantially upgrade the quality of the medical care."

After just a few months, surgical patients are responding positively to the presence of hospitalists, Ahuja says. Patients like receiving additional attention from another doctor and having all-day access to a physician who can answer their questions. Feedback from nurses on the floors has also been positive, she adds. They are happy to have a doctor on staff who is available to answer questions and manage discharges. As a consistent presence on the surgical floor, the hospitalist also gets to know the practice styles and preferences of each surgeon. Over time, Ahuja sees this as a real benefit for well-coordinated care. "As surgeons gain confidence and trust in their hospitalists, they can come and focus on their patient's surgical issues where their expertise is most needed."

Why hospitalists?

The hospitalist trend is not new; in fact, the term was coined in 1996. But at Stanford, the concept just started gaining momentum three years ago, coinciding with the appointment of Ahuja to lead the expansion effort.

Over the past three years, Stanford has more than doubled the presence of hospitalists on patient floors. The hospitalist group now consists of 20 faculty who provide about 80 percent of inpatient care on the general wards and are instrumental in training much of the house staff on providing medical care to inpatients. The six surgical co-management hospitalists are part of a larger team that includes 11 hospitalists on the general medicine floors and a pool of nocturnists, internal medicine doctors who work with house staff at night to cover pulmonary hypertension, cystic fibrosis, heart transplant, kidney transplant, liver transplant, hematology and oncology patients.

Hospitalists standardize many aspects of patient care across all floors and surgical specialties. There's more accountability for outcomes, Ahuja says, because hospitalists are focused on a number of quality matrixes that help reduce length of stay and infection risk and improve overall patient satisfaction. They are also highly trained to care for the very different needs of patients in hospitals.

"The acuity level is higher when patients are in the hospital," Ahuja says. "As hospitalists, we must get to know their medical problems, gain their trust and take care of them, and all of this must occur rather quickly. We get to make a really big impact within a 24-hour period on a large number of very sick patients."

By Grace Hammerstrom