Executive Briefing: Emergency & Hospital Medicine Coordination
Sponsored by TeamHealth
As the hospital industry continues to push collaborative care to the forefront of the agenda, hospitals may be underestimating two critical providers in these conversations: emergency department and hospital medicine providers. "I don't think people have really looked at the role of emergency medicine and hospital medicine in care transitions as much as they should," says Jasen Gundersen, MD, CMO of TeamHealth Hospital Medicine, based in Knoxville, Tenn. "We're working very hard as an organization to change that."
TeamHealth specializes in the management of both emergency medicine and hospital medicine programs, a dual-focus that helps repair barriers between the care settings and ensure more seamless transitions between the two. "We are dealing with a patient across a continuum of care, not an episode," says Oliver Rogers, president of Hospital Based Services at TeamHealth. "To be successful, we need to streamline the entire process and create a sense of urgency in every team member who interacts with the patient."
When problems abound
As with any two specialties, providers in emergency medicine and hospital medicine providers have a few nuances in their workflows and perspective. For instance, emergency physicians are likely to exert sharper focus on patients' immediate needs to ensure they are stable and comfortable. Emergency physicians are also accustomed to operating on working diagnoses as test results come back and the patient continues to undergo assessments.
In the inpatient setting, hospital medicine providers tend to think more in the long-term. They may focus more intensely on diagnoses and consequences of patient admissions. Detailed and specific patient data helps HM physicians determine the severity and volume of that care will need to be delivered when the patient is admitted under their supervision.
These subtle differences in priorities and concentration may lead to communication breakdowns that carry operational repercussions. For instance, HM physicians might ask the ED to order a certain type of imaging test. Though the ED will order the scan, it can later become ambiguous as to who will follow up on the results. This causes delays in care delivery that can eventually harm patient satisfaction, hospital finance and patient safety.
"The ED and hospital medicine department usually have a good relationship," says Dr. Gundersen. "When things break down, it's often due to a lack of communication. This relationship is really a trio — it's the ED, HM and the hospital itself." Operational issues within the system — such as problems with testing services, the availability of equipment or poor throughput — can trigger communication glitches between the two providers and affect numerous other aspects of hospital operations and business.
The repercussions of poor communication
Beginning in October 2013, hospital readmissions can pose a significant threat to hospitals' reimbursement. Under the Patient Protection and Affordable Care Act, Medicare will penalize hospitals if heart attack, heart failure or pneumonia patients return frequently. High readmission rates could cost hospitals up to 3 percent of their regular Medicare reimbursement by 2014.
To avoid these potential setbacks, hospitals are implementing a range of strategies to strengthen patient handoffs and other transitions. One of the most proactive strategies is to tighten communication, hand-offs and collaboration between emergency physicians and hospitalists.
In a study published in the Annals of Emergency Medicine, researchers analyzed the communication patterns of emergency physicians and hospitalists during patient handoffs. Researchers found emergency physicians talked more than hospitalists during the handoffs. Discussions often centered on the patient's presentation, the professional environment and the patient's assessment. The interaction between emergency physicians and hospitalists did not qualify as a question-and-answer dialogue by most means, as the form of the conversation was prevalently information-giving with very few questions asked.
Such imbalance in conversation may not be very noticeable to practicing providers, but it can create problems down the line and fragment care. "Nothing is more concerning to a patient than having an emergency physician tell you one thing and having a hospitalist tell you something different," says Dr. Gundersen. "Having those groups work closely together and manage those communication issues is important, otherwise it can hurt readmissions."
Another study published in the Annals of Emergency Medicine examined handoff communication problems in more detail and found how dangerous breakdowns in ED and HM communication can become. In the study, 40 of 264 provider respondents reported that a patient of theirs had experienced an adverse event or near miss after an ED to inpatient transfer.
Reported incidents included errors in diagnosis, treatment or disposition resulting from communication issues between the providers, such as inaccurate or incomplete information, cultural and professional conflicts, crowding and high workload. Difficult access to patient information, boarding in the ED, confusion over responsibility for sign-out or follow-up and non-linear patient flow were also cited as factors. It doesn't take a full-on hospital crisis or grave error to put a patient's safety at risk — many of these cited incidents, such as high workload, are ordinary circumstances for physicians.
Best practices to reduce siloed mentalities
The following best practices can help hospitals strengthen the relationships and collaborative spirit between their emergency medicine and hospital medicine programs.
• Go to great lengths to build rapport between providers — even outside of the hospital. Sometimes it's simply a matter of understanding other providers' perspectives and personalities. By encouraging regular and casual communication through joint meetings, social outings, newsletters and email blasts, hospitals can strengthen a team spirit between emergency medicine and hospital medicine departments. "The more emergency medicine understands how the hospital medicine department works, and vice versa, the better those two systems will interact," says Dr. Gundersen.
Further, joint metrics and incentives foster common goals between the emergency medicine and hospital medicine departments. The departments can work to overcome operational or communication hurdles that prevent them from reaching their shared performance goal. Once that metric or goal has been met, Mr. Rogers recommends hospitals jointly celebrate and reward the departments' success as a team. These shared incentives can reinforce a culture of cooperation, collaboration and engagement in both the ED and HM departments.
• Implement daily interdisciplinary rounds. "A good hospital medicine program has daily interdisciplinary rounds as a cornerstone of their operating model," says Mr. Rogers. "Expand the group to include ED providers and nursing staff on occasion. This will educate them about downstream problems their actions might create." If problems are identified, EM and HM leaders can meet to develop improvement action plans.
Rounds are one strategy to help avoid problems linked to hospital flow. Wait times and boarding are especially crucial to ED operations given the links between wait time, patient satisfaction and hospital finances. "It's really important that we focus on communication," says Dr. Gundersen. "That way, people will have a more seamless experience. They won't come into the ED as patients and face long wait times or providers resisting one another from different departments."
• Emphasize shared decision-making. Under TeamHealth's management model, EM and HM leaders develop and standardize order sets for patient transfers. These shared expectations among ED and HM physicians help expedite patient care and also increase cost-efficiency by coordinating orders and tests. "In today's environment, observation and clinical decision units are a must-have," says Mr. Rogers. "These can either further evaluate new conditions or manage acute episodes of chronic disease that can be effectively stabilized in short-stay environments. These units involve both hospital medicine and ED providers in the development of protocols and management."
More Articles on Hospitalists and Emergency Medicine:
Patient Satisfaction Levels Similar for Primary Physicians, HospitalistsAHA Report: Poor Communication Causes Most Patient Flow Issues
Study: Continuity, Comprehensiveness of Care Predict Fewer ED Visits