Dr. William Ford knows that working “collaboratively” can be kind of an overused buzzword in medicine, but he also knows that it works.
At least that’s the case at Temple University Hospital in Philadelphia where taking a collaborative approach has made the hospitalist-run observation unit a success.
Dr. William Ford
The hospitalist group at Temple launched the observation unit in early 2007 with 18 beds and about 130 admissions per month. Today, they average 340-380 admissions per month and are planning to expand to 36 beds in the fall.
“It is the cornerstone of our institution,” said Dr. Ford, chief of the section of hospital medicine at Temple and medical director for Cogent Healthcare.
The unit, known at Temple as the clinical decision unit, is a bit different from a conventional observation unit. Rather than handling mostly chest pain patients for 24-hour observation, patients in the clinical decision unit stay 2-48 hours, and the admission criteria include chest pain, heart failure, pneumonia, asthma, simple cellulitis, syncope, and seizures.
The results are encouraging. The length of stay in the clinical decision unit is 0.8-1.2 days shorter for those patients than for similar patients who receive cared in other parts of the hospital. “That’s obviously a huge cost savings for the hospital,” Dr. Ford said.
The key to their success has been the processes used in the unit, he said, which include reliance on multidisciplinary team rounding, regular audits of performance, and weekly meetings among the hospitalists, nurses, and hospital administrators. The unit also tries to keep the lines of communication open with the emergency department and provides the physicians working there with strict criteria for admitting patients to the clinical decision unit.
Dr. Ford and his team also routinely use protocols that they developed, including order sets for asthma, chronic obstructive pulmonary disorder, chest pain, and heart failure.
Although the clinical decision unit has been a success, Dr. Ford cautioned other hospitalists that there are some pitfalls. Hospitals need to be vigilant about making sure they have correct documentation to show that they are compliant with Medicare and Medicaid rules in the unit. Otherwise, they could be penalized in an audit. Hospitalist programs should also consider rotating the physicians who work in the unit. The work can be intense, he said, so physicians rotate back out to their regular duty after a few months. The hospitalists who work in Temple’s clinical decision unit typically round on 18-22 patients during a 12-hour shift, and discharge about half of those.
As Dr. Ford and his team have shown success in managing the clinical decision unit and shortening the length of stay, hospital officials have called on them to take on more responsibility for quality throughout the hospital. The hospitalist group is now responsible for deep vein thrombosis rates, glycemic control, and urinary tract infections for all patients, not just those under their direct care.
It’s a challenge, Dr. Ford said, but the group is approaching it the same way they did the observation unit: collaboratively. For example, they are working with the hospital’s diabetic care committee to influence the education of the nursing staff and the residents on glycemic control. They are also working with the pharmacists to set up standard drug protocols.
“It’s that type of indirect influence” that is critical to hospitalists’ success. Dr. Ford said. “As a specialty, that’s where we’re headed.”