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The Great “ist” Thing

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The Great “ist” Thing

By Jock Hoffman, CRICO

The practice model that began with hospitalist and intensivist is now expanding to obstetrics, in the form of laborist (and even nocturnist and weekendist). While the movement is seen as a benefit to physician lifestyle and retention, is it a good idea for patient care and safety?

Background

The common thread across all of the “ist” practices is that responsibility for the patient’s care is handed off from a physician with whom the patient has a relationship to an unfamiliar colleague—and then back again after the hospitalization (or intensive care, or delivery). It is those two critical handoffs that potentially expose the patient to greater risk and the providers to broader liability. Over the past five years, handoff-related cases represent more than $173 million in incurred losses for the CRICO-insured institutions. More than half of those cases involved a high-severity injury.

Our Recommendation

When the two physicians are in tune with each other and the handoffs are successful, the transferring of care to hospital-based providers is, generally, a win-win: the inpatient is attended to full-time by a physician familiar with the hospital systems, and the office-based physician can practice uninterrupted and still get home for the kids’ bedtime. In order for those handoffs to be successful, three key factors have to be optimized.

Patient awareness

Patients need to understand that “their doctor” will not be taking care of them in the hospital (or delivering their baby) and why. Failure to convey the benefits of this practice—or to address a patient’s concerns—can fuel a sense of abandonment if an adverse outcome occurs under the care of the unfamiliar physician.

Concordance of clinical philosophy and practice

Know who will be caring for your hospitalized patients well enough to work through any differences you may have and to concur on the threshold for consultation. And for each individual patient, be certain that anything out of the ordinary is communicated, received, and understood.

Systematic access, notification, and follow up

The biggest risk in handoffs is a fumble—when critical patient information held by one physician does not reach the subsequent caregiver, or the information is received but mishandled. At best, patients (and their families) perceive “fumbles” as uncoordinated and substandard care. At worst, miscommunication leads to missed complications, delayed diagnoses, and lawsuits. Office-based physicians turning over responsibility for their patients to hospital-based providers—and vice versa—need protocols and systems to avoid losing track of the patient, test results, discharge instructions, medication changes, or any other critical information.


February 1, 2008
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