In discussing hospitalist models, it is essential to keep in mind the relationships between hospitalists and the wider pediatric community. Communication is at the forefront of any hospitalist model and can be the Achilles’ heel of an otherwise high-quality program. Excellent communication to and from primary care physicians (PCPs) can help a program thrive and prosper. PCPs who are kept in the loop regarding their patients’ hospital courses will likely support and continue to utilize the hospitalist service. By communicating in an effective and timely manner, one of the major potential downsides (loss of valuable information) of a hospitalist service can be avoided.
Communication can positively or negatively affect a variety of issues, including but not limited to quality of care, cost of care, patient and physician satisfaction, and liability. With excellent communication, the transition from inpatient to outpatient settings (including transitional care units, chronic care facilities, and rehabilitation hospitals) can be smooth, with minimal to no loss of information.
The concept of assuming care for other physicians’ patients and then returning their care to the PCPs at discharge is an integral component of all hospitalist models. This is generally accomplished via a formal handoff, which is one of the more controversial and variable aspects of hospital medicine. The intentional creation of discontinuity of care permits a physician (hospitalist) to be present in the hospital for an extended period to manage inpatients throughout the day. This ongoing presence is one of the biggest advantages of the hospitalist model. As with most things, however, one must accept the good with the bad. As a result of the handoff, the PCP, with whom the patient has fostered a trusting relationship and who knows the patient’s medical history best, is not caring for the patient when he or she is most ill. This situation can result in a loss of essential information (“voltage drop”) from the outpatient to the inpatient setting and vice versa. Complex and expensive laboratory and radiology data, as well as vital information concerning possible medical allergies, medications, code status, and patient’s likes and dislikes, can be lost or poorly or miscommunicated during the transfer. This could result in a variety of negative outcomes—some relatively benign, and others potentially life threatening.
With excellent communication between the PCP and the hospitalist, voltage drop can be minimized. In a study of 400 discharged patients, researchers found that 19% of patients suffered adverse events soon after discharge; about half of these events would have been preventable if communication had been adequate.1 The Value in Inpatient Pediatrics (VIP) network has sought to standardize the discharge communication process with their “Pediatric Hospitalists Collaborate to Improve Discharge Communication” project. Additionally, The Pediatric Research in Inpatient Settings (PRIS) network is working on handoffs in the academic setting with their I-PASS project. To date, no standard for communication between the hospitalist and ...