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Hospitalists: Ensuring Quality Care

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Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

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