Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years

In surgical comanagement (SCM), surgeons and hospitalists share responsibility of care for surgical patients. While SCM has been increasingly utilized, many of the reported models are a modification of the consultation model, in which a group of rotating hospitalists, internists, or geriatricians care for the surgical patients, often after medical complications may have occured.^1-4

In August 2012, we implemented SCM in Orthopedic and Neurosurgery services at our institution.⁵ This model is unique because the same Internal Medicine hospitalists are dedicated year round to the same surgical service. SCM hospitalists see patients on their assigned surgical service only; they do not see patients on the Internal Medicine service. After the first year of implementing SCM, we conducted a propensity score–weighted study with 17,057 discharges in the pre-SCM group (January 2009 to July 2012) and 5,533 discharges in the post-SCM group (September 2012 to September 2013).⁵ In this study, SCM was associated with a decrease in medical complications, length of stay (LOS), medical consultations, 30-day readmissions, and cost.⁵

Since SCM requires ongoing investment by institutions, we now report a follow-up study to explore if there were continued improvements in patient outcomes with SCM. In this study, we evaluate if there was a decrease in medical complications, LOS, number of medical consultations, rapid response team calls, and code blues and an increase in patient satisfaction with SCM in Orthopedic and Neurosurgery services between 2012 and 2018.

We included 26,380 discharges from Orthopedic and Neurosurgery services between September 1, 2012, and June 30, 2018, at our academic medical center. We excluded patients discharged in August 2012 as we transitioned to the SCM model. Our Institutional Review Board exempted this study from further review.

SCM Structure

SCM structure was detailed in a prior article.⁵ We have 3.0 clinical full-time equivalents on the Orthopedic surgery SCM service and 1.2 on the Neurosurgery SCM service. On weekdays, during the day (8 am to 5 pm), there are two SCM hospitalists on Orthopedic surgery service and one on Neurosurgery service. One SCM hospitalist is on call every week and takes after-hours calls from both surgical services and sees patients on both services on the weekend.

During the day, SCM hospitalists receive the first call for medical issues. After 5 pm and on weekends and holidays, surgical services take all calls first and reach out to the on-call SCM hospitalist for any medical issues for which they need assistance. Surgery service is the primary team and does the discharge summaries. SCM hospitalists write any medical orders as needed. Medical students, physician assistant students, medicine housestaff, and geriatric medicine fellows rotate through SCM. SCM hospitalists directly communicate with the surgical service and not through the learners. There are no advanced practice providers on SCM service. Surgery housestaff attend the multidisciplinary team care rounds with the case manager, social worker, rehabilitation services, and pharmacy with ad hoc presence of SCM hospitalists for selected patients. SCM hospitalists often see sick patients with the surgery service at the bedside, and they work together with the surgery service on order sets, quality improvement projects, and scholarly work.

SCM hospitalists screen the entire patient list on their assigned surgery service each day. After screening the patient list, SCM hospitalists formally see select patients with preventable or active medical conditions and write notes on the patient’s chart. There are no set criteria to determine which patients would be seen by SCM. This is because surgeries can decompensate stable medical conditions or new unexpected medical complications may occur. Additionally, in our prior study, we reported that SCM reduced medical complications and LOS regardless of age or patient acuity.⁵