Co-Management of Hospitalized Patients: The Risk of Poorly Defined Physician Roles
CME Information
Sponsored by: NORCAL Mutual Insurance Company, a member of the NORCAL Group. The NORCAL Group of companies includes NORCAL Mutual Insurance Company, Medicus Insurance Company, NORCAL Specialty Insurance Company and FD Insurance Company.
NORCAL Mutual Insurance Company is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
For questions, please call the Risk Management Department at 855.882.3412.
Method and Medium
To obtain CME credit, read the article then take the quiz and fill out the evaluation form. You can print or email your CME certificate from this application.
Please complete and submit the online quiz by the expiration date indicated below:
Original Release Date: September 15, 2017
Expiration Date: October 1, 2019
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
All clinicians, healthcare staff and administrators involved in the treatment of hospitalized patients.
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Policy
As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Co-management of hospitalized patients means different things to different people. Co-management typically involves a hospitalist and surgeon, although it can occur between other specialists. Unlike traditional consultation arrangements, where general medical consultation is provided on an "as needed" basis, during co-management a hospitalist actively and proactively manages the patient's general medical conditions, along with a surgeon or other specialist.1,2 What distinguishes co-management from a traditional consultant model is equality in responsibility, authority and accountability between the hospitalist and surgeon or other specialist.1
Hospitalized patients with multiple comorbidities may benefit most from co-management. Instead of a reactionary approach to complications associated with comorbidities, early and consistent hospitalist involvement can prevent complications from occurring. Co-management can also facilitate coordination of care in different ways. For example, in some settings, co-management can reduce the number and variety of specialists involved in a patient's hospitalization, while in other settings, it might increase the opportunities for hospitalists to collaborate and communicate with a broader spectrum of healthcare team members.3 However, co-management is not ideal for every patient4 and may not be appropriate for every hospital setting; thus, when contemplating co-management, hospital administrators, specialty and hospitalist groups, and individual physicians should put patient safety first.5
In order for co-management to be safe and effective, communication between comanaging physicians must be robust; roles and responsibilities must be clearly defined, with authority and accountability for the patient's care appropriately shared; and physician expectations must be aligned.6,7 Along with policies and protocols, an effective tool for achieving these co-management goals is a very clear, mutually generated co-management agreement. Also known as service line agreements or memorandums of understanding,5 these documents should provide enough guidance to remove ambiguity from the co-management of individual patients and from the co-management process in general.1,8
This article focuses on co-management involving a hospitalist. As more hospitalists care for patients, the concept of co-management has developed as a way to formalize the hospitalist's role in patient care. Co-management can have many benefits when it is well planned and executed. When disorganized, poorly designed, inconsistently utilized and/or misunderstood, co-management can expose patients to injury and members of the healthcare team to lawsuits.4
Co-management Agreements
Co-management can occur in the absence of co-management agreements, but written co-management agreements are preferred for risk management and patient safety purposes. A co-management agreement aids in the formalization of coordination of care between the co-managing physicians and the facility in which they are caring for the patient. Co-management agreements will vary depending on the facility and specialty service, but typically include:
Delegation of duties for:
Admission and discharge
Writing orders
Following up on test results
Ordering consultations
Preoperative evaluations
Pain management
Postoperative care, including venous thromboembolism prophylaxis
Process for conflict resolution
Communication expectations
The co-management agreement does not need to be called a "co-management agreement," so long as the document(s) adequately defines physician roles and responsibilities.
The Hospital Medicine Society has multiple resources for physicians and practice managers who are interested in adding co-management to their patient care strategies, including examples of co-management agreements. These resources can be accessed following a no-cost registration at: www.hospitalmedicine.org/... (accessed 8/7/2017).
Hospitalist and Surgeon Co-management
For many surgery patients, co-management by a hospitalist and surgeon may be more effective than a traditional consultant model. A patient with comorbidities may be more at risk for experiencing adverse events associated with the comorbidities than for those associated with the surgery.3 During co-management, a hospitalist can proactively manage patient comorbidities, such as diabetes, congestive heart failure and hypertension, and the surgeon can focus on the issues associated with the surgery.6,2
A significant issue in co-management is ensuring physicians are providing treatment within the scope of their clinical expertise and training.5 Consider how a better co-management plan could have affected the outcome of this case.
Case One
Allegation:
The hospitalist and surgeon failed to appropriately manage compartment syndrome, which resulted in amputation of the patient's leg.
An obese, diabetic patient with congestive heart failure was admitted to the hospital following elective left knee surgery. Because of the patient's comorbidities, the surgeon requested co-management with a hospitalist. During the procedure, the surgeon nicked an artery without realizing it. Four hours after the surgery, a nurse noted an absent left pedal pulse. She reported this to the surgeon, who told her he would examine the patient the next morning.
The morning of postoperative day one, the surgeon examined the patient. He diagnosed left foot drop and ordered an ankle-foot orthosis and physical therapy. At noon, the hospitalist examined the patient, who was now complaining of severe pain in her left calf and an inability to wiggle her toes. The hospitalist thought that the patient's symptoms might be caused by arterial insufficiency. He ordered an arterial ultrasound. The hospitalist did not discuss his plan with the surgeon and did not request a consultation with a vascular surgeon or a neurologist. He believed the surgeon was responsible for ordering consultations for surgery-related issues.
The arterial ultrasound was performed the morning of postoperative day two. The ultrasound tech entered a preliminary result in the electronic health record (EHR) that indicated the patient had diminished arterial flow in her left lower leg.
Later that morning, the surgeon examined the patient but did not notice the preliminary arterial ultrasound report in her record. He suspected the patient's symptoms were being caused by deep venous thrombosis. He ordered a venous ultrasound.
On the morning of postoperative day three, a radiologist informed the patient's nurse that the venous ultrasound was negative. The nurse called the hospitalist and informed him that "the ultrasound" was negative. The hospitalist assumed the nurse was referring to the arterial ultrasound and, therefore, discharged the patient. He did not realize the surgeon had ordered a venous ultrasound.
On postoperative day four, the radiologist's entered into the EHR his final report on the arterial ultrasound. His impression was the left leg and foot were not receiving adequate blood flow. The radiologist did not inform the hospitalist of this finding. The hospitalist did not follow up on the arterial ultrasound because he believed it was negative. The surgeon was never aware of the arterial ultrasound results.
Three days after the patient was discharged, she was diagnosed with compartment syndrome. An emergency fasciotomy was done; however, the patient ultimately developed osteomyelitis, which required an above-the-knee amputation.
The patient filed a lawsuit against the hospitalist, the surgeon and the hospital.
Experts who reviewed the case were critical of the surgeon, hospitalist, radiologist and nursing staff. The hospitalist increased the potential for confusion by ordering an arterial ultrasound without consulting with the surgeon. According to experts, he should have deferred all surgical follow-up to the surgeon. But once the hospitalist put himself in the position of diagnosing a post-surgical complication, he was required to meet the standard of care of a surgeon. He failed to meet that standard of care by:
Failing to order the arterial ultrasound STAT
Failing to request a consultation with a vascular surgeon
Basing his discharge decision on a verbal report by the nurse instead of documented negative test results
According to experts, a timely consultation with a vascular surgeon and/or timely response to the abnormal arterial ultrasound could have saved the patient's leg. The surgeon was criticized for failure to appropriately diagnose and treat compartment syndrome. Experts also believed the radiologist should have contacted the physician directly with the arterial ultrasound results.
Poor Communication
In this case, neither the surgeon nor the hospitalist had any real sense of what the other was doing because they were not talking to each other or reading each other's medical record entries. A phone call, conversation or thorough review of the patient's medical record would have significantly increased the probability of the arterial ultrasound results being appreciated in a timely manner. Even though the radiologist was not a co-manager, his failure to directly communicate a critical result to the hospitalist was a significant contributing cause of the patient's injury.
Poor Planning and Coordination
This hospital had a co-management program, but during litigation it became clear that neither the orthopedic surgeon nor hospitalist were clear about their roles and responsibilities associated with the program. The surgeon believed that requesting hospitalist co-management shifted all post-operative patient management responsibility to the hospitalist. The hospitalist was unaware of the co-management program; he ordered the arterial ultrasound because he believed it was appropriate. He did not consider whether the workup of a surgical complication would have been more appropriately handled by the surgeon. However, he did believe ordering consultations for surgical complications was the surgeon's responsibility. The role confusion most likely contributed to the nurse's failure to communicate the results of the venous ultrasound in greater detail. If the surgeon and hospitalist had been aware of and understood the co-management policies, procedures and agreements, they would have been better able to coordinate the patient's care.
Critical Result Communication
Failure to communicate critical radiology findings in a timely manner is a frequent basis of malpractice allegations against radiologists.a The criticality of a finding may require the radiologist to contact the ordering physician directly prior to the delivery of the final report. Different levels of urgency may require different methods of communication.b Posting a critical result solely in the EHR will rarely fulfill this objective.
The American College of Radiology recommends communication in addition to the final report when findings:c
"Suggest a need for immediate or urgent intervention"
"Are discrepant with a preceding interpretation of the same examination and where failure to act may adversely affect patient health"
"May be seriously adverse to the patient's health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in an adverse patient outcome"
The Joint Commission requires accredited facilities to define critical results.d A critical results list can facilitate clinical decision-making and communication between radiologists and ordering physicians. An example of critical findings listed by level of criticality, developed by the ACR Actionable Reporting Work Group, can be accessed at: jacr.org/... (accessed 8/15/2017).
a. Berlin L. Communicating findings of radiologic examinations: whither goest the radiologist's duty? Am J Roentgenol. 2002;178:809–15; Berlin L. Communicating results of all radiologic examinations directly to patients: has the time come? Am J Roentgenol. 2007;189:1275–82, cited in Babiarza LS, et al. Neuroradiology Critical Findings Lists: Survey of Neuroradiology Training Programs. AJNR 2013 34: 735–739. Available at: www.ajnr.org/... (accessed 8/15/2017).
b. Larson PA, et al. Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work Group. J Am Coll Radiol. 2014;11:552-558. Available at: www.jacr.org/... (accessed 8/15/2017).
c. American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. (Resolution 11) 2014. Available at: www.acr.org/... (accessed 8/15/2017).
d. The Joint Commission. Hospital National Patient Safety Goals. NPSG.02.03.01. Available at: www.jointcommission.org/... (accessed 8/15/2017).
Hospitalist and Obstetrician Co-management
Obstetrician and hospitalist policyholders have called the NORCAL Risk Management Department to ask whether a pregnant woman with a non-obstetrical medical issue should be admitted to the obstetrics or general medical service. Co-management can alleviate the discomfort hospitalists and obstetricians have with admitting a patient for a condition that may require diagnosis and treatment outside of their areas of specialty. Consider potential admission strategies for the following situation.
Case Two9
Issue:
Should a pregnant woman with a non-obstetrical medical condition be admitted to the obstetrics or general medical service?
A 30-year-old woman with a diagnosis of Marfan syndrome, who was 20-weeks pregnant, presented to the emergency department (ED) complaining of left leg pain and mild lower back pain. Doppler venous ultrasound showed no evidence of deep venous thrombosis, but there appeared to be decreased blood flow to the leg in the left-lying position, with normal blood flow in other positions. Fetal monitoring indicated fetal well-being.
This case presents the dilemma typically faced with pregnant patients who need to be admitted. In a traditional consultation model, a pregnant patient with a non-obstetrical diagnosis can be admitted by her obstetrician with a hospitalist/medical service consult, or the patient can be admitted by a hospitalist to the medical service with an obstetrical consult. But these patients may require more attention from the physician designated as the consultant. For example, if the patient is admitted to the medical service, to ensure the safety of the mother and fetus, a hospitalist may need substantial access to an obstetrician for a variety of issues, including ordering medications that would not negatively impact fetal well-being. The best solution for obstetricians, hospitalists, and facilities trying to decide how to deal with these patients is to sit down together and create a co-management plan.
Co-management Strategies
Co-management of hospitalized patients is more commonplace for surgical patients,1 but it can also work for pregnant patients with non-obstetrical diagnoses. There are no national guidelines that address the service to which a patient with a non-obstetrical diagnosis should be admitted. However, the emerging practice patterns, while by no means universal, generally seem to be driven by the viability of the fetus.
When the fetus is "pre-viable" (earlier than 23-24 weeks), a pregnant patient with a non-obstetrical diagnosis may be admitted to a medical service with co-management by an obstetrician and hospitalist. It is generally agreed that the best thing for the baby’s health is to treat the mother. The obstetrician would manage various aspects of care to ensure the safety of the fetus, including medications and tests.10 In the later stages of pregnancy, once the fetus is "viable," it is probably better for the fetus if the mother with a non-obstetrical condition is admitted to an obstetrical unit where the nurses can monitor the fetus and respond immediately in the event delivery becomes imminent. Meanwhile, the hospitalist would actively manage the patient's medical condition.10
The risk of injury to the mother and the fetus increases if the hospital does not have clear procedures for determining how the hospitalists and obstetricians will coordinate the care of the pregnant patient once she is hospitalized. Coordination and cooperation is the key. Several experts have opined that from a liability standpoint it is not necessarily important who admits the patient, as long as the patient is admitted to the appropriate unit and the nurses know who to call for what issues. The liability exposure for a physician in a co-management arrangement would be essentially the same whether he or she is the admitting physician. Therefore, managing liability risk exposure depends less on the admitting physician and more on making sure that both the obstetrician and the hospitalist are taking care of the patient's issues associated with their area of expertise.11
The definition of co-management is not settled. Co-management programs can be adapted to different patient populations and hospital environments. Consider the following recommendations:
Co-management Planning
Co-management requires planning. Stakeholders from specialty and hospitalist groups and hospital administration should create policies, protocols, and co-management agreements that include:2,5,11,12,13
Allocation of roles consistent with physician team member scope of specialty
For example, in surgeon and hospitalist co-management, the surgeon would decide whether and when the patient needs surgery and provide post-procedural surgical care and monitoring, while the hospitalist would actively manage chronic medical issues and identify and manage acute medical issues.
Allocation of roles during various stages of the patient's hospitalization
For example, the service agreement would allocate hospitalist/specialist responsibility for:
Admitting patients
Assessing patients prior to procedures
Reconciling medications
Writing orders
Managing complications
Discharging patients, including designating responsibility for writing the discharge summary and communicating discharge information to the patient's primary care physician
Making clinical decisions, including designating responsibility for routine patient safety measures, such as deep venous thrombosis prophylaxis
Relaying orders and opinions to staff and patients
Responding to staff
Following up on test results
Guidelines for selecting patients for co-management and to which service they should be admitted
Reliable methods for contacting members of the co-management team and expected response times
Consider exchanging cellphone numbers.
Expectations for routine communication between co-managers, including timing, method and location
Methods for ensuring that tasks are accomplished
Processes for conflict resolution, addressing both conflicts within the co-management program as a whole and conflicts that occur during a patient's hospitalization
Training methodologies and expectations for communicating co-management agreements, policies and protocols to physicians and staff
Physician Engagement and Compliance during Co-management
The success of a co-management program depends on physician engagement and compliance. Co-managing physicians should consider the following recommendations:7,11,14
Follow the roles set forth in the agreement, unless doing so compromises patient safety.
Do not assume the other group co-managing the patient is taking responsibility for a task unless it has been spelled out in the co-management agreement or discussed and documented.
Do not pressure the other physician to undertake tasks outside of the co-management agreement parameters.
Maintain a dialogue about goals and expectations.
Establish a collegial, rather than a confrontational, tone.
Communicate in person when possible. Excellent communication among co-managers is paramount to effective co-management.
Administrator Facilitation of a Co-management Program
Once protocols, policies and agreements are in place, it is important to frequently assess the effectiveness of the program. Administrators should consider the following recommendations:2,5,11,14
Facilitate training to develop certainty of physician roles in co-management.
Ensure realistic expectations among co-managing physicians.
Utilize physician assistants and nurse practitioners (not hospitalists) for tasks that do not require physician-level expertise.
Co-management can be an excellent option for hospitalized patients who need proactive management of chronic general medical issues. However, co-management requires structure in the form of policies, protocols and agreements. Poorly defined and executed co-management arrangements can result in patient injuries and lawsuits. In order for co-management to be effective and safe, hospitalist and specialist groups and hospital administrators should sit down together to create a co-management program that best meets the needs of patients in a manner that is mutually agreeable to the co-managing physicians.
| Special thanks to Fabiola Cobarrubias, MD and Roger M. Hayashi, MD for reviewing this article.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
Beresford, L. The Co-management Conundrum. The Hospitalist. 2011 Apr. Available at: www.the-hospitalist.org/... (accessed 8/3/2017).
Garg M. Consultations/Co-Management. Clinical Advisor. Decision Support in Medicine. Available at: www.mdedge.com/... (accessed 8/3/2017).
Rohatgi N at al. Surgical co-management by hospitalists improves patient outcomes: A propensity score analysis. Ann Surg. 2016;264(2):275-82. Available at: www.medscape.com/... (accessed 8/3/2017).
Siegal, EM. Just Because You Can, Doesn’t Mean That You Should: A Call for the Rational Application of Hospitalist Co-management. J. Hosp. Med. 2008;3:398-402.
Society of Hospital Medicine. The Evolution of Co-management in Hospital Medicine. Society of Hospital Medicine Website. 2017. Available at: www.hospitalmedicine.org/... (accessed 8/3/2017).
Tadros RO, et al. The effect of a hospitalist co-management service on vascular surgery inpatients. Journal of Vascular Surgery. 2016;61(6):1550-1555. Available at: www.sciencedirect.com/... (accessed 8/3/2017).
Colwell J. Planning is key to successful Co-management. ACP Hospitalist. 2015 Mar. Available at: acphospitalist.org/... (accessed 8/3/2017).
Blum K. What hospitalists must know about co-management. The Hospitalist. 2017 Apr. Available at: www.the-hospitalist.org/... (accessed 8/3/2017).
Case study adopted from Pearlman MD, Desmond JS. Pregnant With Danger. PSNet Website. 2005 May. Available at: psnet.ahrq.gov/... (accessed 8/3/2017).
Lee-Parritz A. Book Review: Medical Care of the Pregnant Patient. NEJM. 2008;358:2528-2529. Available at: www.nejm.org/... (accessed 8/3/2017).
Gesensway, D. Are you OK admitting this patient? Today's Hospitalist. 2011 Jan. Available at: www.todayshospitalist.com/... (accessed 8/3/2017).
Cheng HQ. Co-management: Who’s in Charge?. PSNet Website. 2012 June Available at: psnet.ahrq.gov/... (accessed 8/3/2017).
Society of Hospital Medicine. Co-management Work Group of the Practice Management Committee. A White Paper on A Guide to Hospitalist/Orthopedic Surgery Co-Management. Society of Hospital Medicine Website. 2010. Available at: www.hospitalmedicine.org/... (accessed 8/3/2017).
Butterfield S. Surgical co-management done right. ACP Hospitalist. 2009 Mar. Available at: acphospitalist.org/... (accessed 8/3/2017).
2017