The Surgical Hospitalist: Aligning the Incentives

The Surgical Hospitalist:
Aligning the Incentives of Patients, Hospitals, and Surgeons

Michael S. O’Mara, MD, FACS; Timothy F. Daly, MBA; Cynthia C. Leathers, MPH, MBA; Leon J. Owens, MD, FACS

In 2007, Sutter Medical Center, Sacramento found itself in the same position as many other facilities across the country. Rising costs and decreasing revenue had collided with the crisis of a national physician shortage. The increasing demands of busy practices coupled with long hours and poor reimbursement were crushing the desire of the general surgeons to cover emergency and in-hospital call. The success noted by other hospitals in creating surgical hospitalist and acute care surgery programs spurred the administration to look for a similar solution.

The problem they faced was that no umbrella existed under which surgical hospitalists could reside. In most other hospitals with such programs, the emergency and acute surgery is integrated with the trauma programs; in others, the academic nature of the institution allows 24-hour, seven day-a-week coverage in-house in the form of residents with attending back-up. Sutter Medical Center, Sacramento, operates two separate hospitals on two campuses approximately two miles apart with a total of 650 acute care beds. The only affiliated residency program is family medicine. Neither campus houses a trauma program. All acute general surgery coverage until January 2008 was done on a rotating basis by members of the medical staff who had general surgery privileges.

The real dilemma that exists when investing in a new paradigm in medical care is to address the mandate of the modern era: improve safety, enhance quality, increase patient satisfaction, and lower costs. Common thought is that if you do the first three, lower costs will follow. To lead the process, Sutter Medical Center brought in Surgical Affiliates Medical Group, Inc., a local group with experience in developing a trauma model in a community hospital setting without an established trauma or academic service. This acute care surgery, hospital-based program became the model for the surgical hospitalist program at Sutter Medical Center.

The Program
Sutter Medical Center, Sacramento, contracted with Surgical Affiliates Medical Group, Inc. (SAMGI), a privately held corporation, to implement a surgical hospitalist program. SAMGI provides 24/7 in-house general surgery coverage to both hospitals through a subsidiary group, Acute Care Surgery Medical Group (ACSMG). These general surgeons are available in-house for all acute surgical consults. The joint mission for SAMGI and Sutter Medical Center Sacramento is as follows: To provide acute surgical care in an expert, efficient, team-oriented manner, accomplished by: Establishing a workable system whereby a select group of general surgeons, focusing upon the care of the acute surgical patient in the hospital setting, can act to provide expedient, expert care.

Providing a schedule that allows the individual surgical hospitalist to provide complete care to the patient while allowing clear handoff between surgeons and sufficient time off to maintain a rewarding lifestyle.

Providing coverage and support for non-elective surgical consults, allowing the non-hospitalist surgeons to provide improved surgical care to their elective and established patients while allowing enhancement of their own lifestyles.

Establishing a system of communication and professional respect with referring physicians that allows the care of their patients to be assisted by our surgical hospitalists and with consulting physicians that provide care that goes beyond our training or expertise.

Creating a system of review using physician practice management guidelines (PPMG’s) that are evidence based with the goal of providing safe, sensible, and successful patient care.
Intervening for surgical patients in an appropriate and expeditious fashion to shorten length of stay and decrease risk of complications, thereby decreasing cost and increasing hospital bed availability while improving resource utilization.

The surgical hospitalist program functions with the following guidelines:
A board-certified general surgeon is in-house at all times.
The general surgeons on the team average two non-consecutive 24-hour shifts per week. There are about four full-time equivalent general surgeons.
The general surgeons are supported by physician extenders. NP/PAs work under the supervision of the on-call physician during morning rounds and clinic and provide back-up for emergencies and surgical assistance 24/7.
Most acute surgical consults in the hospital or in the emergency room are referred to the surgical hospitalist on call. Requesting physicians have the right to consult any surgeon they wish, and are not limited to the surgical hospitalists.
The surgical hospitalists do daily rounds and sign-out with one another and with the consulting medical hospitalist and intensivist teams.
An outpatient clinic is held two half-days per week and is limited to only follow-up appointments from inpatient procedures.
No elective surgery is performed by the surgical hospitalist team.
A monthly quality assurance meeting is held by the surgical hospitalists to evaluate care in an ongoing fashion.
The surgical hospitalist team creates policy and procedure guidelines for patient care both for internal consistency and to inform consultants of the preferred mechanisms of evaluation and care.

The Result: Improved Patient Care and Serving the Underserved
Institution of the surgical hospitalist program has improved patient access to in-hospital acute surgical care. Annualized data from the first nine months of 2008 show a significant increase in the number of operations and consults over 2007. In 2007, an estimated 600 acute surgical procedures were performed; in 2008, over 700 are expected to be done. Projected consults from 2007 data was 1,115; nearly 2,500 consults will have been done by the surgical hospitalists in 2008. The majority of consults and operations are for the core of acute surgery: cholecystectomies (32%), appendectomies (29%), laparotomies (21%), and drainage of abscesses (8%). This distribution is similar to what was seen in 2007.

The availability of the surgical hospitalists has led to care that is more expeditious. For the evaluation of the patient with biliary disease, the time to consult from the time of emergency admission decreased from 11.3 hours in 2007 to 6.2 hours in 2008. For appendectomy, there has been no real improvement in the time it takes for a surgeon to see the patient, this taking 5.4 hours from time of emergency room admission in 2007, and 5.6 hours in 2008. However, this delay is the time it takes for the admission and evaluation of acute appendicitis in the Sutter Medical Center emergency department (exam, labs, and computed tomography scanning).

For appendicitis, there has been no significant change in the interval from time of presentation to first incision in the operating room: 8.3 hours in 2007, and 9.7 hours in 2008. For cholecystectomy, this time has dropped from 40.4 hours in 2007 to 21.5 hours in 2008. This rapid evaluation coupled with the round-the-clock surgical and OR availability has reduced the length of stay in cases of both appendectomies and cholecystectomies. Patients with appendectomies have seen a reduction in average length of stay from 3.0 days to 1.7 days. Those undergoing cholecystectomy have had length of stay shortened from 5.1 days in 2007 to 3.6 days on average in 2008. This LOS reduction comes from rapid movement to the operating room and the surgical hospitalist availability to evaluate the patient for discharge at any time of day, unencumbered by office hours or other practice responsibilities.

Looking at the patients who have undergone appendectomy and cholecystectomy by the surgical hospitalists in 2008, the outcomes are excellent. A 1.2% readmission rate is unchanged from that of 1.3% in 2007. No returns to surgery have been needed, and no patients have died following appendectomy or cholecystectomy. Preliminary data on the other operations performed by the surgical hospitalists (laparotomies, abscess drainages) display similar good results and decreased length of stay.

The Result: Patient and Physician Satisfaction
A survey was sent to members of the medical staff, nursing, and case managers. The overwhelming response was positive, with 33 of the 55 responders (60%) indicating very good overall satisfaction with the surgical hospitalist program. Fifty of the 55 responses (91%) stated good or very good satisfaction. Only five responses implied only fair satisfaction, and no one replied that dissatisfaction existed with the surgical hospitalists.

Consulting physicians are universally happy with the new program, with 100% of emergency physicians (11 of 11) remitting good or very good satisfaction. One physician went so far as to say the availability was the best he had seen in his decade in the emergency room. Medical hospitalists were likewise satisfied, with 95% indicating good or better satisfaction (18/19). Ninety percent stated that the response time and overall program had improved greatly from the situation before the surgical hospitalists’ presence. The non-participating general surgeons revealed the most dissatisfaction with the program, with three of nine responses indicating only a fair satisfaction with the program. Concerns seemed to focus around the urgent and acute surgical cases changing the operative schedule for the day and delaying elective cases. Nursing satisfaction was also high (all good or very good) with the primary comments centering on the excellent availability of the surgeons.

As for the surgical hospitalists themselves, there has been great improvement in the quality of their lives. The rotating schedule and flexibility have allowed them time for family and outside projects not always readily available to surgeons in private practice. Reliability of income has left the surgeons more interested in patient care and less on the maintenance of an office, overhead, and insurance issues.

The Result: Lower Costs and Increased Income
By decreasing the time it takes to get to the operating room and decreasing length of stay, the surgical hospitalists have decreased hospital costs. Appendectomy cases have seen a reduction in cost from 2007 to 2008 of 30%. Cholecystectomy cases have seen a 20% decrease in costs. The top five billed procedures during 2008 have been laparoscopic appendectomy, laparoscopic cholecystectomy, open appendectomy, laparotomy with lysis of adhesions, and laparotomy with small bowel resection. When evaluated, the profit margin of these five procedures in 2007 was in the negative; in 2008, a positive profit per case was identified. This includes all insured and uninsured patients. The result of this swing, for the top five operative procedures being performed by the surgical hospitalists, was to convert a substantial dollar loss in 2007 into what promises to be a profit in 2008, a remarkable turnaround that has enhanced Sutter Medical Center, Sacramento’s mission of providing more affordable healthcare to its community.

Beyond the tangibles of cost and profit for the cases directly performed by the surgical hospitalists, are the intangibles of increased bed availability and decreased emergency room utilization. With a reduction in length of stay, for just the cases of appendectomy and cholecystectomy, we predict an increase in availability of 600 bed days because the patients have been discharged appropriately and expediently. This results in beds being available for other patients, increases emergency department throughput, potentially increases hospital revenue, and makes care available to more patients.

Patients who previously had been seen multiple times in the emergency room for surgical problems are now evaluated by the surgical hospitalists. Now these chronic, recurrent problems (including intractable biliary colic, recurrent incarcerated hernias, et al) are dealt with on an urgent basis regardless of patient insurance status. This helps alleviate the impact on the emergency department by these chronic problems. The revolving door nature of these urgent problems is definitively addressed, stopping the continued drain of hospital resources with the appropriate operation.

Conclusions
Implementation of a surgical hospitalist model has been shown previously to be good for patient care and physician satisfaction. With the current decrease in the availability of general surgeons, surgical hospitalists provide necessary care in an efficient, cost-effective manner. Patient care is, at worst, no different than that provided by private practice general surgeons; and at best, an improvement over what surgeons burdened with elective practices and busy offices can provide. By improving patient care, surgeon efficiency, and employee satisfaction, we have shown that a surgical hospitalist model can also decrease costs and provide more efficient use of hospital resources.

The model of acute care surgery can be taken outside of the academic center, away from the trauma program, and implemented in a community hospital in need of general surgery coverage. By building on existing models and employing a system dedicated to providing acute surgical care, surgical hospitalists can provide high quality, cost efficient patient care. At Sutter Medical Center, Sacramento, the surgical hospitalist program has resulted in a successful, sustainable program for the care of acutely ill patients.


Michael S. O’Mara, MD, FACS is medical director of Acute Care Surgery Medical Group, Inc. He can be contacted at mshayo@yahoo.com

Timothy F. Daly, MBA, is Assistant Administrator of Surgical, Ancillary, and Support Services for Sutter Medical Center, Sacramento. He can be reached at dalyt@sutterhealth.org

Leon J. Owens, MD, FACS is president and CEO of Surgical Affiliates Medical Group, Inc. He can be reached at info@samgioncall.com. SAMGI operates a website at www.samgioncall.com where further information is available.

Cynthia C. Leathers, MPH, MBA, is the COO for Surgical Affiliates Medical Group, Inc. SAMGI operates a website at Surgical Hospitalists Services and Programs | www.samgioncall.com where further information is available.