Assigning Hospitalists to Individual Inpatient Units Has Benefits and Drawbacks

Unintended consequences of assigning hospitalists to one or two inpatient units include the temptation to increase patient loads on the clinicians.

Assigning hospitalists to an inpatient unit—also known as geographic cohorting—increases direct care time with patients but often comes with unintended consequences, a new journal article says.

Geographic cohorting of hospitalists is becoming a common practice at U.S. hospitals, with a 2017 survey finding that 30% of medicine group leaders reported clinicians rounded daily on one or two inpatient units. Other research associated geographic cohorting with reduced costs, length of stay, and mortality when the staffing method was included in an accountable care team model.

The new journal article, which was published online by Journal of Hospital Medicine, features a time-motion study of geographic cohorting (GCh) hospitalist teams and non-geographic cohorting (non-GCh) hospitalist teams.

"Cohorting’s benefits are theorized to include increased hospitalist time with patients, while its downsides are perceived to include increased interruptions," the journal article's co-authors wrote.   

The new research data supports the theories:

• GCh hospitalists were found to have the highest predicted time for direct care encounters with patients at 9.5 minutes.
   
• GCh hospitalists were interrupted at a significantly higher rate than non-GCh hospitalists. In the morning, GCh hospitalists were interrupted once every 14 minutes and non-GCh hospitalists were interrupted once every 13 minutes. In the afternoon, GCh hospitalists were interrupted every 8 minutes and non-GCh hospitalists were interrupted every 17 minutes.

Interpreting the data

In comments provided to HealthLeaders via email, two of the journal article's co-authors discussed their research findings, including the observation that GCh hospitalists spent more time with their patients.

"The increased proximity between the physician and the patient may facilitate multiple visits with patients on the same day, as well as longer visits," said Michael Weiner, MD, MPH, professor of medicine, Indiana University School of Medicine, Indianapolis, and research scientist, Regenstrief Institute, Indianapolis; and Areeba Kara, MD, MS, assistant professor of clinical medicine, Indiana University School of Medicine, and hospitalist, Indiana University Health, Indianapolis.

Interruptions appear to be a drawback of geographic cohorting, they said. "Interruptions were pervasive among hospitalists but more commonly noted in the geographically cohorted group. With geographic cohorting, the increased presence of the hospitalist on the unit fosters interprofessional relationships and collaboration, which may increase both timely and untimely communication."

The time-motion study found that the time of each patient visit decreased 14% when the patient load on hospitalists increased from 10 to 20 patients. Hospital leaders should avoid the temptation to increase patient loads on GCh hospitalists, Weiner and Kara said.

"Experience suggests that the anticipated gains in efficiency from cohorting lead to an expectation that cohorted teams should be able to manage more patients. This was noted in our study and has also previously been raised as a concern in a national survey of hospitalists. Ironically, higher patient loads were associated with shorter visits, thus seeming to erode the benefits of cohorting."