February Spotlight – Hospitalist Medicine: Working together as a Team


Submitted by Deborah Gondek, DO

Two years ago, HMS embarked on a partnership with the orthopedic surgery department in order to provide our patients with top quality care at Bryn Mawr Hospital. We felt that it was important for this project to be a joint venture focused on collaborative care from admission to discharge.


Standardizing the process for both our hip fracture and elective joint replacement patients has been our goal. Having the Hospitalists participate has been instrumental to this program’s success. Our Hospitalists perform the initial assessments and are then responsible for pulling the team together and identifying areas that need more focus. They provide the continuity, availability and the knowledge of post-operative complications that this program requires.
For our hip fracture patients, we have enlisted the help of our emergency room partners in rapidly initiating. The aim is to minimize the use of narcotics when possible and implement IV Tylenol use with the hopes of reducing narcotic side effects such as altered mental status which can increase length of stay.  The surgical fracture care plan begins in the Emergency Room with appropriate laboratory and radiographic studies and a simultaneous call to orthopedic surgery and HMS. These patients are admitted to the HMS service with an orthopedic surgery consultation. Surgical risk stratification is performed at that time by our medicine team with findings and recommendations communicated to the orthopedic team. Specific order sets have been written in a collaborative effort by both orthopedics and internal medicine to minimize variation in the process. Our goal is for these patients to be taken to the operating room within twenty-four hours of admission.
We have cohorted our orthopedic patients on one floor so that they can receive the specialized nursing care needed for such diagnoses.  Our nurses are trained in both pre-op and post-op care of these patients. When a higher risk patient is encountered, telemetry monitoring is often required. The nursing department has provided training to the RNs on this unit in reading EKGs so that stable patients need not be moved to other floors simply because they need a monitor.
Post operatively, we work together as a team so that patients receive the attention they require in a timely fashion. To achieve this, daily interdisciplinary rounds have been implemented on this unit. We have also delegated our Nurse Practitioner, Joey Stanley, as our point person to field and address all communications between nursing and Internal Medicine. Each day, she meets with the care team that includes the nursing supervisor, nursing staff, physical therapy, case management and when possible, the orthopedic resident. This helps to address clinical and non-clinical issues as quickly as possible and facilitate discharge planning.
For patients undergoing an elective joint replacement, we have instituted our Perioperative Risk Assessment Clinic within the Hospital. Patients seen by an orthopedic surgeon and recommended joint replacement can then be referred to our clinic for a pre-operative medical evaluation. During these appointments we focus our attention on finding medical issues that can pose risk for post-operative complications. Recognition and treatment of these risk factors help to ensure the best possible outcome for each patient. When the patient presents to our pre-op clinic they are greeted by a nurse for assessment of vital signs, review medications, brief history and performance of an electrocardiogram. Information regarding procedure, surgeon and date of surgery will be provided to the physician prior to evaluation. The physician performs a complete history and physician examination at which time they identify areas that require attention. Arguably, cardiac complications are of greatest concern. Therefore, the current ACC/AHA guidelines on perioperative cardiovascular evaluation are followed. Patients who are identified as increased risk for a cardiac event will be referred to a cardiologist.


With perioperative narcotics use, patients with obstructive sleep apnea are increased risk. Patients who already carry this diagnosis are reminded to bring their CPAP machines. It may become evident though our evaluation and the use of the STOP-BANG screening that a patient is in need of an initial sleep specialist consultation.


Effectively controlling the blood sugar postoperatively is very important too. Optimizing a patient’s HbgA1c is also a part of our checklist. It may be necessary to make adjustments in a patient’s medications preoperatively. Patients are instructed on which medicines and doses can be taken the morning of surgery. Pre-op laboratory studies are obtained during this visit as well and will be tailored to each patient depending on what is discovered during the visit. We discuss with the patient as well as the surgeon, our recommendations for further consultation by other subspecialties prior to providing risk stratification and clearance. This encounter is then detailed in an internal medicine History and Physical, available when the patient presents the day of surgery. This report, including any new ancillary studies, is also sent to the Primary care physician by our clinic.


We have seen the implementation of this care plan improve patient outcomes. By identifying risk and maximizing medical therapy prior to the surgery helps mitigate postoperative complications. A team approach and open communication is essential in order to provide these patients with the best care possible. Everyone has an important part of taking care of these patients. Having a strong partnership with our nurses has helped with streamlining the process and providing better patient care. Our Hospitalist team has been crucial in identifying and integrating medical care that each patient requires. There is no doubt that Bryn Mawr Hospital is on the cutting edge when it comes to our orthopedic program as it is designed that everyone be a part of the patient’s success.


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