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A Week in the Life of a GI Hospitalist

A Week in the Life of a GI Hospitalist. Stanley Miller, MD Gastrointestinal Associates, PC Knoxville, TN. Objectives of Talk . What is a GI hospitalist? What does Stan Miller do as a GI hospitalist? How does it affect patient care to have a GI hospitalist?

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A Week in the Life of a GI Hospitalist

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  1. A Week in the Life of a GI Hospitalist Stanley Miller, MD Gastrointestinal Associates, PC Knoxville, TN

  2. Objectives of Talk • What is a GI hospitalist? • What does Stan Miller do as a GI hospitalist? • How does it affect patient care to have a GI hospitalist? • What does it mean for the GI lab staff and other patient care personnel to have a GI hospitalist in the hospital? TSGNA October 2011

  3. Introduction • Started September 1998 • Currently 11 Physician GI group • 2 nurse practitioners • 1 full-time GI hospitalist • Started GI practice in 1989, last 13+ years as GI hospitalist TSGNA October 2011

  4. Definition of GI Hospitalist • Physicians whose primary focus of care is inpatient medicine are called hospitalists. (Wikipedia) In my case, I practice full time gastroenterology on inpatients so I call myself a GI hospitalist. TSGNA October 2011

  5. GIA Hospitalist Team • One full time physician • One full time Registered Nurse • One full time nurse practitioner • Splits time at two hospitals, mornings with me at Physicians Regional Medical Center and afternoons at smaller North Hospital TSGNA October 2011

  6. Melanie R.N. and Amy F.N.P TSGNA October 2011

  7. Objectives of Hospitalist • More efficient use of physician time • More efficient use of hospital GI lab • More efficient use of office and office based gastroenterologists • Cost savings and improved patient outcomes TSGNA October 2011

  8. Duties of a GI Hospitalist • See inpatient consults • Round on hospitalized patients with GI issues • Perform specialized hospital based GI procedures (to be discussed later) • Admit primary GI focused patients • Answer emergency calls TSGNA October 2011

  9. Job Description Dr. Miller • Monday-Friday 6AM-4PM on call • All night admits, consults held over unless an emergency consult • No office work • Nights, weekends covered by partners • One holiday a year in rotation TSGNA October 2011

  10. Job description • I see consults, take calls from ER and patients referred from office • Round on inpatients for our group daily • All new patients are assigned to office doctor for outpatient followup as needed TSGNA October 2011

  11. Hospital based specialized procedures • ERCP’s, a main area of expertise • 200-300 ERCP’s each year • Rare referrals to tertiary centers now • Problem-back up support when I am gone TSGNA October 2011

  12. Other types of patients • Defibrillator patients • Food impactions • Nursing home patients • Obese, over 400# • Argon plasma coagulation • Balloon dilations • Stents outside biliary tract, ie esophagus TSGNA October 2011

  13. Hospital expertise • Bleeding of gut is common, adept at clips, cautery, injection • Numerous foreign bodies removed of all types over the years • Towels, pens, razors, flossing devices, toenail clippers, coins, batteries, paper clips, sex toy (unsuccessful) and lots and lots of meat. TSGNA October 2011

  14. Hospitalist Contract • Base Salary with guarantee • Productivity based income • Full partnership • 4 weeks off per year, work one holiday • Low office overhead, charging for what is used instead of full share due to lower revenue stream TSGNA October 2011

  15. Advantages • More efficient use of office ASC • Office M.D.’s with few or no interruptions from hospital, earlier start at office • Less congestion in hospital GI lab TSGNA October 2011

  16. Advantages • Hospital M.D. expertise in hospital procedures and patients such as ERCP’s, bleeding, working with defibrillators, anticoagulants • Staff knows who to call in hospital for problems • Working relationship with pathology, radiology, Medicine hospitalists TSGNA October 2011

  17. Advantages • Hospital likes it due to built in efficiencies of expediting care, shorter length of stay • Office doctors have less call time • Hospitalist has no nights or weekends TSGNA October 2011

  18. Impact on Patient Care Consistent Patient Flow • GI lab staff • Same routines working with me daily • Fewer errors with standard protocols i.e. preop antibiotics for PEG, biliary obstruction, etc • Scheduling consistencies since usually I perform/function same way day to day • I learned quirks of GI lab and adapt some also • I have been able to teach as well as learn from my close working relationship with nurses/techs TSGNA October 2011

  19. Impact on patient care • Hospital Staff in ICU and on floors • They know who to call for orders, problems • Staff does not have to go through office voicemail jail to find me • Service and call backs (at least by me) are more prompt and responsive since I am in the hospital providing patient care TSGNA October 2011

  20. Impact on Patient care • For Hospital/Administration • Quicker response for procedures • Decreased length of stay. • We showed 0.5 day decrease in length of stay • $400 decrease cost per stay for acute GI bleeding TSGNA October 2011

  21. Impact on Patient care • For partners of GI hospitalist • Less “on-call” time • More efficient use of time, no lost travel time back and forth • Disadvantage is lose touch on some procedures like ERCP’s TSGNA October 2011

  22. Impact on Patient care • Patients • Fewer complications due to expertise • Fewer transfers out to tertiary centers • Shorter length of stay • Lower cost • Consistent face to see while in hospital although not always their primary MD TSGNA October 2011

  23. Impact on Patient care • For other hospital physicians • They know who to call and what response will be instead of a different GI consultant each day • Faster service in seeing consults, getting procedures since I am in house each day TSGNA October 2011

  24. Disadvantages-Patients • Not able to see usual GI physician • Not able to see GI Hospitalist after discharge from hospital TSGNA October 2011

  25. Disadvantages-GI Lab Staff • If MD is a jerk, you are stuck day to day with a jerk TSGNA October 2011

  26. Disadvantages-Hospitalist • Lower reimbursement for hospital patients • Hospitalist burnout • Consults for everything (red jello, pepto bismol) • Unpredictable work load day to day TSGNA October 2011

  27. The WEEK September 2011 • Colonoscopies 9 EGD 15 • Varices banded 1 Foreign Body 1 • PEG 3 ERCP 3 • Flexible Sigmoidoscopies 9 • Consults 25 • Followup Hospital Visits 68 TSGNA October 2011

  28. Diagnosis for 1 Week • Anemia, GI bleeding, CBD stones, Jaundice, Spontaneous Esophageal Perforation (2), Duodenal AVM bleeding, Nausea and vomiting, Diarrhea, Clostridium difficile diarrhea, Infectious colitis, Colon polyps, Rectal bleeding, Short bowel diarrhea, Ileus, Pancreatitis, Dysphagia, Pyloric stenosis, Bleeding duodenal diverticulum, MALT lymphoma, Esophageal stricture, GE reflux, Post Op Ileus, Heme positive stool, Ischemic colitis, Esophageal Varices bleeding, Gastroparesis, Stercoral rectal ulcer bleeding, Foreign body (nail), Diverticular bleed colon, Crohns colitis, Liver mass, Abdominal Pain, Ascites, Rectal cancer, Iron deficiency anemia, Liver Failure, Cirrhosis, Acute Diverticulitis, Abnormal liver tests shock liver. (39 different Dx) TSGNA October 2011

  29. The Day • 6AM-4PM on call officially • 6AM-pick up consults from night • 6:35AM-ICU rounds • 7-8:30AM-see new consults • 8:30-midday-procedures • 1pm-finish, f/u rounds see more consults as they come in TSGNA October 2011

  30. THE DAY, scrutinized • Pick up overnight consults, 4 • Ischemic colitis • GI bleed, 2 of them • Dysphagia • See ICU patients • 3, one esophageal perforation, one massive GI bleed from ulcer and one abnormal liver tests from sepsis TSGNA October 2011

  31. The Day, scrutinized, cont. • Procedures • Screening colonoscopy, 1 • PEG in cancer patient, 1 • Heme positive stool colonoscopy in patient with defibrillator • ERCP with stone removal • Colonoscopy in diverticular bleed patient • Colonoscopy in hospitalized iron deficiency patient • EGD, hematemesis, esophagitis • Sigmoidoscopy, bleeding stercoral rectal ulcer • Esophageal Motility studies, 2, reflux and dysphagia TSGNA October 2011

  32. The Day, scrutinized, cont. • PM rounds • 10 inpatient followup visits • Consult for PEG in demented patient • Consult for anemia • Consult for abdominal pain in chronic narcotic user, 2 • Consult for abnormal liver tests • Urgent scope to remove meat bolus TSGNA October 2011

  33. What type of patients do I see as a full time GI Hospitalist? • 2010 data Top 12 diagnosis • GI bleeding • Dysphagia • Diarrhea • Blood in stool • Iron deficiency anemia • Nausea and vomiting TSGNA October 2011

  34. What type of patients do I see as a GI Hospitalist, cont? • 2010 data, top 12 diagnosis, cont • Esophageal reflux • Hematemesis • Abdominal pain • Colon polyps • Abnormal liver tests • Bile duct stones (choledocholithiasis) TSGNA October 2011

  35. Diagnosis of interest 2010 Data • Foreign bodies esophagus 19 • Acute pancreatitis 51 • Jaundice 33 • Obstruction of bile duct, unsp 34 • Crohn’s disease 20 • Total of 246 total GI diagnosis coded for my encounters on hospital patients TSGNA October 2011

  36. What type of procedures do I perform as a GI Hospitalist? • 2010 Data • Upper endoscopies of all types 880 • Percutaneous gastro tubes 113 • PEG exchanges 28 • ERCP’s 285 • Sphincterotomies 117 • Stone removal 83 • Stent placement 70 TSGNA October 2011

  37. Procedures performed • 2010 Data • Colonoscopies 367 • Only 18 true screening colonoscopies • Sigmoidoscopies 125 • Esophageal motility readings 93 • Hospital consults 952 • Hospital followup visits 1652 TSGNA October 2011

  38. Unusual Consults • Red Jello ostomy output-GI bleed • Black stools-iron or pepto bismol • Razor blade ingestion • Toenail clippers ingested • Sex toy in wrong place • 100’s of tiny gallstones entire biliary tree • Marijuana Nausea and Vomiting, Hot Showers/Hot Tub TSGNA October 2011

  39. Life as a GI Hospitalist • Summary: Why I am a hospitalist Reasonable hours that are relatively stable Fix it and move on Appropriate compensation Development of niche expertise Lifestyle choice TSGNA October 2011

  40. Summary • Objectives met • What a GI hospitalist is and does. • How having a dedicated physician to hospital GI care improves outcomes • How a GI hospitalist improves patient flow and care in a large suburban hospital. • THANK YOU TSGNA October 2011

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