Hospital Medicine:
The Handbook
A Short Compendium of Effective and Efficient Patient-centered Care
Ramegowda Belakere, MD, PhD
Medical Director/Associate Regional Director, Hospital Medicine, (Envision-EMCARE)
Chief of Staff, Houston Northwest Medical Center, Houston, TX 77090.
Jayanthi Ramu, MD, PhD
Emergency Physician, Jackson Memorial Hospital, Edna, TX 77957.
Former Physician Advisor, Executive Health Resources, PA
Hospital Medicine: The Handbook
Copyright © 2018 by Ramegowda Belakere
All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.
ISBN (eBook Edition): 978-1-54392-962-1
Disclaimer
The information provided in this handbook represents concise, practical, and evidence-based knowledge. The authors are clinicians who see patients regularly. They have made concentrated and careful efforts to collect reliable information from published literature and documents to include in this handbook. However, they make no guarantee concerning the contents herein and specifically disclaim any implied guarantee of suitability for any specific purpose. Neither the authors nor any other party involved in the preparation or publication of this handbook shall be liable for any special, consequential, or exemplary damages resulting in all or part of any user’s use of or reliance on this material. The users must check with their coder/hospital for suitability of ideas expressed here for a specific location, region, or state. The suggestions provided in this handbook are not a substitute for clinical judgment. The content of this handbook is covered by copyright laws. The reproduction of any of the information without prior permission in any form is prohibited.
Akash Jayram, Sky Unlimited Publications 2018,
Sugar Land, Texas 77479.
Preface
After 2O years of successful experimentation, Hospital Medicine has now become a part of the established medical landscape. While core competences in medicine can be attained through innumerable books, journals, etc., there is a dearth for literature aimed at enhancing Hospital Medicine practitioners’ capacity to perform their day-to-day roles effectively. This lacuna, and the demand to fill it, has led us to publish an abridged version of this handbook. Its aim is to help the drivers of inpatient care to understand the goals and roles of Hospital Medicine, and to become efficient ambassadors of the profession.
This indispensable resource is loaded with many not-to-be missed tricks of the trade, allowing practitioners to optimize their everyday performance. Hospital Medicine is addressed from many angles, including quality of patient care, safety, cost, efficiency, communication with primary care physicians, nurses, administrators, and other medical staff, leadership roles of hospitalists, and healthcare economics. Also featured are critical issues such as delivering a death message, determining brain death, withdrawing life support, discharging un-dischargeable, hospice care, patients leaving against medical advice, etc.
The authors have gone to great effort to put together these useful materials in a handy book format that can be slipped into the pocket of a white coat. This handbook is intended for Hospitalists, Internists, Family Practitioners, Internal/Family Medicine Residents, Medical Students, Physician Assistants, Nurse Practitioners, Case Management workers and Hospital Administrative staff.
Hospital medicine is the fastest growing specialty in the United States. We believe that the addition of our handbook with many useful information required for daily rounds will have positive impact on the job performance of hospitalists. We also believe that the book will create awareness among the physician communities about the roles of hospitalists.
Finally, we would like to extend our appreciation and thanks to our colleagues, Dr. Srilakshmi Konidala, Dr. Rajeev Ramadugu, and others who took time to review our draft and made many useful suggestions to improve the quality of this publication.
Ram Belakere, MD, PhD
Jay Ramu, MD, PhD
Contents
Preface
SECTION 1: Vitals of Hospital Medicine
Compassionate Care: The Driver
Communication: The Game Changer
Efficiency: The Difference Maker
Rounding Efficiently
Safety: The Basic Premise
Quality: The Central Element
Conditions Present on Admission (POA)/ Hospital Acquired Conditions
Leadership: The Key Player
SECTION 2: Healthcare Performance: The Validator
Healthcare Performance
Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Conditions Reduction Program (HACRP)
SECTION 3: Healthcare Economics: The Primer
Healthcare Economics
Diagnosis Related Group (DRG)
APR-DRG: All Patients Refined Diagnosis-Related Group
Case Mix Index (CMI)
An Overview of Health Plans for Elderly
SECTION 4: Documentation: The Basic Tenet
Documentation Basics
Inpatient Visits Documentation
Progress Notes for Follow-up
Consultation – Initial visit
Discharge Summary
Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs)
Current Procedural Terminology (CPT): Coding for Professional Service
Flow Diagram of Hospital Service CPT Codes (except Critical Care)
Coding Critical Care
Coding Prolonged Inpatient Care
Coding Discharges
Coding Same Day Admit and Discharge
Relative Value Units and Professional Fees reimbursement by CMS
SECTION 5: Hospital Admission
Outpatient Admission with Observation
Outpatient Admission without Observation Status
Inpatient Admission
SECTION 6: Critical Issues and Solutions
Breaking Bad News to Patient
Delivering A Death Message
Determining Brain Death
Withdrawing or Withholding Life Support
Dealing with Difficult Patients
Discharging the Un-dischargeable
Hospice/Comfort care
Against Medical Advice (AMA)
Pain Management and Opioids Use
SECTION 7: Selected References
Hospital Medicine
The goal is to provide Compassionate and Efficient Care to Every Patient, Every Day
Vitals of Hospital Medicine
•Compassion
•Communication
•Efficiency
•Safety
•Quality
•Leadership
Compassionate Care:
The Driver
Compassionate Care
•Compassionate care is an essential part of patient-centered care.
•Compassionate care is affected by care efficiency, effective communication, quality, and safety.
•The presence or absence of compassionate care directly affects hospital experience of patients and their satisfaction.
•Compassionate care often creates lasting and vivid memories for patients and their families. It helps them retain the overall experience of care in the hospital.
•Compassionate care starts with good basic timely care including pain management, meeting feeding requirements, etc., with the participation of the patient or their family members.
•Compassion encompasses patient care with sympathy, empathy, respect, and responsiveness to the individual patient’s preferences and needs.
•Compassion is seeing the person in the patient at all time.
Pointers for Effective Compassionate Care
•Involve patients and their families actively in their care planning.
•Manipulate the environment, have good lighting, have less noise etc., to enhance the comfort of care.
•Acknowledge their concerns and address them appropriately.
•Show respect for patients, their families, and those important to them.
•Communicate verbally and non-verbally. Make eye contact, and turn your body toward the person speaking. Communication should be human to human instead of physician to patient.
•Touch is important, and shaking or holding hands of patients is appropriate.
•Talk respectfully, and use words that are understandable to patients and their family members.
•Match your facial expression to your heartfelt emotions.
•Listen actively.
•Spend enough time with the patients for their disease and beyond.
•Strive to understand patients’ emotional needs and assists to resolve them if possible.
•Give patients hope, even when their health news is bad. For example, discussion about relieving pain of a terminal cancer patient gives hope for comfortable end of life care.
•Show understanding of patients’ cultural and religious beliefs.
•The measure of compassion includes how quickly the nurse or doctor respond to patients’ care needs, how well the pain, etc., is managed.
•Compassionate care may be lost in a situation of continuous calls from patients for pain medications or other
