In 2011, Neera Ahuja, MD, Director of Stanford’s Hospital Medicine Program and Norman Rizk, MD, Chief Medical Officer, had a vision for optimizing the care of surgical patients, particularly those who had complex, pre-existing medical problems. Many patients were admitted to the hospital for surgical indications, yet their hospitalization could occasionally be complicated by exacerbation of their existing medical problems, such as diabetes, or development of new medical problems, such as delirium or pneumonia. The existing clinical infrastructure provided medicine consultation for surgical patients Monday through Friday from 8am to 5pm by a rotating team of hospitalists, and by a cross-cover team for urgent situations at night and on weekends. But Ahuja wanted to bring more continuity into the care of these patients in the perioperative period, and Rizk knew there were several surgical specialties that would be interested in and benefit from a new clinical model.

Over the next year, Ahuja, Clinical Associate Professor of Medicine, found a way to improve the situation by developing a surgical co-management (SCM) Hospitalist program that focuses on the perioperative period; it is a collaboration between surgeons and hospitalists to care for patients comprehensively before, during, and after surgery. The SCM Hospitalist group consists of six dedicated hospitalists assigned to work with three surgical services: two in orthopedics, two in neurosurgery, and two in cardiothoracic surgery, allowing for 24/7 coverage. As of the summer of 2014, there will be seven hospitalists in the group (three in orthopedics, two in neurosurgery, and two in colorectal surgery).

Each hospitalist follows patients throughout their hospital course. In the pre-op clinic, they assess and then optimize patients prior to surgery to ensure the best possible medical outcome, wait for them during their operations, and see them on the post-op side to oversee their recovery and help prevent or treat any medical complications that might occur.

“Our experience has been that the providers/care team appreciate our involvement, not only for the management of internal medicine-related problems, but also when it comes to availability, since surgeons are often busy in the operating rooms and cannot always be immediately available to the nurses or at the patient’s bedside,” says Ahuja. “Additionally, our data shows that the hospitalist program has demonstrated a reduction in medical complications and length of stay and an overall increase in cost savings.”

One of the hospitalists caring for these sick patients is Alistair Aaronson, MD, Clinical Instructor, Division of General Medical Disciplines. “Many orthopedic surgery patients present with medical comorbidities such as atrial fibrillation, insulin-dependent diabetes, and uncontrolled hypertension. In my role as co-manager, I am able to address the medical comorbidities of the most medically complex orthopedic surgery patients,” says Aaronson. “My goal is to reduce post-operative complications, optimize clinical outcomes, and improve patient and provider satisfaction. Thus far I feel that all three goals are being achieved. Surgeons consult with us on patients they are especially concerned about, and we seek out patients who have multiple comorbidities and could benefit from the expertise of a physician trained in internal medicine.”

Benefits for Both Surgeon and Patient

The positive response the hospitalists have gotten from surgeons has also contributed to the program’s success. As co-managers, the hospitalists are at the bedside, communicating with the social workers, nurses, physical therapists, nurse practitioners, physician assistants, housestaff, and surgeons, and actively writing orders for the patients, rather than writing recommendations in the chart and waiting for the primary team to read them and enter the orders later in the day.

The discharge process has also improved. Each hospitalist goes over discharge medications with the surgical team and then coordinates with each patient’s primary care physician so no information is lost. “When patients visit their primary care physicians, all the information about their hospital course is already available to the physician,” says Sarita Khemani, MD, Clinical Assistant Professor and SCM Hospitalist in Neurosurgery. “The continuity of care that they get as they move from being inpatients to outpatients is really beneficial.”

Perioperative Medicine has sparked the interest of other surgical services such as colorectal surgery; ear, nose, and throat; and ophthalmology, who have requested similar service.

As with all new programs, the SCM program went through an adjustment period in the beginning, as surgeons and the surgical care teams learned how to best integrate with the hospitalists collaboratively in the day-to-day care of their patients. Fortunately, with objective measures from quality improvement metrics, Stanford’s SCM program, novel in its approach of embedding dedicated hospitalist physicians into several surgical departments, is thriving and has started to catch the eye of both academic and non-academic institutions nationally.