Handoffs in patient care have been recognized as being responsible for preventable adverse events27-29
and excess resource use27,30,31
by the Joint Commission, the Institute of Medicine, and the SHM. As such, transfers of patient care are the subject of increased attention from health care researchers, policymakers, administrators, and patients themselves. Because individual hospitalists cannot remain in the hospital 24 hours a day, 7 days a week, some discontinuity in care is unavoidable in hospital medicine. We propose the CICLE hospitalist staffing model to improve the inpatient continuity of care. The CICLE model has been successful in meeting its objective and is associated with reductions in LOS and health care costs without substantial effect on readmission rates and at zero implementation cost. That said, the trend toward higher readmissions rates noted during the period of improved continuity was a surprising finding to the authorship team.
Discontinuity in inpatient care can result in hazards that are threats to patient safety, can increase unnecessary use of resources, and is thought to diminish patient satisfaction.10-12,27-33
Given that some in-hospital handoffs are inevitable, researchers and policymakers are emphasizing initiatives to standardize transfers of care. Nonetheless, in their comprehensive review of the handoff literature, Cohen and Hilligoss34
were unable to point to any reliable evidence linking handoff standardization to substantive gains in measurable patient outcomes. By reducing the number of handoffs and the number of hospitalists involved in any given hospitalization, our CICLE model attacks the inpatient continuity-of-care problem at its very root.
The patient-focused model, a hospitalist scheduling model described by SHM, is also designed to maintain continuity of care.35
Under the patient-focused model, hospitalists work in 2-week blocks during which hospitalists cover their own patients 24 hours per day, for the entire 14 days, but accept new patients only during the first week. Evaluations to measure the effect of the patient-focused model have not been published. Working 14 consecutive days may result in hospitalist fatigue and burnout. Like the patient-focused model, the CICLE model maintains continuity of care; however, with shorter cycles (4 days), it probably lessens the likelihood of fatigue and burnout.
Our work supports the finding of Epstein et al12
that increased fragmentation of care is associated with longer LOS. The CICLE model guarantees at least 3 days (and usually 4 days) of continuity. Patients whose LOS is longer than 4 days are likely to be subsequently cared for by another single hospitalist, which explains the significant improvement in continuity of care and reductions in handoffs under the CICLE model. With fewer hospitalists involved with each admission, plans of care are less likely to be questioned and changed midcourse, resulting in more streamlined and cost-effective care. Whereas a new hospitalist may feel uncomfortable discharging a patient that he/she is meeting for the first time, the hospitalist who has cared for a patient from admission onward can appreciate the progress and may have more confidence in discharging the patient as soon as it is appropriate to do so. Furthermore, by protecting physicians from new admissions on day 3 and day 4 of the cycle, physicians have more time to focus on planning safer discharges and patient education for the patients who remain on their service.
Because the model was designed by the hospitalists themselves, buy-in and engagement are deep and genuine. The dedication to ensuring CICLE's success may be greater than what might have been seen with a leadership-designed, top-down initiative. Knowing that they will have a smaller census to care for on the next day is a real incentive for hospitalists to discharge patients as soon as the patients are ready to go home. This reality may influence behaviors and how time is allocated among patients; a hospitalist may choose to spend more time with patient A, preparing the patient for an afternoon discharge, knowing that the smaller census on the following day will allow the hospitalist to connect more deeply and make up the time with another patient tomorrow. If workflow is considered carefully, CICLE can be a win-win for all stakeholders, especially patients.
Several limitations of this study should be considered. First, it was conducted at a single hospital, and thus the results may not be generalizable. Second, the CICLE teams covered a large proportion of admissions cared for by our hospitalist group, but the remaining patients were admitted directly to the red team under the traditional model, thus diluting the effect of the CICLE model. Third, the CICLE model was designed with continuity and efficiency in mind. Hospitalists working within productivity-based compensation models may not be amenable to a scheduling model that effectively encourages lower hospitalist censuses. Our hospitalists are salaried with minimal bonuses tied to clinical productivity. With shorter LOS and no new admissions beyond day 2 of the cycle, individual professional fee bills may decrease. Finally, the retrospective, observational study design may not be as robust as a cluster-randomized trial or a randomized controlled trial, but pre-outcome vs post-outcome comparison is commonly used in quality improvement initiatives when randomized trials are not possible. That said, there are potential biases inherent in our study design. Our study may have been predisposed to selection-history bias due to changes in hospitalist or patient demographics; however, both sets of demographics were similar across study periods. Individual hospitalists may have matured during the period between the 2 study periods, leading to a potential performance change bias; however, we lost 3 experienced hospitalists and gained 6 with limited experience in hospital medicine. Although our study was vulnerable to circumstantial changes, apart from the CICLE model, we are unaware of any changes in our health care system that could have influenced the outcomes. We have made a full attempt to comply with SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines36
in reporting about our quality improvement initiative.