Background: The buzzword of the decade for hospital medicine is geography. Geographic ACUs have been in existence for years at our institution on non-teaching floors. The ACUs have improved overall throughput, quality and patient experience. Our hospitalists have embraced the ACU philosophy due to ease of rounding, interdisciplinary approach to patient care and its 7on/7off scheduling, which is not standard at our institution. Traditionally at our institution ACUs have not involved residents. However, given the success of these ACUs, hospital leadership encouraged resident teams to function in a similar geographic structure. At our large tertiary academic facility, we converted four non-geographic resident teams into a geographic accountable care unit (ACU) consisting of two teams.
Purpose: The primary goal was to create a resident-led ACU that enhances communication between all providers and improves patient care. The secondary goal included optimizing the educational experience for both hospitalists and residents.
Description: Prior to the inception of the resident ACU in June 2017, there were 4 teaching teams, each comprised of 1 hospitalist, 1 senior resident and 1 intern. Each team carried up to 14 patients that were distributed throughout the hospital, with a mix of telemetry and non-telemetry needs. Our new ACU is comprised of team A and team B, each with 1 hospitalist, 1 senior resident and 2 interns. The hospitalists work a 7on/7off rotation. A “drip” system keeps each team capped at 16 non-telemetry patients per day. Interdisciplinary rounds take place Monday-Friday where the team discusses discharge needs with the case manager, social worker and nurse manager. Data collected pre and post ACU show improvement in multiple metrics: decreased length of stay (5.60 in 2017 vs. 5.09 in 2018), decreased CMI adjusted lengths of stay (4.21 in 2017 vs. 3.82 in 2018), decreased 30 day readmission rates (13.7% in 2017 vs. 12.9% in 2018) and improved patient satisfaction scores (i.e. communication with doctors, staff responsiveness and communication about medications). Additionally geography has enabled more bedside teaching, patient participation and increased nurse involvement and awareness of patient care. Not surprisingly, hospitalist satisfaction in this rotation is high, evidenced by the frequent requests to rotate through the ACU.
Conclusions: Major change comes with a lot of hesitation, especially when change is presented after years of a seemingly smooth resident team structure. However, the improvement in several metrics in the arenas of throughput, quality, and patient satisfaction makes a strong case for a geographic distribution of patients on a resident service. Resident education and a geographic ACU can coexist as evidenced by this new ACU.