Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

A team augmented with a medical team coordinator led to fewer days in hospital and greater satisfaction with care among patients admitted to a general medical clinical teaching unit

ACP J Club. 1993 Jan-Feb;118:28. doi:10.7326/ACPJC-1993-118-1-028


Source Citation

Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. Can Med Assoc J. 1992 Feb 15;146:511-5.


Abstract

Objective

To assess the effects of a medical team coordinator (MTC) on length of hospital stay, frequency of re-admissions, and patient satisfaction for patients admitted to a general medical clinical teaching unit (CTU) from the emergency department.

Design

Randomized, controlled, 3-month trial.

Setting

2 CTUs in a university-affiliated hospital in Canada.

Patients

Adults admitted from the emergency department into the CTUs. Patients were excluded if death was expected within 48 hours or if they were admitted directly to the intensive care unit. 267 patients were included (mean age 65 y, 55% women).

Intervention

131 patients were randomized to usual medical care and 136 patients to usual medical care plus care from a MTC. The MTC was a baccalaureate nurse who worked with the housestaff to expedite the patient's progress from admission to discharge. The MTC attended ward rounds (32% of time), coordinated tests or gathered patient data (30%), collaborated with other health professionals (14%), and carried out ward or team admission tasks (24%).

Main outcome measures

Chart abstractions were done to collect diagnoses, length of stay, discharge destination, hospital re-admissions within 2 weeks, and mortality. Patient satisfaction with medical care was measured at day 4 by the MTC in a subset of 40 patients.

Main results

Patients assigned to the MTC group stayed in the hospital for a mean of 7.43 days compared with 9.4 days for the usual care group (95% CI for the 1.97-day difference 1.02 to 2.92 d, P = 0.04). More patients in the MTC group were satisfied with their care (89% vs 62%, CI for the 17% difference 2% to 52%, P < 0.05). Patient perceptions of being kept informed about care; discharge destination; rate for hospital re-admission within 2 weeks of discharge; and mortality did not differ between the 2 groups. Diagnosis was not associated with changes in hospital length of stay.

Conclusions

Patients in a medical teaching unit, who were assigned to a team augmented by a medical team coordinator, stayed fewer days in the hospital and were more satisfied with their medical care than patients who had usual care without a medical care coordinator.

Source of funding: In part, Ontario Ministry of Health.

For article reprint: Mr. D. Moher, Children's Hospital of Eastern Ontario Research Institute, Room R226, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada. FAX 613-738-4869.


Commentary

An intervention that must be every overworked house officer's dream—adding to the inpatient team a nurse coordinator who will take responsibility for many of the tasks that housestaff find onerous—may well be economically feasible for hospitals. The study by Moher and colleagues did not focus on housestaff well-being, perhaps because that benefit of the intervention is self-evident, but rather on hospital utilization. The improvement in the latter must hearten both administrators and physicians.

The study offers intriguing findings but not definitive answers. It was not designed to measure the direct effect of the medical team coordinator on health expenditures, health outcomes, or long-term health care utilization. As the authors note, they could not determine which components of the intervention reduced length of stay. Further, it is impossible to determine whether these favorable results are unique to this particular nurse and this Canadian teaching hospital. Nevertheless, there are good reasons to believe that this intervention and others like it might work. The administrative tasks—tracking down test results, arranging diagnostic procedures and referrals, coordinating multiple caregivers—have become more complex and essential components of inpatient care. A member of the team who would carry out such tasks with both enthusiasm and competence could be valuable indeed. If such interventions can be shown to improve care in other settings, there is every prospect that both patient care and housestaff education will be more satisfying for all concerned.

Alan M. Garber, MD, PhD
Stanford University School of MedicinePalo Alto, California, USA