Optimizing medical postoperative care: Role of the hospitalist in a department of adult neurosurgery. Prospective comparative observational study.

Introduction: There is no consensus on responsibilities in postoperative care in neurosurgery, although this has grown in recent decades with an aging population and increasing chronic diseases, making management more complex due to patient age and comorbidity. Co-management between surgeons and medical physician has emerged in the English-speaking world and in the private sector in France, in orthopedic, vascular and neurosurgical departments, which moreover increasingly call for medical involvement. The present study therefore addressed the question of the role of the hospitalist in optimizing medical perioperative care in neurosurgery. We analyzed postoperative medical and surgical complications, requests for specialist opinions and hospital stay according to the presence of hospitalists.
Material and Method: We carried out a 6-month prospective comparative observational study in the Department of Adult Neurosurgery of La Timone University Hospital Centre (Marseille, France), from September 1, 2017 to February 28, 2018. All cranial or spinal neurology cases, whether managed surgically or not, whether emergency or scheduled, were included and followed up for 1 to 4 months. Patients managed in functional neurosurgery, pediatric neurosurgery or housed in other departments were excluded. The 229-patient-cohort was divided into 2 arms over 2 months in 2 different units of the Department (Unit A or Unit B), according to allocation of the hospitalist (in September in unit A and October in unit B) with follow-up until the final check-up. "Hospitalist-neurosurgery team" co-management in postoperative care was compared versus standard postoperative care provided by neurosurgeons with medical consultation. Endpoints comprised: length of stay, number of inpatient postoperative complications and medium-term complications with re-admission, and number of medical consultations.
Results: Groups were comparable in number, age, gender, reasons for admission, type of admission (emergency or scheduled) and comorbidity scales (ASA and Charlson). Mean length of stay was significantly reduced, from 10.13±7.76 days (95% Confidence Interval, 8.77-11.49) to 7.07±3.94 days (95% CI, 6.31-7.82) (p=0.0087), without and with the presence of a hospitalist, respectively. The rate of requests for specialist opinion depended on the department in question but was likewise significantly reduced, from 22.81% in Unit A to 14.29%, and from 19.15% in Unit B to 8%. The 30% decrease in medical complications (45% of overall complications) was not statistically significant. There were significant correlations between age, comorbidity on Charlson scale and immediate (but not medium-term) complications.
Conclusion: Postoperative care in neurosurgery can be improved by the presence of a hospitalist, reducing the rates of complications, requests for specialist opinion and hospital stay. The job description, work schedule and organization and financing remain to be defined. Studying other organizations to supplement the present benchmarking could help strike a better balance between time-saving and reinforcement of the medical-surgical team on the one hand and enhanced budgeting for comorbidities and care optimization on the other.
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