Where: Johns Hopkins Bayview Medical Center, Baltimore.
The issue: Reducing ambulance diversion hours and emergency department (ED) throughput time by implementing a hospitalist-led quality improvement initiative.
Ambulance diversion hours at Johns Hopkins Bayview Medical Center had been steadily increasing and were among the highest in the region by 2006, due to overcrowding and lack of available beds in the ED.
“The No. 1 cause of overcrowding in the ED is not too many patients coming in, as many people think, but inpatient boarding: too many admitted patients occupying a bed in the ED because there's no bed available upstairs,” said Edward Bessman, MD, chief of the ED. “Part of the problem is what we call ‘service ping-pong.’ Everyone agrees that the patient needs to be admitted, but they can't agree where the patient should go. Two-thirds of our admitted patients come through the ED, so if you close that ‘front door,’ the hospital suffers.”
While traditional approaches to alleviate ED congestion have targeted the ED directly, the hospitalists in the department of medicine teamed up with the ED to try a different approach that put hospitalists in charge of monitoring available beds. Hospitalists had the authority to assign patients admitted through the ED to one of five department of medicine units. The effectiveness of the initiative, called “active bed management,” was measured in a pre-post study described in the Dec. 2, 2008, issue of Annals of Internal Medicine.
How it works
Hospitalists staff the active bed management program 24 hours a day, 7 days a week. All hospitalists rotate through the active bed management position and have no additional patient care duties during their 12-hour shifts. (Hopkins Bayview added 2.4 full-time equivalent hospitalists to launch the program.) The active bed management hospitalist assesses bed availability in real time for the cardiac intensive care unit (ICU), the medical ICU, and the cardiology, pulmonary and general medicine units. In collaboration with attending physicians, nursing supervisors and charge nurses, the hospitalist performs “prediversion” rounds in the ICUs and identifies patients who can safely be transferred to non-ICU settings.
While tracking bed availability across all department of medicine units, the active bed management hospitalist makes triage decisions for each patient admitted to the department through the ED, in consultation with ED physicians (and, less frequently, other physicians), and assigns the patient to the appropriate clinical setting. Initial consultation occurs by telephone, and the hospitalist may decide to evaluate selected patients in the ED. Patients admitted to a non-ICU unit are transferred out of the ED as soon as a bed is available. ICU admissions are transferred no longer than 90 minutes after the assignment decision is made.
“It can be difficult to persuade people that this can actually work—that hospitalists can triage to an ICU—and it definitely requires a culture change,” said Eric Howell, ACP Member, a hospitalist and lead author of the Annals study. “The ICU doctors are reluctant to give up control and allow a hospitalist to admit directly to their unit. An important part of getting everyone comfortable with the program was setting up a medical admissions oversight committee, which included the heads of all the divisions of medicine. This helped us identify important issues, including cultural issues that might not have been realized outside the unit or the ED, and made it a better system for everyone.”
From November 2006 to February 2007, ED throughput for admitted patients decreased 98 minutes (from 458 minutes to 360 minutes) from the same period a year earlier, despite an 8.8% increase in the ED census. The proportion of hours that the ED was on yellow alert (ambulance diversion because of ED crowding) decreased 6 percentage points, or 182 fewer hours. The proportion of hours that the ED was on red alert (ambulance diversion due to lack of ICU beds in the hospital) decreased 27 percentage points, or 786 fewer hours.
Because active bed management requires collaboration across several departments, “you need strong advocates among the department chairs and at the top levels of hospital management,” said Dr. Howell. “You also need to make sure you get the resources to succeed. It's important not to add this to the existing clinical responsibilities of hospitalists without increasing your staff, or it won't work.”
How patients benefit
When diversion hours are reduced, fewer patients who need critical care lose precious time because their ambulances must go to another hospital. As ED throughput time is decreased, ED patients who are admitted receive appropriate inpatient care more promptly. In addition, “when the ED is crowded with inpatients, nobody can get in, including the walk-ins,” said Dr. Bessman. “So, as our diversion rate has gone down, our rate of walkouts—the patients who wait and wait and finally leave—has also decreased.”
The triage process is currently documented on paper only, which Dr. Howell said has significant drawbacks. “We've designed an electronic triage program that is Web-based, so everyone will be able to see who's waiting in the queue from the ED and what the hospitalist's decision is in real time,” he said.
Words of wisdom
“The bottom line is that you will not move forward unless you empower the ED and the hospitalist unit to partner together to say, ‘This is where the patient is going,’” said Dr. Bessman.
“This program really put our hospitalist division on the map,” Dr. Howell said. “It has given the hospitalists a sense of pride and ownership in a process that nobody else can do as well as we can.”