Where: Denver Health Medical Center, an academic safety-net hospital in Colorado.
The issue: To reduce boarding of patients in the emergency department (ED).
The ED and the medicine wards at Denver Health are very busy. In 2009, the ED was on diversion more than 12% of the time, and boarded patients waiting for a bed in medicine took up 16% of the ED's bed capacity.
Hospital administrators wanted to reduce diversion rates, and the hospitalist service had noticed some obvious inefficiencies in the way boarded patients were treated. “The entire medical service was caring for these patients—hospitalists and residents alike. At any given time, eight different teams could be taking care of these patients in the emergency department,” said ACP Member Smitha R. Chadaga, MD, associate chief of hospital medicine at Denver Health.
Boarded patients were also being moved to medical beds based solely on length of stay in the ED. “Patients would just go up to the floor because they were number one in line without any discussion with the team taking care of them,” said Dr. Chadaga. “But the patient that's been in the ED the longest has the most likelihood of being ready to be discharged, because they've been there for their workup. The team would say, ‘Oh, we were just getting ready to discharge them.’”
In 2009, a group that included hospitalists, ED physicians, social workers and nurses got together to develop a new system for treating these patients.
How it works
A team, comprising an attending hospitalist and an allied health professional, was reallocated from the medicine service to the ED and given responsibility for the care of all medicine patients boarded there.
“We have a dedicated group of internal medicine attendings who do the service during the day. When those duties roll into our evening and night shift, any hospitalist will take over,” said Dr. Chadaga. The team also works on bed management, in collaboration with the nursing supervisors. “We try to look at the entire board. We will say, ‘Patient X has chest pain. Let's get them to a telemetry floor. Patient Y looks like they might need isolation. Let's get them to the proper floor.’ This additional input from an internal medicine physician helps the nursing supervisors get patients to the right floor at the right time, which helps the flow.”
Flow was much faster after implementation of the system, according to results published online in August by the Journal of Hospital Medicine. The time that the ED spent on diversion due to a shortage of medicine beds decreased from 4.5% to 3.3% for a relative reduction of 27%.
The hospitalist-led ED team was also successful in better allocating medicine beds: Discharges of boarded patients directly from the ED went up 61% and the percentage of patients transferred from the ED to medicine and then discharged within eight hours dropped a similar amount. The boarded patients were also seen by a hospitalist an average of two hours sooner.
The study also found that ED physicians and nursing supervisors were happy with the new system and believed it improved care and collegiality. “It was a welcome intervention, because it in some ways offloaded work from the ED physicians,” said Dr. Chadaga. “Due to the confusion of [the old system], the nursing staff had great frustration and often went to our ED colleagues to ask them for advice about [boarded] patients.”
The hectic pace, with lots of pages and consultations, can take a toll on the hospitalists staffing the service. “You have to be careful of burnout,” said Dr. Chadaga. “We try to limit it to two or three shifts in a row to keep those people fresh.”
The team also has to deal with the ebbs and flows of patient volume, according to Dr. Chadaga. The service is usually “medium busy” but it can also be slow or hectic. However, the hospital recently constructed a five-bed observation unit, which the hospitalist ED team also runs. “We now have this multi-pronged system. There's steady work every day from the observation unit and we flex to take the unassigned patients,” she said.
Words of wisdom
Even hospitals that don't have the same capacity/diversion challenges could benefit from copying parts of the intervention, Dr. Chadaga said. “You could put the bed management portion into effect and [have] that discussion with the nursing supervisor. If you're having problems with patients getting transferred among floors, you could offer ...to discuss patients over the phone,” she said. “Any hospitalist group could do part of this.”