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Embedding a hospitalist in the ED

An exclusive admitter in one hospital system cuts LOS by half a day
by Phyllis Maguire

Published in the February 2010 issue of Today's Hospitalist

JUST OVER A YEAR AGO, the hospital bed capacity had reached a crisis point at Franciscan Health System in Tacoma, Wash. Beds were so scarce that patients were stockpiled in the ED for hours before a hospitalist could come down and work up an admission. Even when a hospitalist could process an admission, patients often stayed in the ED for most of the day before a bed could be found.

And diverting hospitalists from rounds for admissions made it harder for them to do dischargesóand free up beds for waiting patients.
"Eight admissions a day seems to be the breakpoint at which hospitalists become saturated."

ĖMaureen Nuccio, MD
Franciscan Health System

Thatís when Franciscan, which has five hospitals in the Tacoma area, decided to launch an ED admitting service at its tertiary facility, embedding a hospitalist in the ED for all day-time admissions.

Maureen Nuccio, MD, the director of the 63-physician hospitalist program at Franciscan, says that the ED admitting service rolled out a year ago in the main medical center has been such a success, that two other hospitals in the system have adopted it. The service not only delivers better and much faster care to patients being admitted, but it has been credited with reducing length of stay in those hospitals by half a day.

Opting for exclusive admitters
When it comes to dividing a hospitalist group into rounders and admitters, many groups have hospitalists admit patients from the ED for just one day, then round on the floor the next day. The thinking is that hospitalists rounding on patients theyíve admitted provides better continuity of care.

The hospitalists at Franciscan, however, took a different approach. To date, admitters have worked on the ED admitting service exclusively. Six admitters now share a seven-on/seven-off schedule in three hospitals.

Having hospitalists work exclusively as admitters, Dr. Nuccio explains, has many advantages. For one, those physicians have become extremely familiar with the ED staff, social workers and case managers.

Dedicated admitters also become adept at triaging admissions to deliver critical care to patients who need it, for example, or to facilitate a transfer from the ED to a nursing home for what might have been only a "social admission" to the hospital.

But while having dedicated admitters has gone smoothly, Dr. Nuccio notes that some of the groupís rounders have expressed interest in working as admitters. As a result, the group will try rotating admitters and rounders on a weekly rotation in one of the three hospitals.

"You donít want to lose your skills in any aspect of hospital care," Dr. Nuccio says. "That cross pollination ensures that people donít get burned out doing any one job."

Following admissions the first day
At what point might hospitalist groups benefit from an admitting service? Dr. Nuccio says that for the Franciscan group, problems started to crop up when each daytime hospitalistóand there are eight rounding during the day shift at the systemís main hospitalóhad to process one ED admit a day, after starting the morning with a census of 15 patients per physician.

Under the new system, hospitalists on the ED admitting service admit between six and eight patients during a 10-hour shift. According to Dr. Nuccio, "eight admissions a day seems to be the breakpoint at which hospitalists become saturated."

Thatís because the Franciscan admitters follow that patient throughout the day, doing the admission, ordering all the tests and acting on test results as they come back. The admitting hospitalists also treat and discharge patients in observation, and they help out with hospitalist consults and treadmill testing when admissions are light.

During that first day, Dr. Nuccio says, itís not uncommon for an admitter to be able to stabilize a patient to the point where the patient no longer needs an ICU bed. When patients are transferred to the floor that day, Dr. Nuccio adds, admitters follow them there, handing them off that evening to the hospitalist providing evening coverage. The lead hospitalist the next morning then divides patients admitted the previous day among the members of the rounding team. (Patients likely to go home from observation stay under the care of the admitting hospitalist.)

Working alongside the admitting physician in the ED is one of the groupís care managers. At 2 p.m. every day, the admitting hospitalist is also joined by one of the groupís midlevels, who processes low-acuity admissions. And once admitters are following four patients being held in the ED, "We bring in a med/surg nurse or ICU nurse to work alongside the hospitalist," Dr. Nuccio says. "That way, the ED nurse doesnít have to take care of those patients."

Getting ED nurses on board
Besides reducing hospital-wide length of stay, Dr. Nuccio says the ED admitting service offers another huge benefit: Giving young hospitalists right out of residency enough time to round on 15 patients a day.

"Very young physicians are not as efficient when they first start," she points out, "so piling on admissions as well as rounding can be too big of an expectation."

But despite the solid results the service has received, Dr. Nuccio says that getting it up to speed presented some challenges. Figuring out how much of the admitting hospitalistís work should fall to ED nurses, for example, has been one issue.

That was easier to work out at the tertiary center where ED nurses were used to not diverting patients and to working with many types of physicians. But once the admitting service was implemented in one of the systemís community hospitals, a no-divert policy was instituted there for the first timeóand the hospitalists had to work to get ED nurses on board.

"Suddenly, we had another doctor down there writing orders that ED nurses had to act on," Dr. Nuccio says.

The admitting service has since delineated which orders ED nurses will help with, which include starting a drip, and which orders med/surg nurses will handle, like directions for physical or speech therapy. It helps that the admitting service and the ED departments now make two copies of patient charts when those patients remain in the ED, so both services arenít chasing each other for one chart. Admission orders remain on one set that the hospitalist and med/surg nurse can access.

Workload perceptions
Creating the new service raised other issues, like the perception from rounding hospitalists that admitters have less work. "The thought is, ĎThey have only eight cases and I have 15,í " Dr. Nuccio says. "You have to remind them that admitters are doing critical care a lot of the day."

And there is always the need to find hospitalists with the right personality. "You are constantly being paged and doing very high acuity work," Dr. Nuccio explains, "and you have to work in the emergency room, which internists historically arenít interested in. You have to be a team player, outgoing and upbeat, and show how you are going to help the ED staff."

Phyllis Maguire is Executive Editor of Todayís Hospitalist.

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