Published in the March 2004 issue of Today’s Hospitalist
Program: Collaborative Inpatient Medicine Service at Hopkins Bayview
Hospitals served: The Johns Hopkins Bayview Medical Center, Baltimore, Md.
Year started: 1996 (with one doctor and two nurse practitioners)
Staffing: Seven hospitalists (and hiring an eighth) plus eight NPs/Pas
Services: Inpatient care provided to the 700-bed, teaching hospital’s 72-bed Zieve Medical Unit 24 hours a day/seven days a week. Hospitalists triage all potential medical admissions that come through the ER. They are responsible for all general medicine consults.
Average daily census: 25 patients a day
Like most U.S. hospitals four years ago, the emergency room at Baltimore’s Johns Hopkins Bayview Medical Center was overloaded. Patients who were scheduled to be admitted to the medicine floor spent an average of two and a half hours in the ER waiting to be moved, frustrating physicians and patients alike.
Perhaps most frustrated of all were the ER doctors. While they watched patients wait to receive the care they needed, admission delays were also crippling the ER’s ability to take care of “treat-and-release” patients. (From the time they walked through the door, patients were spending an average of six and a half hours in the emergency room.)
It just so happened that as the ER doctors were approaching their breaking point, hospitalists were flourishing in the department of medicine at this large, urban teaching hospital. So the two groups worked together to create an admission process that would shave several hours off patient waiting time.
“We were certainly not as frustrated as our colleagues in the ER,” recalls Eric Howell, MD, then a resident and now associate director of the seven-doctor hospitalist service at Bayview, “but it was very important to them, and it was very important to the hospital administration.
Because the department of medicine admits 60% of all ER admissions, we knew we would have to be a huge part of the answer.”
Leap of faith
The new process required a leap of faith on the part of the hospitalists, who would have to trust emergency physicians’ medical judgments. It also required the emergency room physicians to take the responsibility for writing admission orders.
The revamped admission system combines an “admission pager,” which one hospitalist carries each day, and cell phones, which both groups of doctors carry. The leap of faith requires hospitalists to “trust, but not confirm with their own eyes,” the emergency physicians’ assessment that a patient needs to be admitted.
Under the old system, the emergency department would call the medicine department, and a doctor on call would walk to the ER. The physician would work up the patient, decide to admit the person to medicine, and then write up the admission orders. All of this occurred while the patient waited in the ER.
Now, instead of finding one of the 50 residents on call, an ER physician who wants to admit a patient pages a hospitalist using the special “admission pager.” The hospitalist then uses a cell phone to call the ER doctor’s cell phone, and they discuss the case briefly.
Once the hospitalist accepts the admission over the phone, the ER physician writes very brief admission orders that include only the diagnosis, drug allergies and any one-time medications. The patient is then transferred upstairs to the medical floor, where the hospitalist begins a full work up.
The system worked wonders, cutting the average two-and-a-half hour wait to 18 minutes during a two-month period studied between 1999 and 2000. Since then, the delay has crept back up “to about an hour. Dr. Howell attributes this to “a variety of other inefficiencies,” from paperwork to lack of beds. He says the group’s goal is to cut that delay to 15 minutes.
(Dr. Howell says an article on the triage program will appear in a future issue of the Journal of General Internal Medicine.)
A big advantage of the new system, Dr. Howell explains, is that procedures and treatments needed by these patients can begin right away. After all, an ER isn’t set up to care for inpatients like a medicine floor.
If a patient is experiencing a COPD exacerbation, for example, nurses can now give serial treatments with a nebulizer right away. In the ER, by comparison, nurses could deliver one treatment, but they were not set up to offer repetitive treatments.
“Not evaluating the patient with your own eyes can be a scary thing, but it has worked,” Dr. Howell says. Over the years, the medicine service decided that the admission was incorrect and scrambled to get the patient to the ICU in fewer than 1% of the cases.
“It’s a scary thought that you are going to have a patient who might crash on the floor, and people are resistant to that,” he explains. “But if somebody who was having trouble getting patients out of the ER in a timely fashion called me, I would absolutely suggest moving to this type of system.”
A big reason the system has worked at Bayview is that from the beginning, the hospitalists and emergency physicians agreed to meet monthly to discuss how things were going and make changes as needed. As a result, the two groups have standardized key practices and procedures. Everybody now knows the acceptable ranges for blood pressures or abnormal electrolytes that make for a safe medicine floor admission.
“We are continually looking for ways to make patients’ care safe, but also to make the system more efficient,” Dr. Howell says. “The system would definitely fall apart if there wasn’t a way, like these meetings, to get feedback.”
Identifying hospitalists as the only physicians in the hospital who triage potential medicine admissions from the ER has also improved efficiencies in the hospital, he adds. The hospitalist’s job is to get the patient to the floor and then direct that patient to the appropriate provider in cases where there is another physician or a resident who will be following that patient through the hospitalization.
The system has also improved how hospitalists work with their ER colleagues. “Because we work so closely, we have developed a good rapport with them,” Dr. Howell says. “They know what to expect from each of us. Our relationship with the emergency department has become very solid.”
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.