Published in the September 2011 issue of Today’s Hospitalist
TO REDUCE CROWDING, emergency departments have become hotbeds of innovation. Many have instituted clinical-decision or observation units, incorporated the use of handheld ultrasound devices and pioneered fast treatment. Crowding nevertheless persists, with 91% of the country’s EDs crowded beyond capacity.
Those strategies have failed for a reason: Tactics that target the ED alone just don’t work. While studies have shown that bedside registration can reduce ED length of stay in the short term, for instance, those time savings are tough to sustain over the long haul.
Adding a physician for ED triage can decrease ED length of stay and reduce the number of patients who leave without being seen. But adding a physician, researchers have learned, doesn’t put a dent in ambulance diversions “which can cost a hospital anywhere between $1,000 and $9,000 for every lost hour.
Even doubling the size of the ED has little effect. A 2007 study found that a hospital that increased its number of ED beds from 28 to 53 saw no change in its rate of ambulance diversion, ED boarding time or ED walk-outs.
To solve ED crowding, hospitals have to figure out how to increase capacity throughout the hospital “and hospitalists are the ones who can help. That’s according to Eric Howell, MD, chief of the hospital medicine division at Johns Hopkins Bayview Medical Center in Baltimore and at Howard County General Hospital in Columbia, Md.
"Virtually every hospitalist “whether you are a leader, a CMO or a frontline hospitalist who sees patients 100% of the time “can do things to improve ED length of stay and boarding," said Dr. Howell, speaking at a session on EDs and hospitalists at this year’s Society of Hospital Medicine annual meeting.
In his own hospital, Dr. Howell pointed out, the hospitalist group over many years has helped improve ED throughput. To do so, the hospitalists have implemented several interventions, including reinventing their own schedules. The good news? According to Dr. Howell, those initiatives have not only improved patient safety (and hospital revenue), but they’ve also created a wealth of goodwill for the hospitalist group.
Active bed management
To reduce ED crowding, the hospitalists at Johns Hopkins Bayview have relied on a suite of interventions introduced over the last five years. The first was a new system of active bed management that began in 2006, when ED length of stay for admitted patients was hovering around eight hours per patient.
It turns out that "active bed management" is the job description for one of the hospitalists, with group members taking turns as that day’s bed czar. That hospitalist makes twice-daily rounds in each of the ICUs as well as the ED to evaluate congestion and patient flow, assign and facilitate admissions from the ED to all the department of medicine units (including the ICUs), and mobilize resources in response to ED crowding.
As bed czar, Dr. Howell said, "Hospitalists triage patients to the department of medicine. They don’t do any billing, and they don’t round on patients in the traditional sense. They just triage patients 24 hours a day." (One hospitalist serves as bed czar during each 12-hour shift.)
A big part of the job is proactively managing ICU beds. "We found that a full ICU slows down all patients, the ones being treated and released as well as new admissions," Dr. Howell explained. "So we go around to our separate ICUs and say, ‘Hey, you’re almost full. Your doctors ought to start sending out those patients that are ready to go now.’ They shouldn’t wait until the unit is full and be in a frenzy to get patients out."
Acting as that day’s bed czar is "like running a race," Dr. Howell admitted. "It’s a brutal shift, and we schedule doctors to work only two consecutive shifts because it is so difficult."
And when active bed management first began, there was pushback from ICU personnel, particularly in the cardiac ICU, to the "radical" notion that hospitalists should be triaging ICU patients. "But once the CICU became the model of success in the state for primary angioplasty," Dr. Howell pointed out, "the cardiologists became our biggest advocates." As an aside, he added, because physicians need to make the case to attending-level intensivists that patients should be transferred, bed czar is probably not a role that groups could give a midlevel.
According to results of a study Dr. Howell published in the Dec. 2, 2008, Annals of Internal Medicine, the active bed management program in four months decreased the number of hours that the ED was on red alert (ambulance diversion because of a lack of ICU beds) by 27%. It also reduced the number of hours on yellow alert (ambulance diversion because of ED crowding) by 6%, and trimmed ED length of stay by 98 minutes.
Before active bed management was put in place, Dr. Howell said, the hospital had more than 2,000 hours every year of ambulance diversion.
In its first year, the active bed management program got that number down to 500. And since 2008, the hospital has averaged fewer than 100 hours of ambulance diversion a year, a huge difference. "They actually wanted us to just get this down to 1,200 hours, so we blew away their goal," he noted. With so many fewer diverted ambulances and reduced ED length of stay, ED business at the hospital has shot up “and administrators no longer balk at paying hospitalists to run the bed-management program.
Before 2009, the active bed management program was conducted entirely via paper. Physicians had no access to a database that could be queried for research or auditing, nor any electronic mechanism for tracking delays. Decisions were based solely on a physician’s gut feeling; severity scores for the ICU vs. the floor were not being applied. And communications were often delayed or unreliable.
But in 2009, the hospital developed an electronic triage system to capture everything from vital signs and lab results to disposition status. The system tracks where patients will be transferred and whether they have been accepted for admission. The e-triage system also flags still-pending admissions, and it has access to a Web-based bed tracker that automatically pages house staff and a nursing supervisor when a patient has been accepted. The system also time-stamps all actions.
"Before electronic triage, we would have to call an ED doc, but sometimes we couldn’t get a hold of anyone in the ED or we’d hear, ‘We’ll call you back. We’re busy,’ " Dr. Howell noted. "As soon as we put in electronic triage, we had another option."
If, for example, you know that a 50-year-old man is coming in for chest pain and that based on his ECG, troponin, and X-ray, he’s going to observation, "You just click, ‘Assigned to observation, accept bed immediately.’ That starts the ball rolling for everybody to get the patient admitted," Dr. Howell said. He also pointed out that introducing the e-triage system shaved another 40 minutes off of ED length of stay.
Also before 2009, Dr. Howell explained, Johns Hopkins Bayview had a typical academic hospitalist program with somewhat haphazard scheduling.
"We would plug in doctors here or there," he said. "Usually, they would work three to seven days in a row, but not always. Sometimes it was only one or two." Hospitalists admitted patients every day “and hospitalists who responded quickly to calls for admissions from the ED found themselves handling even more calls from the ED.
"So the reward for being efficient was to get more work, which is never a good way to motivate people," Dr. Howell said.
Doctors would typically begin shifts dealing with "leftover" patients, leaving discharges on the back burner. As a result, physicians weren’t discharging patients in a timely manner “and patients kept stacking up in the ED, waiting for beds.
The solution was a schedule that mimicked the way housestaff work, with hospitalists working four-day blocks. The first is an admissions day. "It starts at noon and end at 8 p.m. and you admit as many patients as you can," Dr. Howell explained. Physicians on their second day take overnight admissions. "You come back the second day and get the held-over admissions from the night team up to a maximum of 12,"he said. "You spend the second day seeing your new patients and making dispositions." Doctors spend their last two days rounding on “and usually discharging “the patients they admitted on those first two days.
Now, Dr. Howell pointed out, the majority of patients are seen throughout their stay by the same doctor who admitted them. And when physicians’ work for the day is done, "instead of getting another admission, you get to go home or do research," he said.
By changing their schedule, hospitalists reduced overall case mix-adjusted hospital length of stay from four days to 3.3 days. The new schedule also “in only one quarter “helped reduce ED length of stay by 20 minutes.
A hospitalist-only unit
The last intervention created real capacity. In 2010, Dr. Howell said, the hospital opened a new, hospitalist-only unit that is closed to patients being treated by other doctors. While the unit now has 20 beds, hospitalists plan to eventually expand it to 36 beds.
"It’s been a huge success for patient satisfaction," said Dr. Howell. "It’s also going to help us either maintain or reduce our ED length of stay." Since the unit opened, ED length of stay has consistently been less than 320 minutes.
Dr. Howell admitted that the entire series of interventions put in place represented a great deal of work and investment on the part of the hospital.
But "you have multiple options," Dr. Howell noted. "If you’re the lone hospitalist, you can still round in the ED and see patients who are waiting there as boarders." Doctors can also create virtual capacity by focusing on length of stay or increase physical capacity by opening new units. They can even advocate for admitting patients to hallways. (See "Other throughput options," page 26.)
The key is to realize that "no one else is going to fix this, not the intensivists, not the ED docs," Dr. Howell said. "They want to, but they lack the tools. It’s not going to be the surgeons; it’s going to be you."
Karen Sandrick is a freelance health care writer based in Chicago.
Other throughput options
WHAT’S IT TAKE to reduce ED crowding? At a session held at the Society of Hospital Medicine’s annual meeting this year, Eric Howell, MD, chief of the hospital medicine division at Baltimore’s Johns Hopkins Bayview Medical Center, detailed the series of interventions his hospitalist group has helped implement that have cut ED length of stay from eight hours to five.
Dr. Howell also discussed strategies that other hospitals have tried. Here are a few of the examples he mentioned:
"If patients were waiting for ICU beds but got better, hospitalists could downgrade them to floor status," Dr. Howell said. "If patients were appropriate to be discharged, the hospitalist would do the discharge process just like he or she would on the floor." The program was able to shave off between 3.5 and five hours in ED length of stay (LOS) per patient, dropping that LOS from a high before the program began of around 10 hours.
The hospital opened a 14-bed acute care unit under the control of the ED that saw about 158 patients per week. Opening that new unit cut ambulance diversion nearly in half, reducing the number of diversion hours from 202 to 123 over a six-month period.
And researchers from Oregon Health & Science University demonstrated that increasing ICU beds from 47 to 67 reduced ambulance diversion by more than half, and shaved 30 minutes off of ED length of stay. Those results were published in the May 2005 Annals of Emergency Medicine.
"The concern is that the patient in the hallway would be more likely to have an adverse outcome, but the hallway patients had lower death rates and ICU transfer rates" than those admitted to inpatient rooms, Dr. Howell pointed out. "Whether this result is reproducible or not, I don’t know, but the initial data show that putting patients in the hallway may actually be beneficial."
That might be, he guessed, "because everybody’s so worried about the patient in the hallway. They are the ones who are easy to see or hear, so they are the ones who fit the ‘squeaky wheel gets the grease’ syndrome."