Published in the August 2011 issue of Today’s Hospitalist
ASK HOSPITAL EXECUTIVES what data point they want to improve, and most will likely mention "throughput." Hospitals everywhere are under the gun to get patients out of the emergency department, either to a unit in the hospital or back home.
And while plenty of hospitalist programs are embedding hospitalists in the ED to speed up admissions, New York’s Mount Sinai Medical Center launched an ED hospitalist service with an important twist: While ED hospitalists worked up admissions, their primary job was to focus on patients being boarded in the ED. Hospitalists spent time not only delivering care to patients who were being admitted, but they also rethought which patients even needed to be admitted “and which could be discharged home or receive a lower level of care.
Over a period of nearly two years, the program not only lowered ED length of stay, but it also increased the number of ED patients who were downgraded from telemetry and discharged from the ED to home without
ever being admitted. Here’s a look at the program and at the results that it achieved.
A focus on boarders
Mount Sinai’s experiment with an ED hospitalist program was the latest in a long line of efforts the hospital has tried to address ED overcrowding, including more comprehensive discharge planning and bed tracking. But according to Alan Briones, MD, assistant professor in Mount Sinai’s division of hospital medicine, those efforts hadn’t made enough of a difference.
Dr. Briones says that hospital administrators were particularly unhappy with one aspect of ED care: boarders. "It wasn’t that these patients were being neglected," Dr. Briones explains. "The other doctors were concerned that the department was so busy that the quality of care the patients received wasn’t as good as it should be."
A quick look at the hospital’s ED boarding stats tells the story. As many as 30 patients at a time were waiting in the ED for a bed in a ward, Dr. Briones says “and patients were being boarded as long as 12 hours. Because those patients were not getting continuous care from ED physicians, Dr. Briones and his team created an ED hospitalist position.
Besides caring for ED patients, particularly boarders, the ED hospitalist would also look for patients who could be downgraded from telemetry or even potentially discharged, supervise the residents’ triage duties, and work with ED physicians, nurses and other specialists.
Not smooth sailing
Dr. Briones and his colleagues began piloting the ED hospitalist program in March 2008. While the original idea had been to round on all patients waiting for a bed, the hospitalists quickly realized that they didn’t have enough physicians for such a broad mission. As a result, the hospitalists concentrated instead on the patients who’d been boarded the longest.
The ED hospitalists began working up ED admissions, addressing not only patients’ medical management but their social issues. They followed up on tests, labs and medications, and they administered outpatient medications that patients were already taking or subsequent doses of drugs they had been given in the ED.
Dr. Briones admits that the program wasn’t smooth sailing from the start. Some of the ED physicians and nurses, for instance, were concerned when they didn’t know individual hospitalists or about the hospitalist program in general.
"If nurses don’t know you, they don’t want to take orders from you," he says. He helped smooth over that problem by holding an introductory meeting and putting the hospitalists’ pictures and names on an ED wall.
"The more familiar they are with you," Dr. Briones adds, "the better it gets." And the more experience the ED physicians had with the program, the more willing they were to defer to hospitalists on admitting issues.
When Dr. Briones launched the pilot project, he started tracking data on several measures. Of the 3,555 qualified boarders identified during the six months of the study period, a hospitalist evaluated 634. Here’s a look at how boarders treated by the ED hospitalist fared.
- Lab results. Among boarded patients seen by an ED hospitalist, nearly three-quarters (74.5%) had their lab tests followed up on, compared to only 13.2% of all boarders.
- Medication checking. The ED hospitalist checked up on medications for just under 80% of the patients he or she saw, compared to only 14.2% for all boarders in the ED.
- ED discharges. An ED hospitalist was able to discharge 7.3% of boarders treated and deemed stable enough to discharge home compared to only 1.3% of all boarders.
- Telemetry downgrades. An ED hospitalist was able to downgrade telemetry (from cardiac to general telemetry or from general to no telemetry at all) for 9.6% of the boarders he or she treated vs. only 1.8% of all boarders.
- Length of stay. Before the pilot, ED length of stay was about 700 minutes per patient (732 minutes in January 2008 and 658 minutes in February 2008). During the study period, ED length of stay dropped to 440 minutes, a reduction of between 3.5 and five hours per patient.
Reviving the program
Those were impressive results that Dr. Briones says the program was able to sustain for two years. (Program results were published last year in the Journal of Hospital Medicine.) But then, he noted, a round of budget cutbacks in the hospital forced the ED hospitalist program to shut down.
Without hospitalists dedicated to the ED, he says, the hospital wasn’t seeing the same accelerated throughput. "My work on a floor can’t be interrupted to be an ED hospitalist," Dr. Briones says. "You need someone dedicated to the department for the job."
The consult attending, who worked from 8 a.m. to noon, and the day’s lead hospitalist, who worked from noon to 6 p.m., tried to coordinate care for boarded patients in the ED. "But that was not a dedicated role," Dr. Briones explains, "so it was somewhat superficial."
That was the status quo until the beginning of last month, when new ACGME guidelines led the medical center to reconfigure its physician assistant assignments. Now, says Dr. Briones, a PA is filling the ED hospitalist role, while "our division chief has applied for approval to hire an ED hospitalist." In the meantime, he says, he has been fielding questions from other hospitals about starting similar programs.
Dr. Briones is now working with hospitalists at Henry Ford Hospital in Detroit to get an ED hospitalist program there off the ground.
Lisa Jaffe Hubbell is a freelance journalist based in Seattle.