Published in the August 2005 issue of Today’s Hospitalist
When Baylor University Medical Center in Dallas opens a new 10-bed clinical decision unit attached to the emergency department this month, it will join a growing number of hospitals that are turning to hospitalists to improve throughput and ease ED overcrowding.
While the concept of an interim or observation unit isn’t exactly new, Baylor’s unit is unique because it will be overseen by hospitalists, not emergency physicians. The giant inner-city hospital has high hopes for the unit, which can “fl ex” up to 30 beds in the event of a surge.
“There are a lot of these units, but I don’t think anyone has combined the concepts of hospitalist-run units and flexible staffing to create surge capacity,” says Dichton Packard, MD, chair of Baylor’s emergency medicine department and chief medical officer at Dallas-based EmCare, the country’s largest emergency medicine management group. “We’ll have to see how well this works, but we think it might be a way to alleviate the wait in the ED.”
Alleviating waiting times is a prime objective for Baylor’s emergency department, whose annual volume is a dizzying 75,000. “We already know, without a doubt, that we can move patients out of the ED faster with hospitalists,” Dr. Packard explains. “We’re trying to improve on that by exploring new ways to make those relationships even closer.”
Along those lines, Baylor is finding other ways for hospitalists to work more closely with ED physicians. Its two hospitalist groups, which together admit 90 percent of patients who don’t go to the ICU or trauma service, recently started stationing a hospitalist in its ED during peak-activity times. That hospitalist’s sole job is to handle admissions for the approximately 50 patients daily who end up as “keepers.”
“There is great opportunity out there for creating closer working relationships between the ED and hospitalists,” Dr. Packard says. “I think we’re just starting to open the doors.”
When it comes to the roles that hospitalists can play in the ED, hospital administrators are beginning to realize it’s no longer just about unassigned patients.
Savvy hospital administrators, in fact, are increasingly viewing hospitalists as ED “clog-busters” when they work closely with emergency physicians. Among EmCare’s 23 hospitalist programs in a dozen states, for example, 10 operate as joint ED-hospitalist structures.
“You can take one half to a full day off of a hospital stay when the hospitalist and ED are working closely,” Dr. Packard says. “If you can get that test done now and get those drugs started now, instead of five hours from now, that pays off in patient wellness. As an extra benefit, it sometimes reduces length of stay.”
Other companies that have started in ED management and are now branching out into hospital medicine are seeing similar demand for the combined-program approach.
“Hospitals are seeking this co-management for a number of reasons,” says Stephen Dresnick, MD, CEO of Sterling Healthcare in Coral Gables, Fla., which operates in more than 300 hospitals in 27 states. “Clearly one of the stated goals is to decompress the ED to reduce throughput time.”
Sterling, which recently added hospitalist programs to its nearly three-decade-old ER management business, has found that running both programs in a coordinated fashion offers some distinct advantages.
“When you have the same stable group of four or five doctors staffing the ED and four or five hospitalists who always admit,” Dr. Dresnick explains, “the comfort level between the [groups] becomes such that there’s not a lot of disagreement. The patients get admitted, the orders get done and the hospitalist takes over the care.”
Slashing waiting times
At Pinnacle Health System of Las Vegas, whose hospitalist subsidiary Inpatient Physicians Network contracts with 44 hospitals in the southwest, is also finding that ED throughput is a front-burner issue for hospital administrators. As Pinnacle’s chief medical officer, Amir Bacchus, MD, explains, they expect hospitalist programs to take the lead.
“Hospital CEOs want to see those wait times, which are six to eight hours in Nevada, improve,” he says. “And they know that to do that, you need people to expedite those patients through the system. You literally have to arm the troops, and that’s what they’re looking for in their hospitalist programs.”
That demand is one reason that his group continues to fine-tune its programs. In some cases, it has a designated hospitalist fl oat between the ED and the medicine floors. In others, hospitalists maintain a “near-constant presence” in the ED.
Hospitalist and ED groups don’t have to be linked fiscally or operationally to reduce wait times and streamline ED operations. That’s the experience of Michael Bishop, MD, president and CEO of Unity Physicians Group in Bloomington, Ind., which runs EDs at 10 hospitals, including the 811-bed Bloomington Hospital.
“We run an annual volume of 55,000 in our ED,” he says, “and my guys absolutely love having the hospitalists because it makes their lives so much easier. They don’t have to wait for someone to come in, unless it’s a subspecialist.”
While the hospitalists at Bloomington have no direct financial connection to the ED group, they have developed a close working relationship. The directors of the two groups meet regularly to discuss ways to improve throughput, and the hospitalists often take extra time to update ED physicians on new thinking or treatment approaches for certain conditions. While that might be viewed as interference in some quarters, Dr. Bishop says the input is “very well-received.”
The ED-inpatient medicine connection
It’s well-recognized that having hospitalists “in house” can help improve ED throughput, sometimes significantly. In reports released last year, both the American College of Emergency Physicians and The Center for Studying Health System Change (HSC) pointed to the emergence of hospitalists, in their evolving role as ED support and backup, as a key contributor to the recent trend toward improved ED throughput.
Patient length of stay in the ED is often extended not out of medical necessity, but because of attending physician unavailability, one major reason for ED crowding, the HSC report found. The report notes that hospitalists can play a role in one of two ways.
On the front end, hospitalists can lighten the load either by evaluating patients in the ED to help make an admission determination, or by assuming lead roles in observation or clinical-decision units. On the back end, hospitalists’ presence in inpatient units and closer tracking of patients helps reduce length of stay.
The bottom line, the report says, is that in markets where hospitalists are getting involved in either role, ED overcrowding is starting to subside.
“There’s a growing recognition on the part of hospital administrators that the ED is the front door of the hospital,” says Dr. Dresnick from Sterling Healthcare. “And once they [administrators] get over the threshold and understand that, the hospitalists’ importance becomes much more pronounced than when they were just talking about hospitalists taking on unassigned patients.”
“Where things are working best, across the continuum of care, is where hospitalists are available 24 hours a day to take that hand-off from the ED,” Dr. Dresnick adds. “We’re seeing an understanding of those ED-inpatient issues in a way that we never saw before. You don’t alleviate the ED by improving inflow but by improving outflow, and you do that by having a hospitalist program and freeing up those inpatient beds.”
Pressures from the market
Experts say that the hospital industry is at an important juncture where low performers are failing and better performers are thriving by doing more than just talking about best practices. Dr. Dresnick says that winners are building ED-hospitalist relationships to positively affect everything that happens “downstream.”
As hospitals compete on quality and service, many are beginning to focus on more than intangible measures and “soft” deliverables such as quality. More are now promising that patients who show up in the ED will be seen in 30 minutes or less. And short of increasing ED capacity and staffing, the only way most hospitals can deliver on that promise is by increasing throughput “usually with the strategic use of a hospitalist-ED team.
Piedmont Emergency Medical Associates is using that type of model in its programs. The Charlotte, N.C., company, which employs both emergency physicians and hospitalists and runs joint programs in several markets, promises that hospitalists will show up quickly to perform consults in the ED and handle admissions if necessary.
Beril Cakir, MD, a hospitalist with Piedmont’s affiliated Internal Medicine Associates, says that administrators see the financial and efficiency connection between hospitalists’ timely arrival in the ED. She notes that her group’s commitment to see ED patients within an hour of the call has vastly improved throughput. They are also increasingly seeing improved patient satisfaction.
“It’s actually becoming an expectation that patients will be seen more quickly in the ED,” Dr. Cakir says, “and we’re helping our hospitals fulfill that expectation.” Since hospitalists have committed to showing up within an hour, patient satisfaction scores have improved at the three Charlotte-area EDs where Dr. Cakir’s group uses the team model, she says, in part because of “the good, improved patient flow from the ED to the floor.”
As an added throughput benefit, the hospitalists have also assumed responsibility for admitting patients who come directly from their primary physician’s office, which allows them to bypass the ED.
Dr. Cakir’s group also handles stress tests for stable patients presenting with chest pain, in part because the hospitals don’t have dedicated units. “We can get those results within an hour, which sometimes enables us to avoid one full day of admission,” she says.
In the group’s most recent ED-hospitalist pilot project, hospitalists are working as key members of what Dr. Cakir calls a “pre-code team,” similar to the emerging rapid response teams some large hospitals are using. Although Dr. Cakir notes that the program is still in its early stages, she says it is already decreasing the amount of time ED physicians spend away from their department because of codes.
The next frontier: observation units?
Community Hospitalists in Cleveland is moving toward some of the same strategies being used at hospitals like Baylor, albeit on a smaller scale. Although none of the seven hospitalist programs run by the group is large enough to warrant stationing a hospitalist in the ED full time, the group has implemented a policy that 90 percent of ED patients will be evaluated by hospitalists before being moved to the floor.
“That way, we can be a bit more clinical about the triage decisions being made in the ED,” says the group’s medical director Stephen Shaw, MD. “We can sometimes offer more effective therapy guidance or help make a decision [about admission] when the emergency physician is on the fence about whether or not the patient should come in.”
“That also switches the medical-legal ‘attendingship’ earlier than it might typically occur, which the ED appreciates,” Dr. Shaw adds. “They’re happy to let go of those patients as soon as possible.”
Dr. Shaw, who also serves as program site director at Southwest General Hospital in Middleburg Heights, Ohio, expects that his hospitalists will soon assume even larger roles within their EDs. Southwest General, whose ED remains at capacity most of the year, is considering opening an observation unit that would be overseen by a hospitalist.
Having hospitalists serve as medical directors of observation units makes sense from both a practical and quality perspective, industry observers say. When hospitalists assume responsibility for those patients, it takes them off the ED “rolls” and allows for faster test ordering and, presumably, quicker action “whether it’s a discharge or an admission “on associated results. And when an admission of a stable patient is assured, hospitalists assigned to such units can assume the hand-off earlier and complete the admission process in the unit if a bed isn’t ready.
Medicare requirements may also spur increased presence of hospitalists in these units. The governmental payer now requires closer on-site physician management of patients in observation units, a practically untenable proposition for off-site PCPs, but an ideal role for hospitalists. In addition, Medicare has determined that certain diagnoses can be safely treated in observation units, avoiding a full admission.
“Observation unit directorship is something I think hospitalists will be playing a larger role in,” Dr. Shaw says. “They’re really the best group to effect a 23-hour admission.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.