Published in the February 2011 issue of Today’s Hospitalist
As recently as last fall, Thea Dalfino, MD, chief of hospital medicine at St. Peter’s Hospital in Albany, N.Y., was fielding one e-mail a week that she couldn’t ignore: Floor nurses were complaining “and rightly so “that patients were being brought up from the ED for admission without any orders.
“They were absolutely panicked because they had nothing,” Dr. Dalfino explains. “They couldn’t even give the patient a diet,” let alone something for pain or a dose of their home medications.
The hospitalists weren’t happy either. “We were frustrated because we knew this was not the best way to care for patients,” she says, “but we didn’t know how else to get patients out of the ED as quickly as possible.”
Dr. Dalfino admits that patients were spending too long in the ED, in part because the ED was “waiting for us to get there to write admission orders.” Neither the ED physicians, who didn’t have hospital admitting privileges, nor the hospitalists wanted to write temporary holding orders. All the while, the edict coming down from the very top of hospital administration was to reduce ED wait times and improve throughput.
Across the country, hospitalists are struggling with how to balance speed with caution when it comes to ED admissions. Yes, overcrowding leads to diversion, which is bad for public health and a hospital’s bottom line. But shooing patients out of the ED too quickly “without proper diagnoses and stability assessments “can threaten patient health and hospital revenue if patients are sent to monitored beds they don’t need or wind up on the floor when they should be in the ICU.
And while the dilemma isn’t new, it’s come to a head in many hospitals because of cutbacks in ED and inpatient beds, increases in ED usage, and the presence of both pay-for-performance incentives and 24/7 in-house hospitalists.
What to do? For one, hospitalists are sitting down with their ED colleagues to negotiate how each needs to change to expedite patient flow. Hospitalists in some hospitals, including Dr. Dalfino’s, have broken the impasse by standardizing bridging orders, figuring that even temporary orders are safer than none at all.
Other groups are scheduling admitters at busy hours. Still others are putting their focus on emptying inpatient beds earlier in the day so hospitalists will be available for new admissions “and patients in the ED can move to beds more quickly.
Roadblocks to faster admissions
For hospitals struggling with razor-thin profit margins, crowded EDs are a big part of the problem. Hospitals that can’t maximize capacity are losing money.
Then there’s a big push to improve patient satisfaction, with scores now publicly reported “and scheduled to be tied to DRG incentives (or penalties) “as soon as 2012. A Press-Ganey report last year acknowledged that patients who spend more than two hours waiting in the ED “report less overall satisfaction with their visits” than those there less than two hours. The same report said that the average amount of time patients spent in the ED in 2009 was four hours and seven minutes.
In many hospitals, the roadblock to getting patients to the floor faster is admission orders. Hospitalists are reluctant to issue orders for patients they haven’t seen in part, they claim, because patient assessments from the ED might not be accurate enough to base orders on.
Some hospitalists also resent what appears to be a one-way street, with hospitalists being asked to make all the changes in their work processes to improve flow from the ED. ED physicians in many places, including St. Peter’s, will not write holding orders themselves. And hospitalists complain that ED physicians employed by private groups have even less incentive to compromise.
“The fact that we are employed by the hospital means we have a little more incentive to be flexible,” Dr. Dalfino says, “whereas our ER physicians are privately hired.”
Following a new script
A few years ago, patient-flow problems led Waterbury Hospital in Waterbury, Conn., to hire a consultant to sit down with both the hospitalists and the ED physicians. (The hospital employs both groups.)
The goal was to improve trust and communication; the hospitalists didn’t always trust the ED’s assessment, while the ED doctors felt the hospitalists wanted an unreasonable workup. The negotiation produced a “communication script” to guide the dialogue between the ED and the admitting physician.
The two parties agreed, for instance, that patients with an asthma exacerbation would have an ABG and a basic set of labs. Now, when the ED calls and delivers the agreed-upon information, the hospitalist “if he or she feels comfortable with the assessment ” agrees to have the patient sent to the floor.
Or the hospitalist goes to the ED to evaluate the patient first. The ED doctors also agreed to write holding orders for patients stable enough to be moved upstairs before admission. (Examples include patients with low-risk chest pain, pneumonia and cellulitis.) Holding orders cover diet, antibiotics and pain medications, and they expire after two hours.
The hospitalists “promised the ED that we would be down to see patients within an hour,” says Rachel Lovins, MD, director of the hospitalist program. “The ED now sometimes finds it easier to wait for us to come down than to write a holding order and send the patient up.” Often, a hospitalist is stationed in the ED to do admissions quickly.
One unresolved concern is that patients sent upstairs with holding orders don’t have their code status noted. That, Dr. Lovins believes, can be unsafe if something goes wrong.
“The ER doc doesn’t want to have that conversation with the patient, and I understand that,” she says. “But what if the person gets upstairs and codes? That could be a disaster.” That’s one item that Dr. Lovins says she plans to work on.
A 30-minute deadline
At the 250-bed Central Maine Medical Center in Lewiston, Maine, ED-to-floor time has shrunk by 30 minutes, and overall length of stay for patients seen by the 11-hospitalist group has dropped three-quarters of a day since last summer. The hospitalists achieved those objectives through several initiatives.
One was committing themselves to getting to the ED in 30 minutes. For their part, ED physicians agreed to never just move a patient to the floor without a hospitalist giving them the OK.
“Any party has the ability to say ‘time out,’ ” says John Dickens, MD, MPH, medical director of Central Maine Hospitalists. “They can’t push forward, but any party can slow things down.”
The hospitalists also “regionalized” their rounding. Now, all primary medical patients are on two floors instead of scattered among seven units. That’s allowed hospitalists to focus on discharging patients earlier in the day, freeing beds for new admissions showing up in the ED in the afternoon.
The group also did away with its 4 p.m.-10 p.m. swing shift, adding a “triage” hospitalist instead to the day shift. That physician takes admissions during the day; answers all calls from the ED, ICU and outside regarding transfers; does nonurgent consults; and sees patients in the rehab unit. The new position prevents rounding teams from being interrupted “and allows rounders to be available to jump quickly on late-day admissions.
And in an effort to cope when they are slammed, the group made an arrangement with the in-house intensivists: If available, intensivists will admit select medicine patients from the ED who the hospitalists can’t get to quickly.
“We’re trying to do more with less,” Dr. Dickens says, “and another doctor can provide care if we need it. If the intensivist is available, he can start taking care of the patient immediately.” That option is particularly useful, he adds, when patients are so sick that it’s really “not safe to have holding orders.”
No bridging orders
At the 337-bed Southeastern Regional Medical Center in Lumberton, N.C., hospitalist medical director Darren Sommer, DO, MPH, says that the admitting hospitalist must see patients and write admission orders prior to patients reaching the floor. That policy is easier to achieve now that the hospitalist group has separate admitters and rounders.
The hospital also created a “transition unit” for hospitalist admitters within the ED that helps free up ED beds. Dr. Sommer points out that the unit has been a big patient satisfier, with patients being moved into a private room while still under the watch of an ED physician. The innovations have also helped ensure that no patient comes to the floor with bridging orders.
“I don’t see how bridging orders help,” Dr. Sommer says. “They help move people out of the ED, but they cause bottlenecks on the back side. If the ER doc gave the hospitalist an accurate assessment every time, and the hospitalist by phone could make an accurate assessment on bridging orders every time, then it wouldn’t be a problem. But that doesn’t happen.”
Bridging orders cause bottlenecks on the wards, he adds, because “the floor is not designed to work up a patient with the same efficiency as the ER. All the people who support the ER are apt to do a host of things in an ER setting at a certain pace much differently than on the floor.”
According to Dr. Sommer, hospitalists may also depend too heavily on bridging orders and not respond quickly enough to a new admission. “How much longer does it take,” he asks, “for a hospitalist to see a patient who has bridging orders than one who doesn’t?”
To ensure even faster ED response, Dr. Sommer allows group members to volunteer on their days off to work extra 7 a.m.-7 p.m. admission shifts “and earn lucrative moonlighting pay. These shifts are available on days when the census goes above a particular threshold, which is now the case about 80% of the time. Rarely, Dr. Sommer points out, does he have trouble attracting volunteers.
Following patients upstairs
At the University of Miami Hospital, Andres F. Soto, MD, director of the hospitalist service, also depends on group members to work extra moonlighting admission shifts (5:30 p.m.-10:30 p.m.) to help speed ED admissions during ED call days. Because the process of getting a bed for a new patient coming in through the ED doesn’t start until there are at least preliminary orders for a patient, nearly all patients end up with some preliminary orders.
“We write these orders,” Dr. Soto says, not the emergency physicians. Because many hospitalists feel uncomfortable giving verbal preliminary holding orders over the phone, however, their alternative is to drop what they are doing and go to the ED, see the patient and begin the admission process.
The hospitalists have also changed how they work, Dr. Soto says. “We have said if you are working on the admission and a bed comes through, then the patient should go upstairs and you can finish what you were doing upstairs. We cannot hold the patients downstairs.”
As a former emergency physician who’s now a hospitalist, Dr. Soto tends to see this dilemma from both perspectives. “I don’t think that we should complete the whole workup in the ED,” he says. “That is not cost-effective.” While X-rays and CT scans are done much more quickly when ordered from the ED, he adds, “there are plenty of other tests that are just as efficiently ordered from the floor.”
What to include on interim orders
In Albany, meanwhile, Dr. Dalfino’s group has succeeded in reducing the time patients spend in the ED before they’re admitted. Patients are currently waiting 266 minutes, and the hospitalists are working to get patients to a goal time of 180 minutes. Just as importantly, says Dr. Dalfino, no patients are being pushed out of the ED into inpatient beds without orders.
To help end that stalemate, she sat down with the ED director to create an interim order form. Now, as soon as the ED calls with a waiting admission, the hospitalists ask to speak to the nurse caring for that patient. That nurse fills out the form with the hospitalists’ verbal orders.
The form lists basic pain medications, nebulizer treatments and other typical orders that stable patients with common diagnoses would need in the next four to six hours. The interim order sheet also allows the hospitalists to easily order consults and otherwise get started on a patient’s treatment. The conversation also gives hospitalists a good sense of whether the patient should be seen immediately.
Since the new protocol was put in place in mid-November, says Dr. Dalfino, she hasn’t received one e-mail from the floor nurses. “As a physician,” she says, “I feel more secure in the fact that the patient is going to the floor with at least something.”
The group has also been able to hire another rounding physician, which lowers everyone’s daily rounding census. “The rounding doctors are now encouraged to pick up an admission at the end of their shift, which happens to be exactly when the admitters get most admissions, after 3 p.m.,” she notes. “That allows us to get to patients in the ED faster and to write full admission orders, rather than interim ones.”
For those hospitalists in her 22-physician group who remain uncomfortable giving bridging orders over the phone, Dr. Dalfino notes that they have an alternative: getting to the ED within 30 minutes. “Hospitalists have to recognize,” she says, “that they are getting the patients out of the ED pretty quickly.”
Deborah Gesensway is a freelance writer based in Toronto who reports on U.S. health care.