Home Working With Other Specialties Building rapport with the ED

Building rapport with the ED

December 2013

Published in the December 2013 issue of Today’s Hospitalist

AT SAINT FRANCIS MEMORIAL HOSPITAL in San Francisco, the directors of the hospitalist program and emergency department met early last month for a session that had nothing to do with clinical issues. Instead, Joseph Mallon, MD, who heads up the hospitalist group, got together with the ED chief to sort out the final details of the two departments’ joint holiday party.

The annual affair is one of several social events the two groups hold together every year. The socializing, as well as frequent joint clinical meetings, have gone a long way to build rapport between the two departments.

“It’s harder to be upset with colleagues when you know them personally and have met their families,” says Dr. Mallon. “It gives you a different perspective. We’re all on a first-name basis now.”

The rapport between the two groups may also have been a big factor in some impressive data: Despite having the second busiest ambulance-traffic volume in the city, Saint Francis has achieved a median time-to-provider of less than nine minutes and a turnaround time-to-discharge from the ED of less than two hours. That’s according to a press release from CEP America, the national acute care staffing company based in Emeryville, Calif., that operates both the hospitalist and the ED program at Saint Francis.

The tighter integration between the two services has also helped shorten the average length of stay. Those achievements garnered the hospital CEP America’s 2013 practice of the year award.

“The ER-hospitalist collaboration is why we won site of the year,” says Dr. Mallon. “There’s definitely a mutual respect for each other’s time and opinion.”

Quarterly meetings
In the past, Dr. Mallon notes, the relationship between the two groups had some room for improvement. (The hospitalist program now has 10 full-time and seven part-time physicians, while the ED has nine full-time physicians and nine part-time ones.)

“We had process roadblocks and some personality conflicts that hampered collegiality,” he says. “It really comes down to understanding one another.”

That’s where the joint meetings come in. The ED and hospital medicine departments have held joint meetings every quarter to discuss clinical issues. Frequent topics are sepsis, order sets and ways to remove bottlenecks that interfere with patient flow through the ED.

In addition, the hospitalist group sends a representative to the ED group’s monthly meeting and vice versa. The hospitalists also hold a monthly operations meeting in which a member of the ED department “along with delegates from nursing, case management, administration, pharmacy, radiology and intensive care “participates. It’s during both the joint group and operations meetings that ideas for improving collaboration emerge.

“Bring an ER doctor to work”
The hospitalists now have a much better understanding, for instance, of how their ED counterparts can get swamped; Saint Francis guarantees a time-to-provider of 30 minutes or less, which puts a lot of pressure on the ED doctors.

To help improve that situation, the hospitalists added a 3 p.m.-11 p.m. swing shift, primarily to smooth out throughput and admission snags during peak times.

Likewise, the ED physicians have learned a lot more about the challenges hospitalists face on the wards. “They have a better understanding now about our constraints and issues “with the ICU, with case management requirements, calls from nurses or family situations,” Dr. Mallon says.

And at their last joint quarterly meeting, the two departments discussed a “bring an ER doctor to work” initiative.

“We plan to introduce them on the hospitalists’ morning rounds in the coming weeks,” he noted. “We hope they’ll have a better understanding of why our morning workflow can be very busy, from stabilizing an ICU patient vs. discharging a patient to a nursing facility or home.”

Collaboration spawns solutions
The closer collaboration has prompted numerous process improvements.
The two departments will be working with representatives from infectious diseases and critical care to create a new protocol for early sepsis detection and management and a “sepsis code.” They now plan to have those up and running by mid-2014.

Another innovation generated by the joint hospital medicine-ED meetings is that the hospitalist service decided to increase staffing during flu season from November through February to help with ED throughput.

“We’re trying to staff up in advance now,” says Dr. Mallon, “to see if that will help ED workflow.”

Bonnie Darves is a freelance health care writer based in Seattle.

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