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Going in-house

To reduce ambulance diversions, a team of hospital physicians stays in the emergency department

January 2013

Published in the January 2013 issue of Today’s Hospitalist

WHEN DENVER HEALTH MEDICAL CENTER created a hospitalist-led medicine team to work full time in the emergency department three years ago, the goal was to solve the large tertiary hospital’s ED diversion problem.

It did. According to a study published in the September 2012 issue of the Journal of Hospital Medicine, diversions that could be traced to a lack of medicine bed capacity decreased 27% after the hospital medicine ED team (HMED) was started in 2009. That in turn boosted the hospital’s annual revenue by an estimated $525,600.

But the team’s accomplishments went above and beyond, says study lead author, Smitha R. Chadaga, MD, associate chief of hospital medicine and co-director of the clinical transition unit at Denver Health. The team not only improved the experience and length of stay for inpatients being boarded in the ED, but it increased the rate of admitted medicine patients being discharged directly from the ED. That paved the way for establishing a hospitalist-run observation unit.

The team also scored some important intangibles: improving relations with both the ED doctors and the nursing supervisors in charge of bed assignments. Those supervisors, in turn, have helped the hospitalist group maintain unit-based staffing on the hospital’s medical floors. That was key because unit-based staffing on those floors had “fallen apart at least three or four times,” Dr. Chadaga explains.

“We have a level of trust that didn’t exist before because we didn’t talk that much before,” she says. Now, “if the nursing supervisors are having a hard time figuring out where patients in the ED should go, they can ask us to go look at them and help figure out if they need isolation or telemetry or are having psychiatric issues or sitter needs.” By the same token, “if we have a patient who is really sick and needs to be on a different floor or in the ICU, they help us prioritize that.”

Multitasking and variability
The embedded team is basically unit-based staffing where the target unit is the ED and the five-bed observation unit. Ten of the 40 hospitalists share the assignment, with each physician taking a 7 a.m.-5 p.m. shift alongside a midlevel. The other 30 hospitalists get a taste of the ED work because after-hours coverage is rolled into the existing swing and night hospitalist shifts.

While most hospitalists at Denver Health spend their time on floors six through nine, the ED is on the first floor. That difference in geography used to mean that patients being boarded in the ED while waiting for a bed “tended to be seen last,” Dr. Chadaga explains, even though “they were usually the sickest. We had multiple layers of concern from diversion times, ED flow and patient care.”

Hospitalists on the HMED team spend about three-quarters of their day rounding on patients who have been admitted to the medical service but who are being boarded in the ED and running the protocol-driven observation unit. The other 25% of their time is spent on bed management.

“We do a lot of multitasking,” Dr. Chadaga says. As a result, the service isn’t a good match for hospitalists who don’t like multitasking or unpredictable workloads. The team’s census can vary from a low of five to more than 20.

Less continuity, more handoffs
The group has spent a lot of time trying to figure out ways to stabilize the team’s workload. Putting the hospitalist-run observation unit in place has helped on the low end, says Dr. Chadaga, as has setting up a policy where the team hospitalist helps the dedicated daytime admitter on slow days. For particularly busy days, the group has a contingency plan to redeploy hospitalists from the floors to the ED.

“You don’t want them to be over- or underworked,” she says. “It can be a logistical challenge.”

In addition, these hospitalists are “often pulled in many directions at once. You are trying to help with patient flow, carry the admission pager and care for boarded patients,” Dr. Chadaga notes. “By definition, if there are boarded patients, it means the hospital is really busy.”

And taking care of boarded patients also means having a census filled with very needy patients. While rounding on a floor, “you might have some who are close to discharge, some in the middle and some who are new, so you can pace your day and see the sick people first.” In the ED, however, says Dr. Chadaga, “everyone is sick and having issues because they are all in that first 24 hours of admission. In observation, meanwhile, you are trying to expedite workups.” As for bed management, the physicians are trying “to help the nurse supervisor get patients to the right bed the first time. It can be a very challenging, chaotic day.”

Also, she points out, doctors working on the team need to be comfortable with less continuity of care and skilled in doing extra handoffs. As soon as patients are transferred to regular floor beds, Dr. Chadaga explains, responsibility for their care switches to a different hospitalist or resident team.

More discharges from the ED
The 10 team members all volunteered for the job. Several had worked in emergency medicine before, while others have a special interest in patient flow or in observation medicine.

One important way the team has improved throughput is by significantly increasing the number of patients who never end up tying up a floor bed in the first place. Not only are the team’s hospitalist and midlevel able to
round on boarded ED patients more than two hours earlier on average, but they also significantly increased the percentage of admitted patients discharged directly from the ED. (See “Before and after, below.”)


At the same time, the percentage of patients being transferred to a medicine floor but then discharged less than eight hours later decreased by nearly the same amount. According to Dr. Chadaga, that hasn’t affected the rate of people returning to the ED within 48 hours.

The key lesson she has learned from the innovation is that its organization and management are never finished. Instead, it needs to constantly evolve as hospital needs change.

The current discussion, Dr. Chadaga notes, is whether the observation unit should be expanded and, if so, whether the hospital medicine ED team will still oversee it.” We are looking at whether the observation unit should be its own service,” she explains, because “we are always going to take care of boarded patients.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.