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ED/hospitalist plan improves throughput
Collaboration also reduces diversions
A new plan for admitting patients from the ED at Johns Hopkins Bayview Medical Center in Baltimore jointly developed by an ED physician and a hospitalist, decreased ED throughput for admitted patients 98 minutes (from 458 minutes to 360 minutes) from the same period a year earlier, despite an 8.8% increase in the ED census. The proportion of hours that the ED was on ambulance diversion because of ED crowding decreased 6 percentage points, or 182 fewer hours. The proportion of hours that the ED was on red alert (ambulance diversion due to lack of ICU beds in the hospital) decreased 27 percentage points, or 786 fewer hours.
"Before, this plan, admissions were largely handled from house staff to house staff, which we called 'service ping pong,'" recalls Edward Bessman, MD, FAAEM, FACEP, who was then an ED physician and is now chairman of emergency medicine. "There was a lot of back and forth, where physicians agreed the patients needed to be admitted, but not necessarily to their service."
That problem has been eliminated, because now a hospitalist, in consultation with the treating ED physician, makes the final decisions for admitting ED patients to the cardiac ICU; the medical ICU; and the cardiology, pulmonary and general medicine units. That same position, filled on a rotating basis by all hospitalists, is responsible for 24/7 bed management. ICU admissions are transferred no longer than 90 minutes after the assignment decision is made, while patients admitted to a non-ICU unit are transferred out of the ED as soon as a bed is available.
To implement the plan, Bessman and Eric E. Howell, MD, FHM, director of hospital care for the department of medicine, had to convince administration to take on an additional 2.4 hospitalist FTEs. "It took a while to convince various administration types that in fact if we could solve our admissions problem, we'd solve a large part the ED overcrowding problem," says Bessman. "But we showed them that two-thirds of our admissions come from the ED, and that when it's full, admissions fall off and ambulance diversions increase." In fact, he says, the two actually walked administrators through the ED to show them how full the ED was.
Pointing out the "lost" admissions was critical, Bessman emphasizes. "You can talk about patient safety and satisfaction all you want, but if you really want something to happen, you have to frame it in terms of dollars," he says.
Howell says, "When I talked to the administration, there were internal studies we had done that showed for every two hours of diversion, you lost half an admission. We also found evidence in the literature to support the fact that diversions cost a minimum of $1,000 an hour."
The investment seems to have paid off, Bessman says. "On the expense side we added about $1 million, but we're in the middle of return on investment calculations, and it looks like our return will be about two to one based on incremental volume and admissions," he says.
For more information on using hospitalists to help admit patients from the ED, contact:
Specialists are skeptical at first
It was a challenge to convince administration officials to invest about half a million dollars a year for 2.4 additional hospitalist FTEs required for a new plan for admitting patients from the ED at Johns Hopkins Bayview Medical Center in Baltimore. However, it was just as hard to convince some specialists to cede the responsibility for admitting patients to their units to a hospitalist, as the new plan required.
"In some institutions, coming up with the money might not be the difficult part," says Eric E. Howell, MD, FHM, director of hospital care for the Department of Medicine. "For us, it was equally difficult to gain acceptance of the decision to allow the active bed manager [hospitalist] to, in fact, triage for all divisions."
How were the objections overcome? "It was not an overnight process," he concedes. "Probably the main selling point was giving them input into our process." A medicine oversight admissions committee was created, Howell explains. Through monthly meetings, the primary departments continue to have input into the process, he adds.
"With that collaboration, they signed off on it, and ironically, now they love it," says Howell. "The cardiac intensive care unit, for example, which was one of most reluctant, has seen an increase in primary coronary infusions, and door-to-balloon times have gone down."
Edward Bessman, MD, FAAEM, FACEP, chairman of emergency medicine, says, "We made other changes at the same time, but we are now doing angio within 120 minutes 91% of the time, vs. 40% before we began. Our goal is to have 75% under 90; currently it's almost 60%."