ED/hospitalist plan improves throughput
ED/hospitalist plan improves throughput
Collaboration also reduces diversions
A new plan for admitting patients from the emergency department (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.
A new plan for admitting patients from the emergency department (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.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.