Ambulatory Care Quarterly

ED-based hospitalist team helps cut boarding

Success depends on strong cooperation

One of the problems associated with the boarding of admitted patients in the ED is that the practice inevitably leads to increased diversion when the ED's capacity to care for new patients is diminished. This is precisely the problem that Denver Health Medical Center (DHMC) in Colorado was dealing with in 2009. Too often, incoming emergency patients had to be diverted to other hospitals because the ED was backed up with boarded patients. And every hour on diversion was costing the hospital an estimated $5,000 in revenue.

Administrators were determined not only to reduce the amount of time the ED spent on diversion, but also to ensure that patients who were boarded in the ED were well cared for. The solution they came up with was the creation of an ED-based hospital medical team (HMED) that could divide its time between working with nursing supervisors to appropriately manage patient flow while also taking charge of the care of admitted patients who were still awaiting inpatient beds.

In a study that compared the results of this intervention, measured from Aug. 1, 2009, to June 30, 2010, to a control period when the HMED team was not in place, from Aug. 1, 2008, to June 30, 2009, investigators found that the HMED approach made a significant 27% dent in diversion, tied to lack of bed capacity. Also, discharges of admitted patients from the ED increased by 61% during the intervention period when compared to the control period.1

Researchers note that patient characteristics and ED volume were statistically similar during the control and intervention periods. The ED saw approximately 50,000 patients during the years, including both the pre- and post-intervention periods, explains Smitha Chadaga, MD, the lead author of the study, and associate chief, Division of Hospital Medicine, DHMC.

Involve stakeholders in a trial

Chadaga explains that the idea for an HMED team grew out of a four-day "rapid improvement experiment," one of the Toyota Lean processes that DHMC utilizes when it endeavors to make improvements. "We had emergency department physicians, hospital physicians, utilization management, social work, nursing, and we even had some people involved who didn't have any stake in the outcome just to provide some objective opinions," she recalls. "This solution was devised using input from everyone in the group so, therefore, a lot of the issues that would normally crop up, just in terms of territory or job descriptions, were ironed out during the experiment."

Each person who took part in the experiment then had the task of going back to his or her work environment to report, and then the intervention was deployed, notes Chadaga.

"The hospital medicine team is made up of a dedicated attending hospitalist and a dedicated allied health professional [AHP]," she says. "During the day shift, from 7 a.m. to 5 p.m., the hospitalist and the AHP are housed in the ED, but during the swing and night hours, the hospitalists on those shifts are covering the entire hospital, but the responsibilities of the HMED team are rolled into those duties."

What was required on the part of the ED to accommodate the HMED team? "The first piece of it was real estate. We built this ED with a nine-bed unit that we called a flex unit with the idea that it could be used for observation or for overflow or for surge capacity," explains Lee Shockley, MD, FACEP, clinical director of Emergency Medical Services at DHMC, and co-author of the HMED study. "We have repurposed that and made it essentially an inpatient unit in the ED to be run by the hospitalists, so we did lose nine beds of our capacity in the ED, but what we gained from it was the ability to keep boarded and observed patients in the same location."

There was virtually no resistance to the HMED team because the intervention was rolled out first on a trial basis to see if it would work, explains Shockley. "People were happy to give it a try," he says.

Consider patient care and patient flow

As a level 1 trauma center, there are times when DHMC runs at capacity and the medical floors cannot accept any more patients, observes Chadaga. "In those instances, admitted patients are housed in the ED and the HMED team provides ongoing care to these patients."

Chadaga notes that the HMED team spends about 75% of its time providing patient care to admitted patients in the ED. The team then devotes the remaining 25% of its time to optimizing patient flow. "We have access to the bed board and we work with our nursing supervisors to help get patients to the right floors the first time, especially when patients are boarding in the ED," she says. This is important, notes Chadaga, because in the past, nursing supervisors only had a patient's place in the queue as a guide for when to put patients on an inpatient floor.

"If a patient was in the ED the longest, that patient got put on the inpatient floor first, but patients who have been in the ED for the longest period of time have the greatest likelihood of being discharged," she explains. "Working with the HMED team, which is primarily taking care of admitted patients, we are able to better communicate who is ill and who is closer to discharge. This prevents people from going upstairs to the medical floors only to be discharged shortly thereafter."

Streamline the bed-designation process

From an operations standpoint, the clock starts ticking whenever the ED makes a request for a bed. "If the patient has not been assigned to a floor within an hour, that patient automatically is eligible to [come under the care of] the HMED team," says Chadaga. "ED staff will call that attending when they are ready to give a report, and unless a bed can be found by working with a nursing supervisor, the patient is then under the purview of the HMED team until the patient is assigned to a hospital floor, and then the HMED team will sign that patient out to the floor team."

While all the hospitalists rotate through the HMED team on the swing or night-time shifts, the responsibility of managing patients in the ED who have already been admitted, rounding on them, and then also admitting new patients represents "somewhat of a skill set," observes Chadaga. "All of our physicians are capable of doing it, but we do have a core group of about nine attendings who rotate through the day-time HMED shift just to develop the relationship with the ED and learn the ins and outs of hospital flow and ED inpatient management."

Shockley agrees that the ability of ED clinicians to establish a strong relationship with hospitalists has driven the success of the HMED team in improving patient flow. "Prior to the HMED team, we would make a determination on where a patient needed to be admitted, an admit form would go in, and there was typically a delay before we had a chance to communicate with the internists on the inpatient side of things," he explains.

Once the inpatient staff were consulted, the patient's destination would often change in a process that typically involved a fair amount of rework, adds Shockley. "Having one person to go through in this hospitalist service really streamlines the entire process where we can talk to one admitting team, and they can help in making determinations on where each patient can best be served," he says. "We work with [the HMED team] very closely. It is frequently a matter of a phone call where we ask if they can step over and take a look at a patient. It is much easier than trying to call someone down [from an inpatient floor] who has other things he or she is trying to attend to."

Establish close ties with hospitalists

Since the HMED team was first implemented in 2009, the objectives of the service have changed a bit to accommodate a physical expansion that included the construction of an observation unit in February of 2011. "The HMED team is still housed in the ED, but we now take care of patients in the observation unit, as well as patients who are boarding in the ED until a room opens up on a medical floor," explains Chadaga.

The observation unit expands the options available to ED clinical staff, observes Shockley. "We have the ability to not take an inpatient bed, but rather have the patient placed in our observation unit that is part of the ED, run by the hospitalist team," he says. "It makes transport a lot easier, and it makes disposition a bit easier."

While the HMED team has been a good fit for DHMC, Chadaga stresses that this doesn't necessarily mean it would work well in all ED settings where there are problems with throughput. "I think it depends on what your issues are. If ED physicians have questions about which service to send patients to, then perhaps establishing a full-consultation relationship with hospitalists could speed up flow. If the issue is that there is a lack of communication about which beds are open upstairs, perhaps opening up more dialog between nursing supervisors and hospitalists might work," she explains. "But if you have a lot of boarded patients in the ED who need care, then actually physically [having a hospitalist] located in the ED can work."

There are many different components to patient flow, observes Chadaga. She adds that the success of any particular intervention will depend on staffing levels, an ED's specific needs, and support from the institution. Another factor that can impact effectiveness is satisfaction with an intervention among clinical and administrative staff.

At DHMC, anonymous surveys were distributed to both nursing supervisors and ED attendings one year after the HMED team was introduced. Results showed 87% of respondents felt that the intervention delivered a positive impact on clinical care for boarded patients, communication, and patient throughput.

The one critical requirement to making an HMED team intervention successful is commitment from both the hospitalists and the ED physicians, stresses Shockley. "You need to have a group of hospitalists who are committed to a project like this and committed to communicating with the ED physicians, and a group of emergency physicians who are accepting of having a hospitalist in their department," he explains. "Everything after that is fairly easy. It is just a matter of finding space available and finding the proper procedures to follow, but the foundation is the relationships."

Reference

  1. Chadaga S, Shockley L, Kenison A, et al. Hospitalist-led medicine emergency department team: Associations with throughput, timeliness of patient care, and satisfaction. Journal of Hospital Medicine 2012; 7:562-566.

Sources

  • Smitha Chadaga, MD, Associate Chief, Division of Hospital Medicine, Denver Health Medical Center, Denver, CO. E-mail: smitha.chadaga@dhha.org.
  • Lee Shockley, MD, FACEP, Clinical Director, Emergency Medical Services, Denver Health Medical Center, Denver, CO. E-mail: lee.shockley@dhha.org.