Hospitalist project reports success in improving ED patient flow

A study says involving hospital-based physicians in the care of admitted patients waiting in the emergency department improved revenue.

By Victoria Stagg Elliott — Posted Sept. 26, 2012

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Assigning a hospitalist and an allied health professional to patients admitted to a facility but waiting in the emergency department for a bed improved patient flow through the hospital and saved it more than a half-million dollars, according to a study in the September Journal of Hospital Medicine (link).

“The emergency department is not something that I thought was my purview, but now I think there is a role for an internist-hospitalist,” said Smitha R. Chadaga, MD, the lead author, who launched a hospitalist program for the ED in 2009 at Denver Health, a 477-bed academic safety net hospital in Denver. “And it’s a great opportunity.”

Patient boarding in the emergency department has been a longtime concern of several medical societies. The American Medical Association supports collaboration between organized medical staff and emergency department staff to address the issue. The American College of Emergency Physicians generally is behind initiatives that move admitted patients onto hospital floors as quickly as possible.

One of the key issues is believed to be confusion about which physician — in the emergency department or elsewhere in the hospital — has primary responsibility for a boarded patient. Researchers at Denver Health created a team of a hospitalist and an allied health provider assigned to these patients, rather than a patchwork of hospitalist and emergency department physician care. The hospitalist and the allied health professional monitored the hospital census using an electronic bed board and tracked those close to discharge to get emergency patients needing a bed in one as soon as possible.

“Before we had this team, boarded patients were assigned to one of eight different general medical teams, and they were often the last to be rounded on,” said Dr. Chadaga, associate chief of the division of hospital medicine at Denver Health. “The care was not as good, and the nurses didn’t know who to call.”

Researchers compared 1,901 patients boarded in the Denver Health emergency department before the program was launched with 1,828 patients afterward. The program led to boarded patients being seen by a hospitalist an average of two hours and nine minutes earlier than they previously would have been seen by a physician. Diversion because an emergency department was full decreased by 27%. This is considered particularly important, because each hour an emergency department sends patients to other facilities because of overcrowding costs about $5,000 an hour in lost revenue. The number of patients discharged from the emergency department because they no longer needed to be moved to an inpatient bed increased by 61%.

Researchers estimate that the program earned Denver Health an additional $525,600 in revenue without increasing costs because the physicians and nurses providing care to boarded patients were from the existing hospitalist service. No new staffers needed to be hired.

“This is really an example of how hospitalists can positively impact quality if they focus outside of their usual practice setting,” said Eric Howell, MD, president-elect of the Society of Hospital Medicine.

In response to the study, Sandra Schneider, MD, ACEP’s immediate past president, said: “Emergency physicians are really good at taking care of emergency patients. We are probably not as good as inpatient doctors at taking care of inpatients. Everybody should do what they are trained to do.”Most emergency department physicians and nursing supervisors at Denver Health believed the program improved quality of care, communication and patient flow because the hospitalists dedicated to admitted patients boarded in the ED saw patients sooner and got them into hospital beds more quickly, according to the study. They also talked more frequently to both emergency department physicians and hospitalists elsewhere in the institution.

Experts say this hospitalist team approach for boarded patients has been implemented at a handful of other facilities. The authors said similar programs could work at most facilities with significant boarding problems.

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