Can hospitalists help fix crowding in the emergency department? If a study in a large Baltimore hospital is any indication, they can.
At Johns Hopkins Bayview Medical Center, wait times were cut by two hours, and ambulance diversion was dialed way down, too. But it isn't just time savings and patient flow that improve when hospitalists work with the ED to provide beds and resources, the trust factor also reaches a new high as well. And though that level of professional rapport may be difficult to measure, its impact certainly isn't, said Eric Howell, MD, the lead author of the study. (Ann Intern Med 2008; 149:804.)
Though he's proud of the gains he and fellow investigators saw when they analyzed the effect of bed management by hospitalists, he reserves his greatest praise for the way in which hospitalists and emergency physicians worked together to achieve them.
The hospitalists generally relied on the opinion of the emergency physicians, and vice versa, noted Dr. Howell, the chief of hospital medicine at the medical center. Having one set of physicians scouting beds and providing resources based on the requests from another makes good sense — and good medicine. Bayview slashed the average time that admitted patients spent in the emergency department from 458 to 360 minutes, and decreased the percentage of hours the ED was on diversion due to crowding or lack of intensive care beds by six percent and 27 percent, respectively.
“The hospital can be a pretty tense place with multiple barriers” to patient flow, Dr. Howell said, but once the relationship between the hospitalists and emergency physicians was forged, a partnership of sorts flourished. They now socialize outside of work on occasion, “going to each other's holiday parties,” he said. In fact, he's fished for crabs with the head of the ED, Edward Bessman, MD. When the two took to the open sea, “we didn't really get much, only three or four crabs,” he said. But the catch was not the valued part of his experience, he explained. “Now I can say [to fellow hospitalists] that I have been crabbing with the guy in charge of our ED.”
Just how do hospitalists speed things up so much? During busy periods in the ED, a hospitalist can help avoid or reduce the ping-pong effect — those periods when different departments demur immediate transfer or recommend another unit due to scarcity of beds or lack of other resources, said Dr. Bessman. One reason the system seemed to work so well is that it put bed management entirely in the hands of hospitalists, giving these physicians complete authority to juggle the demands of patient placement and to engineer the flow of bed availability throughout the hospital, he said.
The model could work at other centers, suggested Dr. Bessman, and Dr. Howell agreed. In fact, he has seen it do that at hospitals with fewer than 100 beds. The process “works all over,” Dr. Howell said. And without it, “it can take some salesmanship to get patient out of the ED” for continuation of care elsewhere in the hospital, according to Dr. Bessman.
Richard Schamp, MD, an associate professor of family and community medicine at St. Louis University School of Medicine, said hospitalist-assisted handoff from the ED to inpatient care often saves time and reduces risks. Generally, there is more efficiency in hospital evaluation and discharge planning, as well as improved communication with nursing and ancillary staff, he said. Potentially, “these consistencies all may lead to higher quality of care,” added Dr. Schamp, who is not a hospitalist. But there can be disruptions in continuity of care, too, due to possible communication lapses among the hospitalist, family, and the patient's primary care provider.
Physician groups need to develop a consensus on timeliness of responding to handoff requests, criteria for admission, and triage criteria for assignment to beds in the ICU versus unmonitored beds, said Russell Holman, MD, the chief operating officer for Cogent Healthcare in Brentwood, TN.
“The role hospitalists can play in this scenario is to focus on routinely assessing the need for ICU bed utilization and by directing their daily workflow toward progression of care,” he said. “This means timely completion of discharge orders, continuous focus on care coordination needs during and after hospitalization, and close collaboration with nursing, case management, pharmacy, and others to ensure safe and efficient care team operations.”
The American Board of Internal Medicine has approved a process for recertification in internal medicine with a core focus in hospital medicine. That means that an eligible physician would first become boarded in general internal medicine, then when it comes time to recertify, a physician could opt for a process that has a core focus in hospital medicine, said Dr. Holman, who is a past president of the Society of Hospital Medicine.
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Transition of Care Consensus Standards
Six societies* approved these standards to address quality gaps in transitions between inpatient and outpatient units.
- Clear, direct communication of treatment plans and follow-up expectations.
- Timely feedback and feed-forward of information.
- Appropriate involvement of the patient and family member in all steps.
- Respect the hub of coordination of care.
- All patients should have a medical home or coordinating clinician, and they, their families, and their caregivers should be able to identify it.
- The patient, family, and caregivers should know who is responsible for their care at all times.
- National standards for transitions in care should be established and implemented at the national and community levels.
- Metrics related to these standards should lead to quality improvement and accountability.
*Approved by the American College of Physicians, the Society of Hospital Medicine, the Society of General Internal Medicine, the American Geriatrics Society, the American College of Emergency Physicians, and the Society for Academic Emergency Medicine