As emergency departments face an unprecedented patient surge in the COVID-19 pandemic, a partnership between emergency physicians and hospitalists holds potential for lightening the burden on EPs and enhancing care for patients.
An increasing number of patients seeking care in the emergency department leads not only to boarding the sickest but also to inadequate care of the critically ill, adverse events, and even death, not to mention lower satisfaction scores. Large city hospitals with high occupancy rates see a larger number of patients boarded in the emergency department, Massachusetts General Hospital in Boston among them, which was the site of a recent study on the effect of a dedicated hospital medicine team on ED length of stay.
The Mass General staff tried at first to solve the boarding issue by having inpatient teams come down to the emergency department to care for one or two patients per team, said Kimi Kobayashi, MD, MBA, now the chief quality officer and vice president at UMass Memorial Medical Center in Boston, who is also a hospitalist. “The majority of their patients were, of course, on the inpatient unit and a handful in the emergency department,” he said. “It's not a great patient experience. There were challenges in communication between teams, and it was not optimal.”
Dr. Kobayashi and colleagues from Mass General, including Ali S. Raja, MD, MBA, MPH, the executive vice chief of emergency medicine at the hospital and a co-host of EMN's podcast EMN Live, sought to determine if a hospital medicine team in the emergency department could reduce the median length of stay. (J Hosp Med. 2019;14:E1; https://go.aws/3cAO2Xg.) They also evaluated the effect on ED length of stay and 30-day ED readmission rate, key measures used by the Centers for Medicare and Medicaid Services.
The researchers retrospectively evaluated the care of 8776 patients who were boarded in the ED for at least two hours waiting for a room and were covered by the hospitalist service, that of 5866 patients who spent two hours in the ED waiting for a room and were not covered by the hospitalist service, and that of 2206 patients who were not boarders and did not have two-hour stays in the emergency department.
Nonboarders had the shortest hospital length of stay—4.8 days. Covered ED boarders stayed a median of 4.9 days and noncovered boarders 5.1 days. Length of stay in the emergency department was 5.6 hours for nonboarders, 20.7 hours for covered boarders, and 10.1 hours for noncovered boarders. There was no difference in readmission at 30 days. The authors speculated that the covered patients' longer length of stay in the emergency department reflected the hospital medicine team's choice of patients who had an anticipated longer ED length of stay.
Dr. Raja said the hospitalist team was beneficial to the hospital as a whole and patients in particular. “Patients admitted to the hospital are best covered by specialists who will be taking care of them,” he said by email. “This allows them to receive the same level of care they would if we had enough beds for them, and the specifics of this care are often outside the expertise of emergency physicians. Anytime a patient stays beyond two hours in the ED waiting for a bed, hospitalists should be involved in their care. That way, we can continue moving things forward, even while they remain physically in the ED.”
Dr. Kobayashi pointed out that they didn't cover every patient in the ED in their study because the teams have limited resources and handle only a certain number of boarders. “We didn't want to initiate handoff unnecessarily,” he said. “The team ended up focusing on patients who stayed a long time rather than the person who was going up to the floor in an hour.”
That allowed the hospitalists to initiate care—ordering tests, calling in a consult, making sure the patient's regular medications were ordered. “I ask, ‘Where can I add the most value after my ED colleagues have done my triage?’” Dr. Kobayashi said.
Even though the study took place at a large academic institution, Dr. Kobayashi said hospitals need to understand that a substantial investment in time and money is required. The hospital hired a team of nurses for the project, and made sure there were enough full-time employees to staff the ED. It can be worth the investment, he said. “A lot of major urban hospitals are facing capacity issues. Our sense is that the trend is going to increase rather than decrease,” he said. Housing the team in the ED allowed them to cover more people in a safer manner.
Offload from EPs
Where nurses once would have to page a doctor to come to the emergency department, now the emergency physician can walk over to the hospitalist and talk over a problem right there, and that closer communication benefits patients.
“Now that the emergency physician and medicine teams work closer together, it allows us to look at cases in the gray area where we don't know what's going on with a patient,” he said. “Patients may need the attention of both specialist groups. One patient referred to the boarder team might suddenly need to be intubated and referred back to the emergency physicians with minimum fuss.”
Drs. Raja and Kobayashi said they saw advantages in this model during surges like COVID-19. “In fact, we're increasing our coverage right now in light of everything we're facing,” said Dr. Raja.
Dr. Kobayashi agreed, saying, “It gives us the ability to help offload patients from our emergency medicine colleagues.”
Dr. Raja said the benefits go both ways, to EPs and patients. “It allows our emergency clinicians to clear some mental bandwidth since they can focus on patients coming in from the waiting room instead of patients who were admitted 16 hours earlier by the last shift,” he said. “Patients benefit as well because they have experts on inpatient care managing them.”
Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.