Background: Hospital capacity constraints remain an immense concern throughout the US and has been recognized as a national crisis for greater than a decade. ER overcrowding is of particular concern due to its downstream effects. It occurs when admitted patients are boarded in the emergency room for greater than 2 hours, while inpatient beds become available. Data has shown that ER boarding is associated with adverse patient consequences such as increased mortality, longer length of stay and decreased patient satisfaction. Medical errors can be exacerbated by complex hospital systems and ER overcrowding is an example of a system which creates a high risk environment.
Purpose: At our facility we have a high volume of boarded patients. In order to ensure high quality care, we established an ER hospitalist rotation. This physician implemented inpatient level care to patients located within the ER. We hypothesized that this early care initiative would achieve similar outcomes in patient care as our inpatient wards. Through an interdisciplinary approach we aimed to improve patient throughput and efficiency. Lastly, we sought to increase collaboration and communication between the ER staff and hospitalist group.
Description: The primary role of the ER hospitalist is to round on the daily census of boarded patients. In addition, they lead interdisciplinary rounds which include the ER nurse manager, case manager and social worker. At that time, all bed holds are identified, along with expediting testing for potential discharges. The need for telemetry monitoring is revisited and discontinued as necessary. Through close coordination with the case management team, social barriers to discharge are identified. Lastly, they are available as a resource to ER providers to discuss the potential need for admission on all patients, with a focus on potential 30 day readmission’s.
Conclusions: During the first 2 months of the rotation we were able to make a significant impact on ER overcrowding by facilitating discharges. In our first month, discharges increased 100% as compared to the previous year. Similarly, the following month showed a 146% increase in ER discharges. We attribute this impact to a steady presence and identifying bed holds for appropriate patients through an interdisciplinary approach.In order to assess our ability to improve the culture and communication between the ER staff and hospitalist group, we administered a survey. We received 28 responses from nurses, advanced care providers and case management. 96.43 % of the staff agreed that implementation of the ER hospitalist rotation improved patient care. 85% of those surveyed believed that communication and camaraderie had improved among the ER boarding staff. Through the creation of an ER hospitalist rotation and an emphasis on a multidisciplinary team approach, we were able to improve patient care, efficiency and reduce ER overcrowding.