Background: Geographic localization is the practice of assigning physician and advanced practice provider teams to patients located in the same inpatient unit. Poor localization of hospital medicine teams at our institution was identified as a top cause of increased Emergency Department boarding and Length Of Stay (LOS). The purpose of our process improvement project is to describe the implementation of unit based geographic localization for hospital medicine teams and to report the impact of localization on inpatient LOS and ED boarding.
Methods: This process improvement project was conducted at a 700-bed academic level 1 trauma center and safety net hospital in 3 phases. On 7/11/22 (PDSA1), each of the 11 direct care Hospital Medicine (HM) teams was assigned a designated unit. Our 5 house-staff teams continued to admit patients to their own teams between 7 am and 5 pm. Bed planning placed patients admitted by house-staff teams in their designated inpatient unit. A medicine transition team was created in the EMR for patients admitted by non-house staff admitting teams. These patients were distributed to the various HM teams based on the inpatient unit the patient was admitted to. A weekly reboot on hospitalist switch day reassigned patients to geographically localized teams. On 12/1/22, we refined our “bed before team” model by creating an ED based team that manages patients until they are transferred to an inpatient unit. While bed planning continued to prioritize placing house staff team patients in their designated inpatient unit, the assigned inpatient unit determines the patient’s team for the remainder of the admission for all 16 HM teams. On 2/1/23, we further refined this process by assigning specific contiguous beds to each team. Throughout this process since July 2022, we have conducted twice a day structured multidisciplinary discharge planning rounds on each localized inpatient unit.
Results: The proportion of patients localized to the correct floor on average was 40% during the baseline period, 72% during PDSA 1, 71% during PDSA 2 and 78% during PDSA3. ED visit volumes increased from a baseline of 5662.5 patients per month to 6177.5 patients per month (p-value 0.06). Figures 1.A and B show control charts of ALOS and O/E LOS. Figure 1.C is a control chart of ED boarding time. There was a statistically significant decrease in ALOS between baseline period from 7.8 (n=5301) days to 7.3 days during the intervention period (n=6350, p-value 0.04). The observed to expected LOS decreased from 1.1 during the baseline period to 1.05 during the intervention period (p < 0.001). The average ED boarding time per month decreased significantly from 23,767 hours per month during baseline period to19245 hours per month during PDSA 3 (p value 0.002). An interrupted time series analysis was performed and shows a statistically significant reduction in LOS O/E and ALOS during PDSA 3 (table 1). There was no statistically significant change in readmission rates, mortality and patient satisfaction scores between the baseline and intervention periods (table 2).
Conclusions: Our study showed a significant improvement in ED departure time, O/E LOS and ALOS following geographic localization of our HM teams despite increasing ED volumes. These improvements were noted during PDSA 3 after assigning specific beds to individual HM teams and deferring team assignment to bed planning as opposed to the triaging hospitalist.
