Background: As many other hospitals of its size, our tertiary academic care center frequently operates at greater than 100% capacity. Medical admissions boarding in the Emergency Department (ED) while awaiting inpatient beds represent a bottleneck in hospital patient flow. Hospitalist led management of this group of patients has been identified as a potential solution to improve patient flow.
Purpose: ED boarding patient census is often highest in the morning due to reduced overnight hospitalist staffing. These patients are assigned to a hospitalist inpatient ward team or are still awaiting allocation to an admitting physician. Hospitalists are assigned geographically, with most of their patients being on the same nursing unit. Stable patients in ED boarding are often seen after geographical rounding and completing morning discharges. Discharging a patient in ED boarding without overnight admission completed by the hospitalist service would be uncommon. With the goal of improving patient flow through active management of medical admissions boarding in ED, a hospitalist team led by a senior hospitalist was implemented.
Description: Between April and June 2016, a pilot intervention was implemented where a care team led by a senior hospitalist with the ability to make decisions on patient status oversaw ED boarded patients, Monday to Friday 8am to 4pm. The team consisted of a Senior Hospitalist, advanced Nurse Practitioner/Physician Assistant, enhanced ED case manager, and coordinated its activity with patient placement managers. The team reviewed each accepted but to be admitted patient boarding in the ED, both observation and inpatient status, and could provide direct patient care. They could downgrade or upgrade patient status based on clinical findings, review telemetry indications, triage to appropriate location, or admit and discharge suitable patients, along with attending to acute deterioration issues for boarding patients.
To decide if the pilot intervention will be continued, we assessed the impact of active management and calculated potential cost saving. During the intervention period, 633 patients admitted to the medicine service and located in ED boarding underwent evaluation by the hospitalist led ED team. The mean daily number of patients reviewed by the hospitalist team was 11.9. The ability of a senior hospitalist to re-assess ED boarders resulted in a level of care change status rate of 12.5% and a discharge rate of 8.7%. Overall there were 79 level of care change of status performed, which consisted of 74 downgrades, 3 upgrades, 1 isolation status discontinued, and 1 patient transferred to psychiatry.
To assess if the intervention improved patient flow, we calculated potential hospital days saving due to discharges directly from ED boarding. Decreased hospital length of stay (total LOS decreased 42.29 days) and direct costs ($ 78,893.53 cost savings) were calculated by comparing intervention patients discharged to similar APR DRG observation status patients from prior fiscal year. There were no return visits within 72 hours among discharged ED boarding patients.
Conclusions: A pilot intervention to actively manage ED boarders with a hospitalist led team demonstrated improved patient flow and cost-savings. Embedding a senior hospitalist led team with adequate resources is a potential solution to addressing inpatient capacity issues by triaging patients to their correct level of care, opening capacity in telemetry and other high demand units, as well as discharging patients after re-assessment.