A Hospitalist Model to Address the Quality of Care of Admitted Patients in the Emergency Department

Background:

Emergency department (ED) overcrowding has become a common problem in U.S. hospitals, resulting in increasing numbers of patients admitted to the medicine service being “boarded” in the ED. These patients are typically remote from their primary inpatient team, which can lead to poor patient care and outcomes. In response to this challenge, our institution has developed a hospitalist model to manage boarded patients in the ED.

Purpose:

The purposes of the study were (1) to assess the feasibility of the ED hospitalist role in rendering care to boarded patients in the ED and (2) to collect and describe data on the elements of care delivered by the ED hospitalist.

Description:

The setting of the study was a tertiary‐care 1121‐bed acute‐care teaching hospital. A hospitalist was assigned to the role Monday‐Friday, 8 am‐6 pm during the study period. The goals of the ED hospitalist role were to: (1) ensure patient safety and deliverance of high‐quality care, (2) facilitate inpatient management in association with the primary team (e.g., obtain and follow up key diagnostic tests}, (3) identify the patient's eligibility for discharge and implement the discharge plan, (4) assess the need for telemetry monitoring, and (5) promote patient satisfaction. Boarded patients were defined as those having a length of stay (LOS) ≥ 2 hours in the ED. Data were collected on the number of patients assessed, medication and laboratory tests ordered, ED discharges made, and telemetry downgrades accomplished. The study period was from March 10,2008, through June 30, 2008. The study was approved by the institution's institutional review board.

Results:

In the study period, there were 4363 patients admitted to the medicine service, of whom 634 were evaluated by the ED hospitalist. There were 3555 patients who qualified as boarders (mean of 29 boarders per 24 hours). The mean boarding time of admitted patients was 440 minutes. The mean daily number of patients seen by the ED hospitalist was 8.0. A total of 46 patients were discharged by the ED hospitalist (0.6 discharges/day), and telemetry was discontinued for 61 patients (0.80 downgrades/day). The care of boarded patients included follow‐up of laboratory tests for 74.5% of patients [95% confidence interval (Cl), 71%–78%] and medication orders for 79.8% of patients (95% Cl, 77%ndash;83%). Improvement in ED and hospital throughput was suggested by the discharge rate of 7.3% (95% Cl, 5%–10%) and the telemetry downgrade rate of 9.6% (95% Cl, 8%–12%).

Conclusions:

ED overcrowding is a complex problem with multifactorial causes. Designating a hospitalist to care for admitted patients in our ED helped to ensure safety, enhanced the timeliness of care, decreased telemetry usage, and allowed patients to be discharged from the ED. It may potentially affect ED and hospital LOS, lessen bed and telemetry utilization, and promote patient satisfaction. This model is feasible, and the preliminary data suggest the strategy may provide substantial improvements in patient care.

Author Disclosure:

A. Briones, none; A. Dunn, none; A. Jagoda, none; N. Kathuria, none; B. Markoff, none; R. Jervis, none; S. Hill, none; A. Mumm, none.