Background: Emergency Department (ED) boarding has increased nationwide since the COVID-19 pandemic and poses additional risks to patients, including increased length of stay, worsened health outcomes, and overall mortality (1,2). Oregon Health & Science University (OHSU), a 562-bed academic health center and tertiary/quaternary referral center for the region, has faced increasing capacity constraints causing prolonged ED boarding for Medicine patients and decreased access for patients through the transfer center. To address this, OHSU implemented capacity-based transfers to community hospital partners; however, delays in transportation and bed assignment for these patients sometimes led to stalled care. At times, up to 20% of the inpatient Medicine census is boarding in the ED. The Division of Hospital Medicine (DHM) was therefore asked to develop an ED-based hospitalist role to support capacity efforts and improve care for ED boarders.
Purpose: The primary aims of the ED hospitalist pilot were to support capacity-based transfers from the OHSU ED to community partners through enhanced patient screening and providing interim management of patients awaiting transfer. The secondary aims were to improve the quality of care for ED boarders and improve ED staff well-being through more streamlined multidisciplinary communication.
Description: The OHSU Division of Hospital Medicine (DHM) is an academic hospitalist group that cares for patients distributed among six direct care hospitalist teams (the Clinical Hospitalist Service, or CHS), and six resident teams. CHS uses as an admitter-rounder, level-loading model. Teams care for patients across all adult acute care units and are not geographically structured. DHM also assumes care for Medicine patients boarding in the ED while awaiting inpatient beds.In late October 2024, DHM launched a pilot in which a dedicated hospitalist (CHS E) cared for all CHS-assigned ED boarders and provided interim care to ED patients accepted for transfer to partner hospitals who experienced delays in transport or bed availability. This hospitalist joined daily multidisciplinary rounds with the ED boarder nurse manager and the ED case manager. The intent was for patients to transition off the ED hospitalist service once a ward bed became available to preserve capacity for new admissions. Longstanding level-loading and continuity expectations made these transitions difficult. CHS shifted to a geography-based patient assignment process in late February 2025, which resulted in improved cohorting of ED boarders on CHS E. However, it generated significant provider dissatisfaction due to increased handoffs and reduced continuity. Although no increase in reported patient safety events was noted during the pilot, hospitalists expressed concern for patient safety due to the increased fragmentation of care. The geographic model and ED hospitalist pilot were discontinued in late March 2025.
Conclusions: Implementation of an ED-based hospitalist with primary patient care responsibilities was limited by a strong cultural preference for level-loading and continuity, which was felt to be an important mitigator of cognitive load and contributor to patient safety. Systems without geographic team assignment may face substantial cultural and operational barriers to cohorting ED boarders on a single team. A triage-only ED hospitalist model, without primary patient responsibilities, could mitigate these barriers but would require additional resources.
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