Background: Emergency Department (ED) overcrowding and lack of hospital bed capacity are pervasive problems made worse by the Covid-19 pandemic. Bed capacity is a significant concern at Academic Medical Centers (AMCs), as patients depend upon AMCs for specialized in-hospital care not available at other regional hospitals. Bed capacity shortage is acutely felt at rural AMCs, as there may be only one AMC in existence for a large geographic area. The author’s institution (Dartmouth-Hitchcock Medical Center, DHMC) is a 396-bed rural academic medical center serving patients across four states. DHMC receives thousands of inter-facility transfer requests every year. Due to bed capacity limits, the hospital medicine service at DHMC declined 512 transfer requests from July to November 2021. DHMC is a member of a healthcare system that includes four affiliate hospitals. When not at full capacity, these affiliates represent an alternate location for patients who initially present to the AMC and require admission but not necessarily the breadth of services provided at the AMC. In the literature, prior interventions have been described in which patients undergo inter-facility transfer from the ED of an AMC to other regional non-AMC hospitals. To our knowledge, this has not been described at a rural AMC. Further, we are not aware of prior interventions in which patients already admitted at an AMC are transferred acute-to-to-acute status to an affiliate to improve system-wide bed capacity.

Purpose: We created a dedicated “Dartmouth Regional Triage” (DaRT) hospitalist position and implemented a standardized process for identifying and facilitating transfer of patients from a rural AMC ED or AMC inpatient unit(s) to regional non-AMC hospitals.

Description: Prior to the intervention, the triage hospitalist assisted with admissions, staffed the internal medicine consult service and took all transfer center calls and admission requests. Sectional leadership lobbied for additional FTE support to off-load admitting and consult responsibilities from the triage hospitalist, thus creating the DaRT hospitalist, who works Monday-Friday 8 am to 5 pm and is now free to focus on facilitating inter-facility patient transfers from the AMC to affiliate hospitals. We also created processes to streamline the identification of patients for inter-facility transfer and the process of making this happen. The DaRT attends a daily bed capacity meeting with representatives from all affiliates to determine current and anticipated open beds within our medical system. The DaRT then identifies and facilitates transfer of patients admitted on the hospitalist teams at the AMC to affiliate hospitals (Fig. 1). The DaRT also works with ED staff to re-direct qualifying patients from the AMC ED to affiliate hospitals (Fig. 2). In the four months since implementation, the DaRT has re-directed 69 admissions from the AMC-ED and an average of two patients/week from the inpatient hospitalist services at the AMC to affiliate hospitals. By increasing bed capacity, this intervention will pay for itself 10 times over, with anticipated cost savings over $3 million, on an annualized basis.

Conclusions: The DaRT has successfully re-directed low-acuity patients from the AMC ED and AMC inpatient hospitalist teams to affiliate hospitals within our regional healthcare system. This frees up bed capacity at the AMC, ensures adequate patient volume at affiliate hospitals and leads to significant cost savings.