Background: The first 24 hours of a patient’s hospitalization is a vulnerable time period, with many aspects of care occurring at a time when patients are at their highest levels of medical acuity. Compounding this, delays in care during the transition from the ED to an inpatient level of care could result in potentially avoidable negative outcomes.
Purpose: Our hospital, an 800-bed quaternary care institution, admits over 19,000 patients yearly through the emergency room to the medical teams. Approximately half of these patients are admitted to our fulltime hospitalist group; the remainder are admitted to a large pool of voluntary physicians. Our hospital leadership team sought to decrease the amount of time between admission and the initial inpatient physician encounter, with the hope of improving the quality of care delivered early in the hospitalization.
Description: In September 2016, a redesigned admission workflow began requiring all newly admitted patients to be seen by a physician within 4 hours of the admission order being placed by the ED team. Advanced Care Providers (ACPs) were no longer responsible for completing electronic history and physicals (H+Ps) on admission. If a voluntary physician was unable to see an admitted patient within four hours, our hospitalist group would perform the admission on their behalf, with the voluntary physician assuming care thereafter. To accomplish this, our hospitalist group was able to expand our pool of admitting teams, and strategically stagger shift times in line with ED admission demands.
A tool was developed to audit the number of H+Ps completed by physicians within the 4 hour window, using this as a surrogate marker for the initial encounter. We then compared H+P completion times for the one year prior to and after the rollout of this new initiative to determine the degree of compliance, and are now examining quality indicators during the same timeframes.
Conclusions: In the year prior to the redesign, 19,183 patients were admitted through the ED to the medicine service, with 42.6% of H+Ps being completed by physicians, and 57.2% of admissions authored by ACPs. The average time to completion of the H+P after admission was 256.15 minutes. In the year after the rollout was completed, 19,359 patients were admitted; 99.6% of H+Ps were completed by physicians, the majority by fulltime hospitalists. Time to H+P decreased by over one hour to 194.8 minutes.
Prior to the redesign, 235 rapid responses were performed during the first 24 hours of admission; after the redesign, this number decreased to 205, a 13% change. Average case-mix-index (CMI) during the post-redesign time period was increased (1.305 vs. 1.382).
A redesigned workflow related to the initial inpatient encounter, emphasizing early evaluation by a physician, has resulted in a decrease in rapid response scenarios during the first 24 hours of hospitalization, despite higher-acuity patients being admitted to the hospital. Hospitalist availability in this process has been integral to its success.