Background: In many urban hospitals, Emergency Department (ED) crowding and patient boarding is an increasing challenge. Admitted patients often spend prolonged periods of time in the ED while waiting for an inpatient bed. These ED boarded patients can have delayed or inadequate care, increased adverse events and increased mortality. Furthermore, these ED boarded patients place additional strain on already overburdened ED.
Purpose: To describe the implementation of an ED Hospitalist Service based in an urban academic hospital.
Description: In July of 2018, the Division of Hospital Medicine collaborated with the Department of Emergency Medicine to establish an ED Hospitalist Service, a full time medical service dedicated to caring for ED boarded medical patients. Eligibility for the service included all patients admitted to the Internal Medicine Service who remained boarded in the ED awaiting an available inpatient bed. Patients admitted to non-medicine services, including Surgery, Medical ICU, were not eligible. The ED Hospitalist Service is a 15 full-time equivalent hospitalist group. Daily, the service has a census of 45 patients and is staffed by three Internal Medicine hospitalists. The service operates 24/7, with hospitalists working 12-hour shifts, 7am-7pm and 7pm-7am. On days of increased ED patient census, an additional “Volume Surge” hospitalist is called in, 10am-10pm, to provide coverage for an additional 15 patients. The ED Hospitalists are primarily responsible for advancing the care of these ED boarded patients. All consultants, procedures and studies available to the inpatient Internal Medicine Service was also available to the ED hospitalists. Additionally, ED hospitalists ensured that patients admitted under their care received essential home medications to ensure appropriate management of chronic diseases. On average, ED hospitalists worked 14 shifts per month. The ED Hospitalist service cared for over 1100 unique patients monthly.
Conclusions: We have successfully developed and implemented an ED Hospitalist service in a busy urban academic medical center. Initial feedback suggests that ED physicians are significantly satisfied with the ED Hospitalist service. The number of Internal Medicine patients boarded in the ED who ED physicians have to care for has substantially decreased. These improvements have allowed ED physicians to dedicate more of their time on new acute arrivals. Our ED Hospitalists are also very satisfied with the program, as evident by low employee turnover. Furthermore, we converted the typical lost time associated with ED boarding into active clinical time, which resulted in some initial improvement in inpatient length of stay. Future work will focus on quantifying the effect of the ED Hospitalist Service on hospital throughput metrics and patient clinical outcomes.