Background: Many studies have demonstrated the negative effects of emergency department (ED) crowding on outcomes, including increased length of stay, inpatient mortality, and risk of readmission. Early evidence suggests effective and timely triage of patients with hospitalist input can mitigate some of the detrimental effects of ED crowding. In contrast to prior studies focused on ED triage, our pilot paid particular attention to changes in disposition and their subsequent financial impact.

Purpose: To implement a cost-effective new process that reviews patient disposition for patients planned for admission from the ED to the Department of Medicine inpatient services, including the option to downgrade patients to the observation unit. The MTAD also facilitated expedited handoff from the ED to inpatient teams, assisted with transfer to another hospital during periods of higher ED and inpatient strain, and discharged from the ED with expedited follow-up when appropriate.

Description: The primary aim of the MTAD was to improve ED throughput and appropriate disposition of admitted patients through close collaboration with emergency medicine teams, bed management nurses, and inpatient teams. During its initial pilot period, we staffed one MTAD on weekdays from 10 AM to 8 PM. The MTAD reviewed every request for admission to inpatient Department of Medicine services, including twelve different general medicine and subspecialty services, as well as the medical intensive care unit. The MTAD also expedited handoff from the ED to inpatient teams and facilitated changes in level of care. During the first four months of the pilot, the MTAD reviewed 909 patients and acted on 302 patients (33.2%). MTAD was responsible for 55 downgrades to the ED observation unit (~6% of reviews), nine transfers to another hospital (~1%), nine short stay admissions (finished by the MTAD, then discharged; ~1%), and 19 reassignments to services in other departments (primarily surgical; ~2%). In addition, 210 reviews (~23%) resulted in a change of service among Department of Medicine inpatient teams. As a result of this work, the MTAD is estimated to have saved $320,000 during the four months when data were collected ($5,000 per avoided admission). The projected annual cost savings of $960,000 provides a favorable return on investment given the implementation cost of $569,000. We are currently analyzing improvements in time-to-admission and changes in adverse events (e.g., ICU transfer after arriving on the floor) since start of MTAD.

Conclusions: The MTAD is an innovative hospitalist role that optimizes patient disposition, potentially improving ED throughput and reducing costs and adverse events. Our intervention generated a favorable return on investment by identifying patients who could be cared for in an observation status or as outpatients. The role differs from other interventions in situating a hospitalist within the ED, where close collaboration and opportunities to intervene by bedside assessment exist. This contributed to success in identifying patients who could be cared for in settings outside of an inpatient admission.