Background: Boarding of admitted patients in the Emergency Department has become an increasingly large problem throughout the country. Longer boarding times are associated with a wide range of adverse effects, ranging from patient discomfort to medical errors and death. Emergency Departments are not designed to provide inpatient care and require frequent diversion of attention and resources to new, critically ill patients. Transferring patients to the quickest in-patient bed available within a hospital system can significantly decrease boarding times and improve patient care.
Purpose: Our objective was to decrease the number of medicine patients boarding in the emergency department at a large urban tertiary center through interventions that required strong working partnership between the Emergency Department (ED) and Hospitalist division. The goal was to transfer patients to the first safest available bed across four hospitals within our health system, as well as shift culture towards a practice of system-based admissions.
Description: The intervention entailed a multifaceted approach, including creation of transfer criteria that were approved by ED and Hospitalist Service, a novel workflow where patients were simultaneously admitted while transfer was initiated to avoid management delays, weekly multidisciplinary review of cases that took longer than anticipated or had complications, and real-time escalation to ED and Hospital Medicine (HM) leadership to address barriers to transfer. Additionally, a dedicated Hospitalist Physician Assistant (PA) and Emergency Department provider (PA or Resident) were placed in the ED to identify patients appropriate for transfer, obtain consent to transfer, and help inpatient teams navigate the transfer process. We compared the number of patients transferred from the ED to a Medicine bed within our system from 2/2021-10/2021 with the number of transferred patients from 2/2022-10/2022. The number of patients transferred increased by 79.6% (from 334 to 600). Process improvement meetings with ED and HM leaders identified that there was a significant delay from time of transfer initiation to acceptance by a hospitalist at the receiving hospital. This led to the creation of a central hospitalist role, whose responsibility is to review, triage, and accept patients on behalf of the different hospitals in our system.
Conclusions: Inter-hospital transfers were increased approximately 80% through a joint ED-Hospitalist initiative, which entailed developing transfer criteria and new workflows for identifying patients, and incorporation of ED and Medicine Transfer PAs. Joint process improvement meetings reviewed data on transfers regularly, reviewed quality concerns, and developed program enhancements. Efforts to promote transfers across hospitals for busy health care systems are most likely to be successful through leadership by hospitalists and ED stakeholders.