Background: The Institute for Healthcare Improvement tells us that successful discharge planning starts at admission; however, when that admission occurs to a closed Intensive Care Unit (ICU), traditional discharge planning can be delayed until the patient transfers to a general floor. This delay can be exacerbated as a hospital’s adult medical-surgical bed occupancy rises, increasing the boarding time for patients who no longer require an intensive level of care but cannot move due to lack of bed availability.
Methods: Identifying that our academic institution operates at a consistent state of full capacity (92% or higher across all adult medical-surgical units), we created an algorithm to transfer care from our Medical Intensive Care Unit (MICU) team to our hospitalist team when a patient was deemed appropriate for transfer but there was no available bed. Patients on this “boarding” team were seen at least daily by a hospitalist physician and had the same access to care coordination, social work, pharmacy and allied health resources as a patient on the traditional Hospital Medicine units. These “boarding team” patients were either subsequently transferred to the general unit as a bed became available or discharged by the hospitalist physician from the physical ICU. Patients with identified floor beds at the time of transfer order placement continued to be moved out of the MICU to a General Medicine unit.
Mean length of stay (LOS) and observed to expected (O:E) LOS, based on the Centers for Medicare and Medicaid Services’ mean LOS for the patient’s primary diagnosis-related group, for patients admitted to the MICU team but discharged by a Hospital Medicine team during the transfer algorithm period were compared to that of patients who had been directly transferred out of the ICU to a General Medicine unit during the same time period. Expired patients were excluded from analysis. To assess for differences that might be related to efficiencies of a hospitalist team compared to a resident team instead of the initiative itself, similar mean and O:E LOS analyses were conducted looking at the year prior to the initiation of the transfer algorithm.
Results: During the first five months of the transfer algorithm, ICU “boarders” transferred to the care of a hospitalist team had a mean monthly LOS of 8.27 days and a mean O:E of 1.30. Compared to those patients discharged from the non-hospitalist teams (mean LOS of 11.36 days and O:E LOS of 1.56), transferring care of the “boarding” patients to a hospitalist attending before a non-ICU bed became available resulted in a decrease in O: E LOS of 0.26. Analysis of mean LOS and O:E LOS for the same 5 months in the year prior to the transfer algorithm showed no consistent difference between ICU patients discharged by the hospitalist teams versus the non-hospitalist teams.
Conclusions: Highly occupied acute care hospitals will likely continue to experience prolonged boarding times in the intensive care unit and this can have adverse effects on the patient’s total length of stay. Early transition of MICU patients to a hospitalist-attended service in our institution has shown significant improvement in both mean LOS and O: E LOS as compared to the traditional model of allowing a patient to remain in the care of the intensive care team until a general unit bed opens. As the scope of Hospital Medicine continues to expand and evolve, these findings suggest another opportunity for hospitalists to support the operational mission when traditional resources (available beds on Hospital Medicine units) might not be available.