Background: Like all large academic medical centers (AMCs), we face capacity challenges. On most days, bed occupancy is often greater than 90% and long boarding times in the Emergency Department (ED) leads to poor patient experience, care delays and risk for adverse outcomes. While many AMCs have approached this problem by acquiring new facilities or erecting new buildings, these were not immediate options for our system. In contrast, community hospitals often have lower occupancy and could benefit from additional patient traffic. This has led us to ask: “Can patients from our AMC receive the same quality care at a site not owned by our health system?”
Purpose: Using an innovative care model, we partnered with a local high quality community hospital, to share space and leverage regional resources for general medicine patients. We utilized our hospitalists to screen and facilitate transfers from our ED, as well as provide care to patients from our health system in a community setting.
Description: Using data from our general medicine population, we identified 15-20% of our patients that required minimal or no subspecialty consultation or intervention. We set this patient population as the ideal subset to be cared for by hospitalists at a remote location. An agreement between our institution and the community hospital was executed. The agreement allowed us to transfer eligible and agreeable patients to a special unit at the community site located less than 5 miles away. All rooms are private with a private bathroom at that setting. Patients are cared for by our academic physicians in collaboration with nursing, staff, hospitalists and consultants from the community site.
To facilitate patient transfer, we instituted two interventions: 1) A “triage hospitalist” in the ED during peak admission hours, actively screening patients for eligibility in collaboration with ED providers and staff, and educating patients and families about our unit. 2) A “triage algorithm” for all of our hospitalists to follow when contacted about an admission from the ED. This encouraged prioritization of our unit regardless of capacity, and re-triage of appropriate patients to our unit. Since the launch of the unit on Sept 4th until Nov 26th, 2018 (12 weeks), we have transferred 301 patients from the Emergency Department to the unit, 170 (56%) of those patients were sent by the dedicated triage hospitalist, an additional 58 (19%) were re-triaged from another hospitalist service. The rest were transferred directly by ED providers. Including other admission sources (e.g. direct admit from clinic), the average daily census for the unit was around 18 patients for the month of November, 2018. Inpatient discharges were approximately 68% with an average length of stay (LOS) of around 3.6 days, whereas 32% of discharges were observation with an average LOS of 40 hours. Early feedback from patients and families, in addition to providers and staff in the ED and on the unit, has been extremely positive.
Conclusions: Innovative solutions to capacity constraints are needed in a complex healthcare environment to facilitate appropriate utilization of available capacity while enhancing patient experience and improving access to care. This model can be potentially duplicated at other medical centers facing similar capacity challenges. In addition, utilization of hospitalists for triage in the ED can further support this innovative strategy.