Background: The traditional role of hospitalists is to provide care to patients hospitalized with acute medical conditions. Over the past few years, this has evolved to improve care transitions and stewardship of hospital resources. Many hospitals may embed hospitalists in the Emergency Department (ED) to improve patient flow into the hospital; however, there are sparse comprehensive programs in which hospitalists evaluate, triage, manage, and arrange outpatient follow-up for select ED patients.
Purpose: The purpose of SAPPHIRE (StrAtegic Pilot Program for Hospital InteRnal Medicine and Emergency Care) was to reduce admissions using a collaborative practice model between the Division of Hospital Internal Medicine (HIM) and the Department of Emergency Medicine at a tertiary care center. The goal of SAPPHIRE was to evaluate medical patients ED staff deemed ‘likely to be admitted’ to the hospital and (i) determine if the patient could be discharged with follow-up or (ii) expedite admission if the patient required hospitalization.
Description: After multidisciplinary stakeholder input from physicians, nurse practitioners and physician assistants (NPPAs), nursing, scheduling assistants, and administrators, SAPPHIRE was launched in August 2021 (initially on weekdays from 7am to 4pm; and eventually expanded to evenings and weekends 6 months later). SAPPHIRE consisted of an HIM physician, HIM NPPA, and scheduling assistant with a dedicated work space in the ED. Adult patients (aged ≥18 years) who were likely to be admitted to the hospital were flagged on the ED track board for evaluation. SAPPHIRE reviewed the medical record, evaluated the patient and determined if the patient: (i) may be discharged from the ED with follow-up with an outpatient provider, or (ii) required hospital admission. SAPPHIRE documented a note and gave recommendations to the ED team. For admitted patients, SAPPHIRE communicated with the “medical officer of the day” to expedite bed assignment for appropriate hospital service. For patients discharged from the ED, SAPPHIRE scheduled virtual follow-up or home visits by the community paramedics team; under the supervision of SAPPHIRE. SAPPHIRE also created pathways for patients requring complex care by discussing with the “subspecialist officer of the day” who reviewed each case in real-time and scheduled expedited outpatient appointments. Between August 2021 and February 2023, 2572 patients deemed “likely to be admitted” were evaluated by SAPPHIRE. The median age was 66 years (range 18–99 years), and 49% were women. Of all patients, 30.2% (n=777/2572) were discharged from the ED with follow-up. The remaining 1795 patients were hospitalized under HIM (62%), Cardiovascular Medicine (7.2%), Gastroenterology (5.7%) and Critical Care (5.7%), among other specialties.
Conclusions: SAPPHIRE proved to be an innovative, collaborative model of care, in which hospitalists provide a comprehensive consultative service to eligible patients in the ED. SAPPHIRE improved ED patient flow by expediting patients who needed admission to the hospital, and by providing timely outpatient appointments in general medicine or subspecialty clinics to those who could be discharged. Importantly, SAPPHIRE provided continuity of care until the patient was evaluated in the outpatient setting to decrease the risk of re-evaluation in the ED. SAPPHIRE leveraged existing staffing resources and technology and may be rapidly adapted and scaled at other institutions.