Background: Hospital bed capacity is limited across the nation due to increased demand and staffing shortages. Capacity shortages result in hospital diversion and therefore impact Emergency Department (ED) length of stay and ED medical boarding. A large tertiary hospital typically serves as the referral hub for many smaller hospitals in the region, and optimizing bed capacity within the region requires innovation in patient triage and management. Outpatient management of lower acuity patients traditionally admitted to the hospital, as well as facilitation of local care for patients not needing specialized tertiary hospital care, optimizes healthcare resource utilization. Hence, we piloted a telehospitalist program to optimize medical triage and medical management in community EDs and hospitals.
Purpose: Our aim was to identify safe, alternative outpatient care plans that mitigate the need for hospital admission and transfer to the tertiary hospital by providing consultative support for ED staff. The telehospitalist would collaborate with local ED staff and identify patients who could be discharged home with outpatient follow-up instead of acute care hospitalization, while promptly identifying and prioritizing patients requiring transfer to a tertiary care hospital as opposed to local care at a community hospital.
Description: A telehospitalist based at the tertiary care hospital provided medical support to four community hospitals and EDs. The telehospitalist reviewed ‘admit likely’ patients flagged by the ED provider and assessed them virtually if needed. Efficient bidirectional communication was established between telehospitalists and ED clinicians by leveraging Electronic Health Record (EHR) technology, along with the option for the ED provider to initiate a referral through the tertiary care hospital Admission and Transfer Center.A total of 633 telehospitalist patient interactions during the pilot (January 2022 to April 2023) were analyzed. Of these interactions, a majority were ED patients from smaller community hospitals (n=550; 87%), while the remaining were from inpatient settings (n=61) and outpatient clinics (n=22). Of these patients, only 229 patients (36%) were transferred to the tertiary hospital due to the need for specialized services, while 64% received care locally, either via local admission or outpatient follow-up care. For patients discharged from the ED, 3-day and 7-day ED readmission was 3.2% and 4.6%, respectively.
Conclusions: Telehospitalists successfully collaborated with community ED providers and facilitated efficient triage of patients needing tertiary care, while promoting local care either in local hospitals or by arranging outpatient follow-up. Telehospitalists also provided medical consultations to ED staff that advanced care while awaiting a medical bed opening. Telehospitalists optimized patient triage and management with no patient safety events and minimal ED readmission rates following ED discharge.