Background: Emergency room overcrowding is a national crisis largely attributed to high volumes of admitted patients awaiting beds in the Emergency Department (1). Studies have shown that ED overcrowding delays care for all patients, increases length of stay, and reduces overall quality of care (2). Contributing to this are potentially unnecessary floor admissions. With the success of observation units in providing efficient care, there remain opportunities for admitted patients with anticipated early discharges. Hospitalist oversight of admitted patients in the ED can improve throughput by identifying those patients needing expedited testing or review to enable discharge directly from the ED, thereby reducing bed utilization. We developed a workflow to identify and allocate resources towards discharges for patients on hospital day one, who could otherwise have remained hospitalized for numerous days after.
Purpose: To optimize hospital bed resource utilization through a prospective real-time review of admitted patients awaiting inpatient beds in the Emergency Department via a multidisciplinary approach.
Description: A hospitalist-led, multidisciplinary round occurs daily in the ED holding area which contains admitted patients awaiting hospital beds. A hospitalist physician advisor, case management, nurse practitioner or physician assistant, nurse manager are present. Each independently reviews the list and discusses findings during rounds with the focus on patients where reason for admission is tenuous or likely to be resolved that day, predicting patients who can be safely discharged that day. Bed holds are placed on those patients by the logistics team. A HIPAA compliant group chat is created daily to review obstacles and give updates, including removing the holds if new information necessitates. Code 44 Medicare downgrades are also reviewed and communicated via the chat. Tracking this process from March through November 2021, we reviewed 356 patients placed on bed holds. 45% of identified patients during rounds were successfully discharged that day. Leading diagnoses for patients able to have expedited discharge were chest pain, falls, and musculoskeletal pain. Reasons why discharge failed were tracked to see if there were any remediable delays or institutional barriers to discharge that could be addressed. Anemia, pending psychiatric disposition, and arrhythmia had the highest discharge rate when holds were placed. All data is shared regularly between hospital medicine and emergency medicine departments in a monthly collaborative to optimize the admission process and identify opportunities to better standardize care for these diagnoses.
Conclusions: A daily, physician-led multidisciplinary rounds in ED holding can successfully identify a significant portion of admitted patients able to be discharged that day in order to relieve overcrowding and improve throughput. Data from this process can then be mined for opportunities in joint ED/inpatient throughput initiatives.