Background: In 2006, the Institute of Medicine issued a report on the state of emergency care, which identified overcrowding and patient boarding as major concerns. Subsequent research has confirmed that boarding in the emergency department (ED) leads to adverse events including medication errors, higher mortality, and lower patient satisfaction. In answer to this, hospitalist groups have demonstrated success with assuming care of patients in the ED and opening a separate unit for boarders. However, this requires significant resources including hiring of both physicians and nurses and many institutions do not have the necessary resources. In answer to this at our urban academic center, the hospitalist group has created a consult service to aid in the care of ED boarders.
Purpose: The goal of the hospitalist consultation service in the ED is to provide safer care for patients awaiting an inpatient bed and to help the ED with throughput by ensuring that patients are assigned to the right level of care as telemetry beds are limited and in high demand.
Description: The hospitalist consultation service in the ED was launched in September 2022. It is available during regular business hours and covered by the hospitalist who covers general medicine consults throughout the hospital. Acute, complicated patients and those where the level of care may be in doubt are prioritized. Hospitalists are encouraged to work collaboratively with the ED provider to identify appropriate patients. The consultant will enter a detailed note and communicate recommendations verbally on seen patients. ED providers enter and execute orders accordingly. Hospitalists will also work with the flow center to help facilitate bed placement. If a patient receives a bed after being seen, the hospitalist consultant will provide a warm hand off to the inpatient team.
Conclusions: Our hospitalists have found this consultation service valuable. From a flow standpoint, hospitalists have improved consultant engagement with ED patients which has helped to expedite work-up including the scheduling of procedures. From a patient safety perspective, our consultation has often resulted in improved triage and safer medication administration with more thorough reconciliations. Admission related patient safety reports from 9/2022 to 10/2023 were analyzed. There was no clear trend to a decrease in patient safety reports since the start of the consult service. The admit delay time in the ED was assessed to determine impact on flow. This is the median time from disposition decision to leaving the ED for an inpatient bed. In theory, the hospitalist consultant could improve this measure of ED flow by ensuring that level of care is appropriate and by communicating with the flow center. Unfortunately, we have been unable to move this metric. Patient safety and patient flow are fundamentally multidisciplinary. A hospitalist consult service is valuable, but engagement from other services is truly needed to effect measures and bring about more meaningful change.