Active Bed Management by Hospitalists and Emergency Department Throughput

Context Can hospitalists help decrease crowding in emergency departments? Contribution This prepost case study describes a quality-improvement partnership between hospitalists and a university-affiliated emergency department. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to particular units. After implementing the program, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours that the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6% and 27%, respectively. Implication A hospitalist-led bed management program improved emergency department throughput and ambulance-diversion status. The Editors The Institute of Medicine's 2006 report, Hospital-Based Emergency Care: At the Breaking Point, is explicitthere is a crisis in U.S. emergency departments (1). Ninety-one percent of emergency departments are crowded beyond capacity (1). Emergency department crowding often results in ambulance diversion: the practice of redirecting ambulances destined for a crowded emergency department to another facility. Diverting ambulances prolongs the lead time until therapy can be initiated and has been associated with increased mortality rates (2). In 2003, ambulance diversion occurred nationwide at the rate of 1 ambulance every minute (3). The primary cause of emergency department crowding is inpatient boarding, that is, holding admitted patients until a hospital bed becomes available. This procedure not only reduces patient satisfaction but also may negatively affect patient outcomes and quality measures (48). Most of the 12 recommendations in the Institute of Medicine's report concentrated on factors within emergency departments and ways in which emergency departments interface with the larger health care system. However, 1 strategy focused on hospital processes and efficiency as a way to ameliorate crowding (1). Hospitalist physician groups, internists specializing in the care of hospitalized patients, are now ubiquitous (9). By the nature of their work in coordinating patient care from admission through discharge, hospitalists are uniquely positioned to effectuate efficiency. Our group of hospitalists partnered with the emergency department to address the problem of crowding in our emergency department. We describe the effect of our hospitalist-run service called active bed management. The primary objective of this service was to facilitate the safe transfer of patients from the emergency department to the appropriate inpatient clinical setting. Methods Setting and Design This study took place at Johns Hopkins Bayview Medical Center, a 335-bed university-affiliated medical center in Baltimore, Maryland. The emergency department is a designated level-II center for adult trauma, adult burn, and primary stroke. With capacity for 30 primary treatment rooms, the emergency department registered 54607 visits in the fiscal year ending June 2007. Historically, approximately 25% of the patients registered in the emergency department are admitted, which forms 61% of the hospital's total admissions. Roughly 75% of department of medicine admissions come from the emergency department, totaling approximately 9700 patients annually. The hospitalist division had 14.7 full-timeequivalent physician faculty, 3.0 nurse practitioners, and 4.6 physician assistants at the time of the study. In Maryland, the controlling authority for emergency medical services is the Maryland Institute for Emergency Medical Services Systems. It has defined 2 levels of ambulance diversion. First, an emergency department is put on yellow alert when experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely. During this period, the Emergency Department requests that absolutely no priority II or priority III patients be transported to their facility. Second, red alert is the designation used when a hospital does not have any electrocardiography-monitored or critical care beds available. During red alert, patients who are likely to require this type of care are not to be transported to the emergency department; instead they are taken to the next closest appropriate hospital (10). These distinct alerts can be invoked separately in coordination with Maryland Institute for Emergency Medical Services Systems, which keeps a record of all alerts for all institutions in Maryland. Using a prepost design, we compared the relevant institution-level clinical data from the intervention period (November 2006 to February 2007) with data from the control period (November 2005 to February 2006) (Figure 1). This study was exempt by the institutional review board. Figure 1. Study flow diagram. JHBMC = Johns Hopkins Bayview Medical Center. Active Bed Management Intervention Before active bed management, the emergency department assigned patients who were admitted to 1 of 5 department of medicine admission services (cardiac intensive care unit [ICU]; medical ICU; and cardiology, pulmonary, and general medicine units). For all units except the general medicine unit, once the department of medicine house officer or a physician assistant was informed of the proposed admission by emergency department personnel, they were expected to evaluate the patient in the emergency department and initiate the transfer to the assigned hospital unit. For the general medicine unit, patient assignments were communicated from the emergency department through a page to a triage physician (hospitalists from 8 a.m. to 8 p.m. and house officers overnight), and once accepted, transfers from the emergency department to the medical floor occurred without in-person evaluation by the department of medicine. Active bed management, done in 12-hour shifts, is coordinated and staffed solely by the hospitalist service 24 hours a day, 7 days a week. All hospitalists in the division rotate through the active bed management role, and the active bed management physician is freed from all other clinical care duties so that his or her only clinical responsibility is facilitation of the active bed management processes. Active bed management was strategically designed around 3 fundamental elements: proactive management of department of medicine resources, evaluation and assignment of all departmental admissions, and mobilization of additional resources by the bed director. Proactive Management of Department of Medicine Resources The active bed management hospitalist assesses bed availability in real time for 2 ICUs (12 beds each), the intermediate care unit (3 beds), 2 subspecialty units (cardiac and pulmonary), and the 4 large general medicine units. These continuous assessments are designed to identify potential resource shortages, such as limited ICU beds, before they occur. Assessments are done through collaboration with unit-specific attending physicians, nursing supervisors, and charge nurses in real time, as well as through twice-daily prediversion rounds in the ICUs. Prediversion rounds provide the ICU teams with information on hospital bed status and identify patients who can be downgraded from critical care status and transferred to nonintensive care settings. Prediversion rounds also serve to collect accurate bed information to allow collaboration between the active bed management hospitalist and emergency department physician on patient flow. Evaluation and Assignment of New Admissions to Department of Medicine Inpatient Clinical Settings The active bed management hospitalist makes collaborative triage decisions about the optimal clinical setting for each patient who requires admission through consultation with all admitting physicians (predominantly emergency department physicians) initially by telephone. Pertinent clinical data are documented on a triage template, and the hospitalist then decides about the need to evaluate selected emergency department patients directly. Authority to make determinations on the assignment of patients to beds in the various services in the department of medicine has been granted to the active bed management hospitalist by the department chairman. Once the hospitalist accepts the admission, the emergency department attending writes brief admitting orders from preexisting order sets. Non-ICU admissions are transferred to the inpatient floor as soon as a bed is available. The receiving medical teams are notified about patients on initial triage and on their arrival to the inpatient unit. Intensive care unit admissions are transferred to the unit no longer than 90 minutes after the disposition decision has been made. This brief period allows ICU teams time to ready themselves and stabilize other patients (if necessary) while facilitating the timely transfer of critically ill patients out of the emergency department. Role of the Bed Director The bed director position was created as part of this intervention to support the active bed management hospitalists. The bed director is the hospitalist leader on call (either division chief or associate division chief). The active bed management hospitalist notifies the bed director if the hospital is put on red or yellow alert, if an alert seems to be looming, or if emergency department throughput for admitted patients is long and resultant crowding is occurring. The bed director has the authority to activate additional resources, both internal and external, to the department of medicine to address such issues in real time. Some resources available to the bed director to shorten delays in throughput and prevent ambulance diversion include calling in additional hospitalists, redirecting admissions to departments outside of medicine, and assigning medical admissions to nondepartment of medicine inpatient beds (where they will be cared for by the hospitalists). The Johns Hopkins