Hospitalists Hold Key to Admissions Door for ED Patients

The Hospitalist. 2013 August;2013(08):

August 1, 2013|The Hospitalist

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

IOM reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the "admission door." Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

Quick Tips for Hospitalists

Take an ED leader to lunch and brainstorm.
Invite an ED member to a hospitalist staff meeting to discuss ED flow.
Develop a team of passionate hospitalists to work on ED admission flow.
Develop a “SMART” (specific, measurable, attainable, relevant, time-bound) goal around ED admissions.
Track ED length of stay for your group’s admitted patients (via dashboard).

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.