Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service
BACKGROUND: It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS).
OBJECTIVE: To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder.
INTERVENTION: The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed.
PRIMARY OUTCOME AND MEASURES: The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate.
RESULTS: There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates.
CONCLUSION: Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.
© 2020 Society of Hospital Medicine
Patient Eligibility
Similar to the workflow before the intervention, the ED team was responsible for determining a patient’s need for admission to a medical service. Patients were eligible for EDB service coverage if they waited in the ED for more than two hours after the request for an inpatient bed was made. The EDB charge nurse was responsible for identifying all eligible boarder patients based on time elapsed since bed request. Patients were not eligible for the hospital medicine EDB service if they were in the ED observation units or were being admitted to the intensive care unit, cardiology service, oncology service, or any service outside of the Department of Medicine.
The EDB service did not automatically assume care of all eligible patients. Instead, eligible patients were accepted based on several factors including EDB clinician census, anticipated availability of an inpatient bed, and clinical appropriateness as deemed by the physician. If the EDB physician census was fewer than 10 patients and an eligible patient was not expected to move to an inpatient unit within the next hour, the patient was accepted by the EDB service. Patients who were not accepted by the EDB service remained under the care of the ED team until either the patient received an inpatient bed or space became available on the EDB service census. Eligible EDB patients who received an inpatient bed before being picked up by the EDB service were considered as noncovered EDB patients. Alternatively, an eligible patient may initially be declined from EDB service coverage due to, for example, a high census but later accepted when capacity allowed—this patient would be considered a covered EDB patient.
Handoff and Coordination
When an eligible patient was accepted onto the EDB service, clinical handoff between the ED and EDB teams occurred. The EDB physician wrote admission orders, including the inpatient admission order. Once on the EDB service, when space allowed, the patient was physically moved to a dedicated geographic space (8 beds) within the ED designed for the EDB service. When the dedicated EDB area was full, new patients would remain in their original patient bay and receive care from the EDB service. Multidisciplinary rounds with nursing, inpatient clinicians, and case management that normally occur every weekday on inpatient units were adapted to occur on the EDB service to discuss patient care needs. The duration of the patient’s stay in the ED, including the time on the EDB service, was dictated by bed availability rather than by clinical discretion of the EDB clinician. When an EDB patient was assigned a ready inpatient bed, the EDB clinician immediately passed off clinical care to the inpatient medical team. There was no change in the process of assigning patients to inpatient beds during the intervention period.
Study Population
This study included patients who were admitted to the general medical services through the ED during the defined period. We excluded medicine patients who did not pass through the ED (eg, direct admissions or outside transfer) as well as patients admitted to a specialty service (cardiology, oncology) or the intensive care unit. Patients admitted to a nonmedical service were also excluded.
