Hospitalists Can Help Reduce ED Crowding

With emergency departments overflowing and inpatient units struggling to control their patient flow, more hospitals are creating observation and short-stay units and looking to hospitalists to play a leading role.

The Society of Hospital Medicine issued a white paper on the subject in 2009, providing an operational guide and tool kit for hospitalists on how to set up an observation unit.

“We're not in a place where people are right and left opening up observation units right now,” said Dr. Adrienne Green, chair of the expert panel that wrote the white paper. “But I think that we're definitely in a place where people are thinking creatively about flow and doing things along the lines of an observation unit in many different formats.”

Even hospitals with excess capacity and good patient flow should consider the benefits of setting up an observation or short-stay unit, Dr. Green said, because insurance companies increasingly won't pay for the full stay of a patient who doesn't meet inpatient criteria.

A traditional observation unit handles patients who are being evaluated for a diagnostic syndrome that could indicate a life-threatening disease, as well as patients with an emergent condition that requires care for a longer period of time than is appropriate for an ED stay.

To be successful, observation units need high-level institutional support and adequate staffing, the expert panel said. Dr. Green, who is also the associate chief medical officer at the University of California, San Francisco, recommended that the units have dedicated providers, protocols for common conditions, and a designated physical space.

Some hospitals operate “virtual units” and sprinkle patients all around the hospital, but Dr. Green said that approach is less likely to work well. Although the use of virtual units gives space-challenged hospitals more flexibility, it can also be less efficient.

In addition, having a small staff that is primarily focused on running the unit on a daily basis is critical, she said, because those people will “own it.” These are the people who will create the protocols used in the unit, so that every patient who comes in with an asthma exacerbation receives a standard set of orders, tests, and treatments. “If you don't have that, it's unlikely that you'll be able to move people through the unit in an efficient way,” Dr. Green said.

Although the SHM white paper focused on observation units, hospitals can consider other creative ways to address flow issues. “There's a lot of ways you can help with overcrowding other than purely an observation unit,” Dr. Green said.

The Virginia Commonwealth University Health System in Richmond, for example, created an internal medicine admitting team that includes a hospitalist, a senior internal medicine resident, a nurse, and a social worker. Following the formation of the team in 2005, patients' length of stay in the ED decreased, the number of patients transferred to the ICU within 24 hours of admission declined, and revenue from ED consults rose.

Northwestern Memorial Hospital in Chicago uses a combination of an observation unit and a short-stay unit to manage ED crowding and patient flow issues. Northwestern's approach started in the ED, with emergency physicians opening a 23-bed observation unit to handle borderline patients who were being boarded in the ED. Located one floor directly above the ED, the unit opened in 2003 and made it possible to reduce the number of patients leaving without being seen, as well as hospital diversions.

But over time, the ED became overwhelmed again, and the observation unit began taking patients from the ED waiting room. To accommodate these patients, the hospitalists at Northwestern were asked to create a short-stay unit.

The short-stay unit was launched in January 2008 with 30 beds, and is designed for patients whose stay is expected to be 23–72 hours. Generally, these patients are too sick for the observation unit. So far, the unit has been able to decrease the length of stay for these patients, to an average of about 2 days.

It has been difficult to come up with a single model that works for everyone all the time, said Dr. Matthew P. Landler, medical director of Northwestern's short-stay unit. The key, he said, is to have several strategies available for different kinds of days.

“You don't want to get locked in with hard-and-fast rules, because some days those hard-and-fast rules are appropriate and work, and then other days they don't,” said Dr. Landler, who is an assistant professor of medicine at Northwestern University.

One way to keep up with constantly changing needs is to assign a team of nurses to act as patient-throughput coordinators. These nurses take the time to analyze the capacity issues that arise each day and coordinate between the hospitalists and the ED staff.

Aside from these formal systems, Dr. Landler advises his hospitalist colleagues that the best way to improve communication and understand the patient flow coming from the ED is to just quickly round on ED patients with the attending physicians there.

“The better we understand each other, the better the whole throughput and flow situation is,” Dr. Landler said.