The emergency room at Reading (Pa.) Hospital, a Level II trauma center, was built to house 280 patients at a time. When the new facility opened in 2005, that number of beds would suffice. However, the hospital had been seeing an influx of ED visits that brought an average of nearly 100 patients over capacity on a daily basis.
Clinicians working in the ED knew something had to be done. When patients are held up in the ED for a long time prior to admission, it can cause longer overall lengths of stay and higher morbidity rates. On top of those negative outcomes, patients who are kept waiting to be admitted often are highly unsatisfied.
So, a team of hospitalists, ED physicians, nurses and quality improvement experts at Reading Hospital gathered to see what they could do to affect change and get patients to the right place in a timely fashion to "create capacity" in the swamped ED, according to Charles Barbera, MD, (left) chair of Reading Hospital's department of emergency medicine.
A multidisciplinary team was needed because patient throughput stretches beyond just the ED. "I can't preach more that ED throughput is not just a problem of the ED. It's an organizational problem that needs to be dealt with throughout the facility," says Bob Vance, (right) senior director for quality analytics and improvement at Reading Hospital.
Once they got together, the leaders discovered several areas ripe for improved efficiency, according to Dr. Barbera.
The team focused on patients' overall time spent in the ED from arrival to admission, broken down into time intervals throughout the care episode. They found one specific change could have a huge on ED boarding times: increasing collaboration between the emergency physicians and hospitalists.
The co-management challenge
Historically, physicians in the ED worked separately from hospitalists. Both groups of physicians would perform similar tasks on one patient, but would do so separately, which adds time on to the admitting process. Co-management helps alleviate that problem.
"We started working with colleagues in the hospitalist program, and as soon as we decide someone isn't going home, we co-manage that patient," Dr. Barbera says.
Reading Hospital started staffing hospitalists in the ED during the day to collaborate with emergency physicians on care plans for patients who would be admitted to the hospital. After the ED physicians first assess the patient and determine a hospital admission is necessary, the hospitalist joins the care plan, and the two co-manage the patient before he or she gets to the inpatient bed.
The transition may sound simple, but traditionally, these clinicians were not trained to work in tandem.
"It wasn't always easy and pretty," Dr. Barbera says. "This was a change from the way the ED physicians were trained and how the hospitalists were trained as well. We weren't trained to co-manage patients at all."
To make this culture change a reality, Dr. Barbera and Walter Bohnenblust Jr., MD, (left) director of hospitalist services at Reading Hospital, named clinician "champions" for the project who solidly, vocally supported the effort. They were there to remind everyone of the new protocol and why the change was necessary. Both physicians also noted early communication and buy-in from leadership were important aspects of this project's success.
Through this change, the median length of stay in the ED dropped from 370 minutes to roughly 300 minutes, according to Mr. Vance. Additionally, patients have been happier, as they are not stuck in limbo after discovering they would be admitted to the hospital.
"The patients are much happier, and it's easier to take care of happier patients," says Dr. Bohnenblust.
Downstream effect
Now that patients are getting out of the ED and into inpatient beds more quickly, thanks to the collaboration between ED physicians and hospitalists, Reading Hospital faces new challenges related to patient throughput.
"It's not just the ED and the hospitalists. [The problem] is bigger than our two groups. Sometimes we were doing things so fast that others couldn't keep up with us," Dr. Barbera says. For example, radiologists would receive an X-ray for a patient that is in the ED, but by the time they read the film, the patient was already transferred. "We're meeting with them now because they don't have a process for that," Dr. Barbera says.
Among other changes, the hospital is currently piloting a system that would link a patient's bed assignment to a notification to the patient transportation team that the patient should be moved to a new unit. The old system required two notifications, one for bed assignment and one for transportation.
Overall, the co-management of patients has proven successful. "We've seen an increase in ED volume but not in ED length of stay," Dr. Barbera says. "We've created capacity."