Abstract
IntroductionBecause lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement.MethodsWe conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of âlateral transfersâ or assignment errors in patient placement, 2) median length of stay (LOS) for âallâ and âadmittedâ patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process.ResultsIn pilot 1, the number of âlateral transfersâ (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for âallâ or for âadmittedâ patients. In pilot 2, the number of âlateral transfersâ was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for âadmittedâ ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for âallâ patients and inpatient occupancy did not change.ConclusionInclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of âlateral transfers.â Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients.
Highlights
Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem
In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and equipped all emergency physicians with portable phones in order to improve the efficiency of the process
We found a 49-minute (352 vs. 401 minutes) decrease in median length of stay (LOS) for âadmittedâ ED patients during the study period compared with the control period (P=0.04)
Summary
Lack of inpatient capacity is the single most important factor associated with emergency department (ED) crowding.[1] more efficient bed management can potentially alleviate ED crowding and reduce overall ED length of stay (LOS). This is true in institutions such as ours, where boarding of inpatients in the ED is a significant problem. Unnecessary hand-offs and delays in treatment by improper bed assignment may adversely affect quality patient care and satisfaction These concerns prompted an organization-wide project in our 650-bed institution to expedite the admissions process to the hospital medicine service, which accepts more than three quarters of all admissions. It is the training site for medical students and rotating residents from other specialties
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