Abstract and Introduction
Abstract
Introduction Because 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.
Methods We 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 "lateral transfers" or assignment errors in patient placement, 2) median length of stay (LOS) for "all" and "admitted" 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.
Results In pilot 1, the number of "lateral transfers" (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 "all" or for "admitted" patients. In pilot 2, the number of "lateral transfers" 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 "admitted" ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for "all" patients and inpatient occupancy did not change.
Conclusion Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of "lateral transfers." 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.
Introduction
Lack of inpatient capacity is the single most important factor associated with emergency department (ED) crowding.[1] Consequently, more efficient bed management can potentially alleviate ED crowding and reduce overall ED length of stay (LOS). This is particularly true in institutions such as ours, where boarding of inpatients in the ED is a significant problem. The determination of proper bed and unit placement for admitted patients is typically guided by hospital-specific protocols. For example, a peritoneal dialysis patient with pneumonia may be admitted to the Renal Floor with nurses trained to handle dialysis care, rather than on the respiratory floor based on the diagnosis of pneumonia. Lack of adherence to protocols may cause "waste" associated with improper bed and unit placements. 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. Our hospital is a Level I trauma and tertiary care referral medical center. The ED has an annual volume of 110,000 visits and supports a training program in emergency medicine with 36 residents. It is also the training site for medical students and rotating residents from other specialties.
The criteria for assigning admitted patients to inpatient beds are not only complicated, but may also change over time. It became evident that admitting hospitalists and emergency physicians (EP) in our institution were insufficiently trained and informed to uniformly follow the protocols. A project was undertaken to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize. The PPMs are clinically experienced registered nurses who are trained in the institution-specific criteria for correct unit and bed placement depending on the admission diagnosis and acuity level. Their specialty practice experience (typically in critical care, telemetry nursing or supervisory roles) supports decision-making related to placing patients in the right bed at the right level of care. In order to facilitate their task, the PPMs were trained in determining status (observation versus inpatient) and level of care (intermediate or intensive care unit versus floor bed) using InterQual (McKesson Company®), our hospital's case management support tool. This clinical decision support tool is used as a guide for case managers to answer questions about appropriate levels of care and resource use.[2]
Our goal was to systematically improve communication and decision making via a single three-way phone call that involved the EP, hospitalist and PPM. The purpose was to provide the appropriate hand-off and also determine the appropriate unit/bed selection for all hospital medicine patients admitted through the ED. At the same time, it was important to ensure that any changes minimized delays to ED departure as studies have shown that such process changes may otherwise be associated with increased inpatient LOS and inpatient cost.[3]
Western J Emerg Med. 2014;15(6):687-692. © 2014 Western Journal of Emergency Medicine
