By Dorothy Brooks
To address ED boarding in the most logical and effective way, understand the scope of the problem. That means gathering good data regarding which patients have received admission decisions and are awaiting placement to an inpatient bed, and which patients are in some other stage of their ED encounters. Collecting these data was one of the chief reasons why emergency care providers at the University of New Mexico Hospital (UNMH) in Albuquerque teamed with hospitalists to develop a new hospitalist triage role specifically focused on making admissions decisions in a streamlined and efficient manner.
“From the ED standpoint, what we hoped to see was just a more honest accounting for how many patients are actually boarding in the ED,” explains Grant Scott, MD, an emergency physician at UNMH and a co-investigator on the initiative. “Before this intervention, you would have a good number of patients who may, for all intents and purposes, actually be boarders, but they were not being accounted for as boarders from the hospital standpoint.”
This could create downstream problems. As a large academic center, UNMH was accepting many transfers from outside the system. “If hospital administration can’t ‘see’ the patients who are going to be admitted who are already in the ED, they have a harder time in knowing when to accept incoming transfers based on available [inpatient capacity],” Scott says.
Another even bigger priority for the ED concerned patient care. “When we started this project ... we had a lot of experience with delays to patients receiving admission orders, and that really caused a bit of a safety problem for patients,” Scott observes. “Patients would be in a limbo space between ED evaluation and formal admission orders. A lot of times, important medications or treatments would be missed during that time.”
In such cases, the ED might address the acute indications that brought these patients into the department. However, other important medications that the patients might be on at home would not be administered during that period. “That was the impetus for pushing for this initiative,” Scott says. “By getting those patients formally admitted, we would start addressing all of their problems, not just their acute or presenting complaints.”
Even before investigators implemented the hospitalist triage role, they understood this intervention alone was unlikely to reduce the number of patients who were boarded in the ED because they simply would be making admission decisions on patients earlier, explains Christopher Bartlett, MD, MPH, associate vice chair of quality and safety in the department of internal medicine at UNMH and lead investigator on the project. “One could say, though, that this is a required element to improve throughput from a hospital perspective,” he says.
Then, with accurate data in hand, the focus can shift to alleviating the downstream bottlenecks that prevent patients from actually going to inpatient beds sooner.
After piloting the new role in November and December 2019, investigators began a staged implementation of the new approach from January 2020 through July 2020. They defined a post-intervention period as lasting from July 2020 through December 2020. Throughout this period, investigators reported the time to an admission decision for ED patients decreased significantly, from an average of a little longer than five hours at baseline to an average of a little longer than two hours in the post-intervention period. Further, feedback on the approach regarding ED-internal medicine relations improved among emergency care providers, and largely was mixed for internal medicine physicians.1
To develop the triage hospitalist role, investigators scrutinized all the steps that were involved in making an admission decision on an ED patient. The way the process worked at the time, such decisions might begin with a discussion between the ED provider and an internal medicine resident, who would then escalate a request to admit a patient up the chain of command in a process that could take several hours. “How do we put the decision-maker closer to the point of contact [with the ED provider], thereby eliminating the sources of delay?” asks Bartlett, division director of inpatient operations and flow at UNMH.
When the hospitalist triage role was piloted, the individual serving in that position was situated in a workroom in the ED where he or she could easily access emergency care providers and patients. “Quickly after we started piloting this, though, COVID reared its ugly head, and that workroom was quickly identified to have too many people in it,” Bartlett shares. “It wasn’t safe for clinical teams to be in there. A room on the floor above [the ED], which is actually adjacent to our ICUs, is now used by the triage attending [hospitalist].”
Also during the pilot phase, investigators developed an ED admission request form (EDAR) that emergency care providers would use to initiate all patient admission requests to the triage hospitalist within the hospital’s secure messaging system. “We had really hoped that the initial [EDAR] message would actually just be a starting point for the discussion between the ED team and the internal medicine team, and that the two attendings would then go to the bedside and talk to the patient and make sure everyone was on the same page about the admission and answer any questions,” Scott says. “For a large number of admissions, there doesn’t seem to be the need for much discussion.”
Thus, in cases where the patient shows a clear indication for admission, the EDAR form is all that is required. “For anything that is more complicated, the triage hospitalist will speak with the [ED provider] who initiated the admissions request,” Scott says. “The expectation from the ED side is that if the triage hospitalist has any questions, we would want [him or her] to come down to the ED and talk with the attending provider.”
When serving in the hospitalist triage role, Bartlett notes that whenever there are areas of uncertainty regarding a patient, he will either use the hospital’s secure messaging platform to communicate with the emergency care provider or visit the ED to discuss the case. However, Bartlett adds that when there is a difference of opinion between the emergency care provider and himself regarding the proper placement of a patient, he will speak with the care provider in person. “I think that is really important because those kinds of conversations are far more constructive when done in person,” Bartlett says.
Since the initial study of the hospitalist triage role, the approach has been fully implemented, and the responsibilities of the person serving in the role have expanded.
“That person is really the point person for all of the different internal medicine admitting teams,” Scott shares. This means the person serving in the position is not just making admissions decisions about patients coming from the ED, but also patients coming from the ICU or those transferred in or out of the hospital. “The hospital triage attending is the person who is kind of leading all of that and distributing those patients to the various other teams,” Scott adds.
However, from the ED’s standpoint, the hospitalist triage person has remained the primary point of contact with respect to admission decisions. That has simplified the process for emergency care providers. “The overall time-to-admission has remained pretty consistent since the intervention [study],” Scott says. “That is an appropriate amount of time to give the triage hospitalist to actually review the case and look at the patient’s labs. We want [his or her] expertise in determining whether the internal medicine service is the correct service for the patient.”
Bartlett acknowledges one of the cognitively challenging aspects of the triage hospitalist role is that the consult requests are coming from everywhere. “They are coming from downstairs in the ED, they’re coming from all of our ICUs, and we are also serving as the point person for transfer requests from outside hospitals,” he says.
All these requests populate into the secure messaging platform in the queue with the ED requests. “We just go at them one at a time,” Bartlett says.
One significant operational change the hospital has made since the initial study has been to add an additional physician role to filter external transfer requests into the hospital. “Previously, all of that was done by the triage hospitalist,” Scott notes. “Now, the hospital has a separate physician who evaluates external transfer requests to see if they are truly something that has to come to us vs. ... another hospital that doesn’t have all the tertiary care capabilities that we have.”
The addition of that role has taken some of the external transfer load off the triage hospitalist. “The vast majority of external transfers that come in now will be going to surgical services or ICUs initially, and then may come to the triage hospitalist as a transfer out of the ICU eventually,” Scott says. “But we probably don’t see as many direct transfers to an internal medicine service as we used to.”
There also has been another change in the hospitalist triage role that likely has improved its standing among internal medicine providers since the approach was tested. “Our division is rather large, and there was an expectation that, at least initially, everyone was going to rotate through [performing the role]. Some individuals really pushed back. It’s hard to take on a new role or do something different,” Bartlett explains. “Over time, we have shifted toward preferencing the [hospitalist triage] shifts for people who are interested in this specific work, and that group has increased.”
Bartlett says there were three to six internal medicine physicians; now, there are 10 to 15. “There is actually a big group of us who like doing the shifts,” he adds.
Bartlett suggests the key to the sustainability of the intervention was the integration of the EDAR form into the hospital’s secure messaging system. “Giving the ED a required step that would lead to a standardized approach to communication really increased our uptake [of the new approach],” he says. “That was truly an important step for sustainability.”
Bartlett and Scott encourage colleagues to consider incorporating a process through which the hospitalist triage person can meet with the emergency care provider and the patient regularly when making an admission decision. “Everyone here got very used to communicating exclusively through the secure messaging system,” Scott observes. “They have become comfortable with that as the sort of default, unless there are really specific questions or difficult conversations or disagreements.”
Scott adds creating a hospitalist triage role requires buy-in on both sides. If ED leaders believe quick admission decisions is problematic, but the hospitalists do not, “I don’t think this will be successful,” Scott says. “If I were to do something similar somewhere else, I would really try to engage those two groups, and make sure you have support from them before you try to push for it to happen.”
REFERENCE
1. Bartlett C, Scott G, Pizanis C, et al. The hospitalist triage role for reducing admission delays: Impacts on throughput, quality, interprofessional practice and clinician experience of care. Journal of Clinical Outcomes Management 2023;30:71-78.
This intervention alone likely will not reduce the number of boarded patients. But with accurate data in hand, the focus can shift to alleviating the downstream bottlenecks that prevent patients from going to inpatient beds sooner.
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