A model of a hospitalist role in the care of admitted patients in the emergency department

Emergency Department (ED) overcrowding has become an important problem in North American hospitals. A national survey identified the prolonged length of stay of admitted patients in the ED as the most frequent reason for overcrowding. This complex problem occurs when hospital inpatient census increases and prevents admitted patients from being assigned and transported to hospital beds in a timely manner. The practice of holding admitted patients in the ED, known as ‘‘boarding,’’ is typically defined as the length of stay (LOS) in ED beginning 2 hours after the time of admission to the time of transfer to the wards. In a study of daily mean ED LOS, Rathlev et al. concluded that a 5% increase in hospital occupancy resulted in 14 hours of holding time for all patients in the ED, and an observational study found that when hospital occupancy exceeds a threshold of 90%, the ED LOS for admitted patients correspondingly increased. Thus, efforts to decrease overcrowding will need to address both ED and hospital throughput and LOS. Most importantly, overcrowding has important consequences on physician and patient satisfaction and the quality of patient care. Between 1995 and 2005, ED visits rose 20% from 96.5 million to 115.3 million visits annually, while the number of hospital EDs decreased from 4176 to 3795, making an overall 7% increase in ED utilization rate. Similarly, there was a 12% increase in the total inpatient admissions for all registered hospitals in the United States from 31 million in 1995 to 35.3 million in 2005. However, despite this increase in demand of ED utilization and inpatient admissions, there had been a steady decline in the supply of hospital beds, from 874,000 in 1995, to 805,000 in 2006. These factors have exacerbated the problem of ED overcrowding and boarding. Not only does boarding entail additional consumption of space, resources, equipment, and manpower, it also potentially compromises patient safety. Typically, hospitalists and inpatient medical teams are engaged in providing care to patients in the wards, while ED physicians and nurses are busy taking care of newly-arrived ED patients. Non-ED physicians may have the false impression that their boarded patients, while in the ED, are receiving continuous care and so may decide to delay seeing these patients, which can jeopardize the quality and timeliness of care. Studies have shown that ED overcrowding may potentially lead to poor patient care and outcomes and increased risk for medical errors. ED overcrowding potentially causes multiple effects, including prolonging patient pain and suffering, long patient waiting time, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff. In a report by the Joint Commission Accreditation of Healthcare Organizations, ED overcrowding was cited as a significant contributing factor in sentinel event cases of patient death or permanent injury due to delays in treatment. Boarding critically ill patients who are physiologically vulnerable and unstable can allow them to be subjected to treatment delays at a pivotal point when timesensitive interventions are necessary, ie, sepsis or cardiogenic shock—the ‘‘golden hour’’ in trauma. Medical errors are usually not caused by individual errors but by complex hospital systems; and ED overcrowding is a prime example of a system problem that creates a high-risk environment for medical errors and threatens patient safety. Our hospital commonly has 5 to 15 boarders and often has 20 to 30 boarders at any time. Approximately 90% of these patients are admitted to the Medical Service. In response to this challenge, our institution has designated a full-time hospitalist to manage boarded patients. The primary goal of this new role is to ensure patient safety and the delivery of high-quality care while admitted patients are in the ED (Table 1). The objectives of the study were to determine: (1) the impact on quality of care by assessing laboratory results acted upon and medication follow-up by the ED hospitalist, and (2) the impact on throughput by assessing the number of ED discharges and telemetry downgrades.