That’s a tricky thing to do, he says, “because the benefit to us isn’t huge, we’re self-sacrificing to help the ED, and that’s what I want hospitalist groups nationally to be thinking: how we can make the whole system better and not just make our own job better.”
Source: National Hospital Ambulatory Medical Care Survey, Hyattsville, Md., National Center for Health Statistics; 2004.
Figure 1. Percent distribution of ED visits in the U.S. in 2004, by immediacy with which the patient should be seen.
Dr. Glasheen believes the professional structure in his institution is representative of what other hospitals will function like in the next 10 years.
“You have a backbone structure of basically four types of physicians: emergency medicine docs, hospitalists, intensivists, and a surgical team,” Dr. Glasheen says. “Everyone else, more and more, is serving in a consultative role.” Having that backbone allows you to tackle the issues, which are primarily complex, systems-based issues, he says. “It is no longer [a matter of just] the ED trying to deal with capacity issues. Now they have an ally on the inpatient side.”
An excess of patients for the number of beds means some patients spend a disproportionate amount of their stay in the ED, and that challenges communication and efficiency. “The challenges may be simple things, such as it being harder for a hospitalist to get to the ED to see a patient than it is upstairs,” Dr. Glasheen says. “[Or] it’s harder to decide who really has ownership of that patient.” In his hospital, as soon as a patient is assigned to a hospitalist, the primary responsibility for that patient is seen as the hospitalist’s.
But there are other issues. “Even if we are able to get down [to the ED] and write orders, that is problematic for the ED and the hospitalist; as a hospitalist we don’t have the nurses with staffing ratios and skills in the ED that they have on floors and in the ICU,” says Dr. Glasheen. “It is not always possible to get things done as efficiently as they probably could if the patients were in a proper unit. Locally and globally in my experience, the biggest issue is: How do you take care of these patients who now spend their inpatient stay in the ED?”
Source: Howell EE, Bessman ES, Rubin HR. Hospitalists and an innovative emergency department admission process. J Gen Intern Med. 2004;19(3):266-268.
Figure 2. Medical admission cycle times in hours, pre- and post-intervention.
Collaborations, Models, and Solutions
A number of hospitalists raise the issue of managing internal medicine residents doing rotations in the ED.
“We were approached recently by the ED because most of our admissions are called in directly to the medical residents,” says Jason R. Orlinick, MD, PhD, head of the section of Hospital Medicine at Norwalk Hospital, Conn. “I think the ED would like to talk directly with the medical attending assuming care for the patient. One of the things we haven’t done well is meet on a regular basis to discuss communication issues.”
The hospitalists and emergency medicine group at Dr. Orlinick’s institution have entertained the idea of setting up a direct triage system whereby medical residents are taken out of the picture. “The emergency medicine docs would page us directly—at least during the busiest hours of the day. Eventually, the hope is to make it a 24-hour, seven-days-a-week, 365 [days-a-year process],” says Dr. Orlinick. By bringing this to the emergency medicine physicians, the intent was to send the message that hospitalists recognize ED overcrowding as an institutional issue and want to improve communication with their ED colleagues to improve patient care.