A New Position
Or, instead of the two approaches above, you might take a 180-degree approach. You could create a new triage doctor position. This hospitalist would have no other responsibilities. In other words, while on triage, a doctor does not have a list of patients to round on and manage. The triage doctor’s only duty is to maximize ED throughput by quickly providing an opinion about whether a patient is appropriate for admission to the hospitalist service, and to assist moving them out of the ED and to the floor quickly. Eric Howell, MD, director, Zieve Medical Services, Johns Hopkins Bayview Medical Center at Johns Hopkins University in Baltimore has studied this third option, the use of a triage hospitalist who has no other clinical responsibilities, in a teaching hospital setting. Dr. Howell first implemented this as a daytime-only service, however, it proved so invaluable to improving emergency department throughput that it is now in place 24/7. He has published a study of this system and described the evolution in the following post on the SHM list serve:1
“Until 2006, when our gen-med service admission numbers were lower (approximately24 a day), we had the triage hospitalist carry a 50% clinical load, so that they could dedicate 50% time to triage. As our volume increased, and after we expanded the triage service to the ICUs and specialty floors, we dedicated one doc 24-7 (two, 12-hours shifts, actually) to the sole task of triage.
“It initially sounded like a large amount of resources just to triage, but at our 330-bed hospital, it has increased ED capacity substantially. The effect has been not to just increase ED visits and department of medicine admissions, but to increase surgical admissions through the ED, as well. The effect has been to dramatically reduce ambulance diversion. So, now the hospital funds the 24/7 triage position without a second thought.
“We have had enormous success and even expanded the hospitalist triage role to non-hospitalist wards showing dramatic decrease (25%) in ED length of stay. ”
Practical Measures
I’m skeptical a triage pager system, such as Dr. Howell describes above, is a good idea for most hospitalist practices. It is very expensive for a practice to devote physician manpower solely to non-billable services. The payoff, as measured in more productive or less-stressed hospitalists, would not justify the investment. Instead, as Dr. Howell did, you would have to look for a return on the investment outside the hospitalist practice itself, such as improvements in ED throughput.
Remember, Dr. Howell’s study was done in a teaching setting, and I suspect the reason a dedicated triage doctor proved so beneficial was it kept interns from setting up camp in the ED to complete the time-consuming admission process and delaying the patients’ transfer out of the ED. The triage doctor ensures nearly all ED admissions quickly move to the floor where the admitting team will make the time-consuming, initial (admitting) visit. In a non-teaching setting, that process isn’t burdened with trainees who take so long to admit patients, therefore, a dedicated triage hospitalist system probably would not result in such dramatic improvements in ED throughput.
Recommendations
I’ll finish by offering a summary and recommendations, based on my reasonably extensive experience, but almost no research data.
- For practices smaller than 10 hospitalists, the decision to use a triage pager can be based on preference. It won’t have significant impact on interruptions or work flow.
- Larger practices, especially those with more than 20 hospitalists, should first try to use a clerical person to field incoming referral calls during weekday business hours. The clerical employee would then page the hospitalist due to get the next new patient, and that hospitalist would call the referring doctor to learn about the patient directly.
- Large practices in teaching hospitals should think about whether it would be worthwhile to dedicate a hospitalist solely to the task of triage in hopes of reaping benefits elsewhere in the hospital, such as ED throughput. TH