Improving Handoffs From the ED

Historical efforts to overhaul handoffs between the ED team and inpatient team have proved difficult due to process complexity and the need for a coordinated change across multiple stakeholders. To address this issue, researchers formed a multi-departmental quality improvement team with leadership from medicine, emergency medicine, nursing, admitting, and patient transports who formed workgroups focused on communication of expected discharges to admitting, nursing handoffs, provider handoffs, and the transport process. Following implementation of a new handoff process designed with input from all workgroups, average time between “ready bed” and patient arrival on the unit improved from 106 minutes to 71 minutes, representing savings of 14.6 patient hours per day. The researchers suspect the improvement was due to discharges being communicated to admitting before discharge increasing from 59% to 90%, nursing and provider handoff times decreasing 32% and 65%, respectively, and more consistent transport processes.

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Hospitalist-Directed Transfers & ED LOS

Hospitalist-led transfers for stable ED patients may help improve overcrowding, but studies are lacking that assess the impact on length of stay (LOS) of such transfers from an ED to an inpatient ward at affiliated hospitals. For a study, charts were reviewed for patients admitted to hospitalist services from EDs at a reference hospital or a nearby affiliate hospital. Patients transferred to affiliate hospitals had shorter ED LOS (9.23 vs 16.94 hours); lower risk of significant events, specifically upgrade to ICU care (2.1% vs 4.8%); and lower 30-day readmission rates following their index admission (17% vs 23%). Upon multivariate analysis, transferred patients had a shorter ED LOS on average by 7.62 hours.

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A Collaborative Effort for ICU Triage

Evidence suggests that inappropriate triage of critically ill patients to non-ICU settings can lead to poor patient outcomes, with early unexpected ICU transfers associated with increased mortality. A collaboration by hospital medicine, emergency medicine, and critical care clinicians in triaging critically ill patients in order to address such transfers was assessed for a study. Over 4 weeks, 0.76% of nearly 13,000 patients triaged in the ED were admitted to the medical ICU. Of 19 potential false positives (patient admitted to ICU and transferred to the floor or discharged within 24 hours), only three were deemed unnecessary ICU admissions. Of 10 potential false negative patients (patient discharged from the ED and admitted to the ICU within 24 hours or admitted to a ward team and transferred to the ICU within 24 hours), six were deemed to be inappropriately triaged to a ward team on presentation. Of 24-hour admission to the medical ICU, 84.2% were deemed necessary.

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Improving Medication Reconciliation in the ED

Medication reconciliation upon hospital admission is a time-consuming process that is prone to errors for a multitude of reasons, including poly-pharmacy, non-compliance, over-the-counter (OTC) medication use, poor recall of medication history, and limited family and pharmacy access. A direct collaboration between hospitalists and pharmacists in the ED in an effort to reduce medication-related error frequency and improve admission efficiency was analyzed for a study. A team of five, full-time pharmacists working from 6:00am to midnight every day performed a completed medication history review including all prescription, herbal, and OTC medication use, evaluated adherence and appropriate dosing, reviewed interaction potential and adverse drug reaction presence, electronically entered the information into the patient’s electronic medical record, and verbally communicated pertinent recommendations to the admitting hospitalist, who completed medication reconciliation. Use of this collaboration over 10 months resulted in a $600,000 cost avoidance in the ED of study’s tertiary care, 500+ bed urban/suburban teaching hospital. Hospitalist admission times were reduced by 10-25 minutes with the program, resulting in more timely care, improved patient throughput, and possibly the completion of more admissions per shift.

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Managing Admitted Patients Boarding in the ED

At tertiary academic care centers that frequently operate at greater than 100% capacity, medical admissions boarding in the ED while awaiting inpatient beds represent a bottleneck in hospital patient flow. Hospitalist-led management of this patient population may help address this issue. For a pilot intervention, a care team consisting of a senior hospitalist with the ability to make decisions on patient status, advanced nurse practitioner or physician assistant, and enhanced ED case manager oversaw ED boarded patients. The team could down- or upgrade patient status based on clinical findings, review telemetry indications, triage to appropriate location, or admit and discharge suitable patients, along with attending to acute deterioration issues for boarding patients. The intervention was found to decrease hospital lengths of stay by a total of 42.29 days and direct costs by more than $78,000 due to discharges directly from ED boarding when compared with similar patients from the prior fiscal year. No return visits within 72 hours were observed among discharged ED boarding patients.