Where: Baystate Medical Center, a 650-bed tertiary care center in Springfield, Mass.
The issue: Reducing transfers of inpatients between wards.
Back in 2010, it was common for patients at Baystate Medical Center to be transferred from one inpatient bed to another. “We had a pretty high rate of what we call “lateral” transfers … and there were a number of reasons why this could have occurred,” said Niels K. Rathlev, MD, Chair of Emergency Medicine at Baystate.
“[For] a patient with pneumonia who also is dialysis-dependent because of renal failure, the question then becomes does this patient go to a respiratory floor, or does this patient go to the renal floor?” described Dr. Rathlev. “Neither the hospitalists nor the emergency physicians know all of the institutional idiosyncrasies as to who goes where.”
The physicians also struggled with choosing the appropriate status for a patient—regular admission, intensive care, stepdown, or observation—even though there was a computer tool available to help them. “The emergency physicians honestly did not want to learn Interqual. They wanted to be clinicians. The same was true of the hospitalists,” he said.
The solution developed by Dr. Rathlev and colleagues was to create a new position, the patient placement manager (PPM).
How it works
Patient placement managers are registered nurses who already work for the hospital in administrative capacities. Their work experience gave them expertise in placing patients in the proper bed and status. Under the new system, they shared this expertise with emergency physicians and hospitalists.
“We [involved] the PPMs in a 3-way phone call,” said Dr. Rathlev. Initially, the emergency physician called the PPM whenever (s)he was ready to admit a patient, and then the PPM would get the admitting hospitalist on the phone and call the ED doctor back so the 3 of them could discuss where the patient should go.
After some experimentation, the procedure was revised to have the emergency physician send a simple electronic medical record alert to the PPM and hospitalist, both of whom then reviewed the patient's EMR before calling the emergency physician to discuss. The ED doctors also got cordless portable phones to facilitate the calls enabling them to answer calls without having to find a landline.
The system dramatically reduced unnecessary transfers, according to a comparison of 2 control and intervention periods published in the September 2014 Western Journal of Emergency Medicine. “We found a very high rate of lateral transfers—about 9%—during the control periods, and we were able to drop those by about two-thirds, to about 3%, during the study period,” said Dr. Rathlev.
The refinements with the EMR and portable phones provided additional improvements. “What was surprising in the second pilot, when we made a couple more changes, we also found that for admitted patients, there was a reduction in their length of stay in the emergency department,” he said. “We'd like to think that that's because we involved folks at the initial stages of the admission process and everybody understood exactly where the patients were going and the plan of care was started earlier.”
Figuring out the best way to set up those phone calls wasn't easy. Before the portable phones were acquired, one or more participants in the call were usually left waiting. “We [emergency physicians] would sit around and wait for that phone call to come back, or we would wait for the secretary to page us overhead and say, ‘The hospitalist and the PPM are on the call, they're waiting for you.’ [Then] we might be tied up in a code or doing a procedure,” said Dr. Rathlev.
The phone calls might also help reduce other length-of-stay metrics, because the PPMs provide advice on whether to categorize a patient as observation or admitted. “If they should have been assigned to observation, they should be on protocol [with] hopefully a total length of 24-36 hours, as opposed to several days,” Dr. Rathlev said, noting that some hospital procedures may move faster for patients in observation status.
Words of wisdom
While a PPM is likely not needed in small facilities with few choices regarding where to admit a patient, the system may make sense for other large hospitals, according to Dr. Rathlev. “If the hospitalist service is concerned that a lot of inefficiency is occurring after patients arrive on the floors, because either the status determination is incorrect or the patient went to an incorrect bed, then I do think that this is something that would be very useful,” he said.