Partnering up to increase patient capacity

An academic medical center joined forces with a nearby community hospital.


Background

Like many academic medical centers, Michigan Medicine has high patient demand and is consistently at 90% to 95% capacity, often with dozens of patients in the ED waiting for a bed. To better serve patients without building or acquiring a new facility, the hospital launched an offsite hospital medicine service at St. Joe's, a community hospital located about five miles away.

The new Michigan St. Joe's service on the 10 East Medicine Unit started with 14 beds in September 2018 and in January 2019 expanded to 26 beds, with 24/7 coverage from University of Michigan hospitalists and geriatricians, said Rafina Khateeb, MD, MBA, FACP, medical director of the unit. The Michigan Medicine physicians collaborate with nursing, staff, hospitalists, and consultants from the community site, she said. To date, the unit has admitted more than 1,000 patients.

How it works

General medicine patients who require minimal or no subspecialty consultation or intervention are eligible to transfer to the unit, which features private rooms and bathrooms. A triage hospitalist at the Michigan Medicine ED screens patients for eligibility during peak admission hours, and most admissions come from the ED, said Dr. Khateeb, a clinical assistant professor and director of clinical strategy for the division of hospital medicine at University of Michigan Medical School. Outside those hours, all Michigan Medicine hospitalists follow a triage algorithm that prioritizes the unit when contacted about an admission from the ED. “We've screened over 10,000 patients to get over 1,000, so on average we're screening 10 patients to get one,” she said.

A small sliver of admissions has come from University of Michigan clinics either directly or from referrals to the St. Joe's ED. “We're working on promoting these additional admission routes given it's much more convenient for the patient to . . . not have to transport via ambulance across town,” Dr. Khateeb said.

Results

In the first 12 weeks since the unit launched, about 68% of patients were treated as inpatients with an average length of stay (LOS) of about 3.6 days, while 32% were under observation with an average LOS of 40 hours, according to an abstract presented in March at Hospital Medicine 2019. As of May 2019, the average daily census for the unit was 21.4 patients. Overall feedback from patients and families has been very positive, said Dr. Khateeb.

More recent data showed about half the ED LOS for patients who came to the unit versus those admitted to similar units at Michigan Medicine, she reported. “So instead of spending 18 hours in the ED until they get a bed, they're spending eight, nine, maybe ten if it comes down to that,” Dr. Khateeb said.

Challenges

Still, the biggest challenge is patient acceptance. “Even when we present it to them in the ED and we talk about all the benefits and all the feedback we've had from patients . . . 40% of the patients say, ‘No, I'm used to this place. I don't want to go anywhere,’” said Dr. Khateeb, adding that the acceptance rate drops to about 26% after midnight.

Another challenge is that the hospitals currently use different electronic health records (EHRs), which means that workarounds are essential to share patient records. For example, when a patient is discharged from the unit, their discharge summary gets automatically scanned back into the Michigan Medicine EHR, but any additional records, such as a consultation or a test result, must be manually scanned, Dr. Khateeb said. “There's a lot of work, unfortunately, that we're having to do to link the two health systems until St. Joe's transitions to the same EHR in January 2020,” she said.

Words of wisdom

Other medical centers that are at capacity could consider collaborating with a nearby hospital that has open beds to create a mutually beneficial solution, said Dr. Khateeb. “Sometimes we get stuck in thinking that these are our competitors, when it's an opportunity to think outside of the box and be creative with a solution that's a win for everyone,” she said.

Next steps

Dr. Khateeb continues to keep an eye on patient outcomes on the unit, including transfers to the ICU or back to Michigan Medicine. To enhance the referral process from clinics, she is also doing more outreach to outpatient clinicians, who were surprised to hear that they have the option of direct admission to the unit. “Because the bed capacity was so limited at Michigan Medicine for the past few years, providers stopped using direct admissions completely. They just sent patients to the ER,” she said.

In addition, data analytics staff created an algorithm-based prediction tool that scores patients in the Michigan Medicine ED within about two hours of their arrival and rates them as likely to be discharged, likely to be admitted, or marginal, Dr. Khateeb said. “We're going to start using that as an additional tool to identify patients that need to be screened to make it more efficient for the dedicated triage hospitalist,” she said.