Bringing hospital medicine to the ED

A hospitalist-led boarder service reduced length of stay.


Background

In a perfect system, admitted patients would immediately start receiving an inpatient level of care, not wait for hours in the ED. But most hospitals are not perfect. “Due to the lack of bed capacity, we often found that we couldn't give that to them,” said hospitalist Kimiyoshi J. Kobayashi, MBA, MD.

Instead, hospital medicine teams at Mass General were covering boarders on an as-needed basis, a less-than-optimal solution, he said. “That's why we decided in conjunction with our emergency medicine colleagues to implement a system that was more comprehensive.”

As director of inpatient medicine for the department of medicine, Dr. Kobayashi, along with other leaders, supported the creation of a 24/7 hospitalist-led ED boarder service.

How it works

During the day, the boarder service has at least one attending hospitalist physician and two to three advanced practice practitioners. Two to three hospitalists usually provide nighttime coverage. The service has eight bays (mostly stretchers separated by curtains) within a section of the ED, and the team works side by side with ED nurses and physicians, said Dr. Kobayashi.

“Frankly, the census for the ED boarder service was always high enough that the ED leadership decided to create a dedicated area,” he said. “And oftentimes, [the hospitalists] would actually have to care for patients outside of that dedicated area.”

Two hours after a bed is requested, a patient still in the ED becomes eligible to be covered by the service. The patient either stays in the same ED bay or moves to the ED boarder section, with the boarder team taking over care. (Patients can be eligible for ED boarder care but not receive it due to such factors as the clinician census of the boarder team, anticipated availability of an inpatient bed, and clinical appropriateness.) Once an inpatient bed becomes available, the patient is transported and handed off to the inpatient team.

Results

From July 1, 2016, to June 30, 2018, Dr. Kobayashi and colleagues retrospectively compared ED and total hospital length of stay (LOS) among 16,668 admitted patients in three categories: nonboarders who received an inpatient bed within two hours of a bed request (12%), boarders covered for any length of time by the ED boarder service (53%), and boarders not covered by the ED boarder service (35%).

Not surprisingly, nonboarders had a lower ED LOS (5.6 hours) than covered boarders (20.7 hours) and noncovered boarders (10.1 hours), according to results published online in November 2019 by the Journal of Hospital Medicine. The ED boarder team focused on caring for patients who were likely to have a long LOS in the ED, Dr. Kobayashi noted. While nonboarders had the shortest total LOS (4.76 days), covered ED boarders had a significantly lower total LOS than noncovered boarders (4.92 days vs. 5.11 days). “We believe [this] supports the notion that the ED boarding team was able to expedite the inpatient care that the patients needed and was able to therefore take advantage of that waiting time,” he said.

Challenges

The service is resource-intensive, with a dedicated nurse manager and nursing team who had to be hired and trained appropriately, as well as additional hospitalists to accommodate the increase in census. There were also expenses for outfitting the ED boarder area, and operationally, the team had to plan handoff, communication, and triage procedures, he said.

Lessons learned

Although not directly addressed in the study, there were educational considerations as well, since residents were used to taking patients from the ED team rather than hospitalists, said Dr. Kobayashi, who is now an assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore. “I think there are both negatives and positives to it,” he said. “On the one hand, it may be a positive that residents received passoff from a fellow medicine provider. . . . On the negative side, obviously, it might be harder to take a fresh look at the case.”

Next steps

The service is still active, and the researchers are now studying its quality of care and best applications. For example, maybe the teams shouldn't aim to cover 100% of boarders, since that might expose patients to unnecessary handoffs, Dr. Kobayashi noted.

Words of wisdom

Launching the service required a lot of collaboration across departments, but hospitalists working more closely with ED colleagues increased collegiality, he said. “I think my biggest piece of advice is rallying around and agreeing at the core that what we're doing is trying to improve the care of patients boarding in the ED.”