Hospitalist's Innovation in ED Is a Plus for Patient Flow

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.