Edward S. Bessman

Active bed management by hospitalists and emergency department throughput.

Context Can hospitalists help decrease crowding in emergency departments? Contribution This prepost case study describes a quality-improvement partnership between hospitalists and a university-affiliated emergency department. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to particular units. After implementing the program, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours that the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6% and 27%, respectively. Implication A hospitalist-led bed management program improved emergency department throughput and ambulance-diversion status. The Editors The Institute of Medicines 2006 report, Hospital-Based Emergency Care: At the Breaking Point, is explicitthere is a crisis in U.S. emergency departments (1). Ninety-one percent of emergency departments are crowded beyond capacity (1). Emergency department crowding often results in ambulance diversion: the practice of redirecting ambulances destined for a crowded emergency department to another facility. Diverting ambulances prolongs the lead time until therapy can be initiated and has been associated with increased mortality rates (2). In 2003, ambulance diversion occurred nationwide at the rate of 1 ambulance every minute (3). The primary cause of emergency department crowding is inpatient boarding, that is, holding admitted patients until a hospital bed becomes available. This procedure not only reduces patient satisfaction but also may negatively affect patient outcomes and quality measures (48). Most of the 12 recommendations in the Institute of Medicines report concentrated on factors within emergency departments and ways in which emergency departments interface with the larger health care system. However, 1 strategy focused on hospital processes and efficiency as a way to ameliorate crowding (1). Hospitalist physician groups, internists specializing in the care of hospitalized patients, are now ubiquitous (9). By the nature of their work in coordinating patient care from admission through discharge, hospitalists are uniquely positioned to effectuate efficiency. Our group of hospitalists partnered with the emergency department to address the problem of crowding in our emergency department. We describe the effect of our hospitalist-run service called active bed management. The primary objective of this service was to facilitate the safe transfer of patients from the emergency department to the appropriate inpatient clinical setting. Methods Setting and Design This study took place at Johns Hopkins Bayview Medical Center, a 335-bed university-affiliated medical center in Baltimore, Maryland. The emergency department is a designated level-II center for adult trauma, adult burn, and primary stroke. With capacity for 30 primary treatment rooms, the emergency department registered 54607 visits in the fiscal year ending June 2007. Historically, approximately 25% of the patients registered in the emergency department are admitted, which forms 61% of the hospitals total admissions. Roughly 75% of department of medicine admissions come from the emergency department, totaling approximately 9700 patients annually. The hospitalist division had 14.7 full-timeequivalent physician faculty, 3.0 nurse practitioners, and 4.6 physician assistants at the time of the study. In Maryland, the controlling authority for emergency medical services is the Maryland Institute for Emergency Medical Services Systems. It has defined 2 levels of ambulance diversion. First, an emergency department is put on yellow alert when experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely. During this period, the Emergency Department requests that absolutely no priority II or priority III patients be transported to their facility. Second, red alert is the designation used when a hospital does not have any electrocardiography-monitored or critical care beds available. During red alert, patients who are likely to require this type of care are not to be transported to the emergency department; instead they are taken to the next closest appropriate hospital (10). These distinct alerts can be invoked separately in coordination with Maryland Institute for Emergency Medical Services Systems, which keeps a record of all alerts for all institutions in Maryland. Using a prepost design, we compared the relevant institution-level clinical data from the intervention period (November 2006 to February 2007) with data from the control period (November 2005 to February 2006) (Figure 1). This study was exempt by the institutional review board. Figure 1. Study flow diagram. JHBMC = Johns Hopkins Bayview Medical Center. Active Bed Management Intervention Before active bed management, the emergency department assigned patients who were admitted to 1 of 5 department of medicine admission services (cardiac intensive care unit [ICU]; medical ICU; and cardiology, pulmonary, and general medicine units). For all units except the general medicine unit, once the department of medicine house officer or a physician assistant was informed of the proposed admission by emergency department personnel, they were expected to evaluate the patient in the emergency department and initiate the transfer to the assigned hospital unit. For the general medicine unit, patient assignments were communicated from the emergency department through a page to a triage physician (hospitalists from 8 a.m. to 8 p.m. and house officers overnight), and once accepted, transfers from the emergency department to the medical floor occurred without in-person evaluation by the department of medicine. Active bed management, done in 12-hour shifts, is coordinated and staffed solely by the hospitalist service 24 hours a day, 7 days a week. All hospitalists in the division rotate through the active bed management role, and the active bed management physician is freed from all other clinical care duties so that his or her only clinical responsibility is facilitation of the active bed management processes. Active bed management was strategically designed around 3 fundamental elements: proactive management of department of medicine resources, evaluation and assignment of all departmental admissions, and mobilization of additional resources by the bed director. Proactive Management of Department of Medicine Resources The active bed management hospitalist assesses bed availability in real time for 2 ICUs (12 beds each), the intermediate care unit (3 beds), 2 subspecialty units (cardiac and pulmonary), and the 4 large general medicine units. These continuous assessments are designed to identify potential resource shortages, such as limited ICU beds, before they occur. Assessments are done through collaboration with unit-specific attending physicians, nursing supervisors, and charge nurses in real time, as well as through twice-daily prediversion rounds in the ICUs. Prediversion rounds provide the ICU teams with information on hospital bed status and identify patients who can be downgraded from critical care status and transferred to nonintensive care settings. Prediversion rounds also serve to collect accurate bed information to allow collaboration between the active bed management hospitalist and emergency department physician on patient flow. Evaluation and Assignment of New Admissions to Department of Medicine Inpatient Clinical Settings The active bed management hospitalist makes collaborative triage decisions about the optimal clinical setting for each patient who requires admission through consultation with all admitting physicians (predominantly emergency department physicians) initially by telephone. Pertinent clinical data are documented on a triage template, and the hospitalist then decides about the need to evaluate selected emergency department patients directly. Authority to make determinations on the assignment of patients to beds in the various services in the department of medicine has been granted to the active bed management hospitalist by the department chairman. Once the hospitalist accepts the admission, the emergency department attending writes brief admitting orders from preexisting order sets. Non-ICU admissions are transferred to the inpatient floor as soon as a bed is available. The receiving medical teams are notified about patients on initial triage and on their arrival to the inpatient unit. Intensive care unit admissions are transferred to the unit no longer than 90 minutes after the disposition decision has been made. This brief period allows ICU teams time to ready themselves and stabilize other patients (if necessary) while facilitating the timely transfer of critically ill patients out of the emergency department. Role of the Bed Director The bed director position was created as part of this intervention to support the active bed management hospitalists. The bed director is the hospitalist leader on call (either division chief or associate division chief). The active bed management hospitalist notifies the bed director if the hospital is put on red or yellow alert, if an alert seems to be looming, or if emergency department throughput for admitted patients is long and resultant crowding is occurring. The bed director has the authority to activate additional resources, both internal and external, to the department of medicine to address such issues in real time. Some resources available to the bed director to shorten delays in throughput and prevent ambulance diversion include calling in additional hospitalists, redirecting admissions to departments outside of medicine, and assigning medical admissions to nondepartment of medicine inpatient beds (where they will be cared for by the hospitalists). The Johns Hopkins

Hospitalists and an Innovative Emergency Department Admission Process

After treatment in an emergency department (ED), patients often wait several hours for hospital admission, resulting in dissatisfaction and increased wait times for both admitted and other ED patients. We implemented a new direct admission system based on telephone consultation between ED physicians and in-house hospitalists. We studied this system, measuring admission times, length of stay, and mortality. Postintervention, admission times averaged 18 minutes for transfer to the ward compared to 2.5 hours preintervention, while pre- and postintervention length of stay and mortality rates remained similar.

Evidence-based diagnosis and thrombolytic treatment of cardiac arrest or periarrest due to suspected pulmonary embolism

When a previously healthy adult experiences atraumatic cardiac arrest, providers must quickly identify the etiology and implement potentially lifesaving interventions such as advanced cardiac life support. A subset of these patients develop cardiac arrest or periarrest due to pulmonary embolism (PE). For these patients, an early, presumptive diagnosis of PE is critical in this patient population because administration of thrombolytic therapy may significantly improve outcomes. This article reviews thrombolysis as a potential treatment option for patients in cardiac arrest or periarrest due to presumed PE, identifies features associated with a high incidence of PE, evaluates thrombolytic agents, and systemically reviews trials evaluating thrombolytics in cardiac arrest or periarrest. Despite potentially improved outcomes with thrombolytic therapy, this intervention is not without risks. Patients exposed to thrombolytics may experience major bleeding events, with the most devastating complication usually being intracranial hemorrhage. To optimize the risk-benefit ratio of thrombolytics for treatment of cardiac arrest due to PE, the clinician must correctly identify patients with a high likelihood of PE and must also select an appropriate thrombolytic agent and dosing protocol.

Impact of antibiotic choices made in the emergency department on appropriateness of antibiotic treatment of urinary tract infections in hospitalized patients

BACKGROUND Overuse of antibiotics to treat urinary tract infections (UTIs) is common in hospitalized patients and may begin in the emergency department (ED). METHODS For a 4-week period we reviewed medical records of all patients admitted to the hospital who initiated treatment for a UTI in the ED. RESULTS According to study criteria, initiation of antibiotics was inappropriate for 55 of 94 patients (59% [95% confidence interval {CI}, 48%-69%]), and continuation after admission was inappropriate for 54 of 80 patients (68% [95% CI, 57%-78%]). CONCLUSION Failure to reevaluate the need for antibiotics initiated in the ED to treat UTIs may lead to overuse of antibiotics in hospitalized patients.

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.

Factors Associated With Emergency Department Length of Stay for Patients With Hip Fracture

Time to surgery, which includes time in the emergency department (ED), is important for all patients with hip fracture. We hypothesized that patients with hip fracture spend significantly more time in the ED than do patients with the top 5 most common conditions. In addition, we hypothesized that there are patient, physician, and hospital factors that affect the length of time spent in the ED. We retrospectively reviewed our institution’s hip fracture database and identified 147 elderly patients with hip fractures who presented to our ED from December 18, 2005, through April 30, 2009. We reviewed their records for patient, practitioner, and hospital factors of interest associated with ED time and for 6 specified time intervals. Average working, boarding (waiting for an inpatient room), and total times were calculated and compared with respective averages for admitted ED patients with the top 5 most common conditions. Univariate and multivariate analyses were performed before and after adjusting for confounders (significance, P = .05). The mean total ED time (7 hours and 25 minutes) and working time (4 hours and 31 minutes) for patients with hip fracture were similar to the respective overall averages for admitted ED patients. However, the average boarding time for patients with hip fracture was 2 hours 44 minutes, longer than that for other patients admitted through the ED. Factors significantly associated with longer ED times were a history of hypertension, history of atrial fibrillation, the number of computed tomography scans ordered, and the occupancy rate. Admission to the hip fracture service decreased working time but not overall time. Substantial multidisciplinary work among the ED, hospital admission services, and physicians is needed to dramatically decrease the boarding time and thus the overall time to surgery.

Pathophysiology and Treatment of Acute Myocardial Ischemia and Infarction

Atherosclerotic vascular disease has been present in humans for thousands of years. Atherosclerotic lesions were identified in Egyptian mummies dating as early as the 15th century B.c. In the 19th century, researchers speculated that arterial wall injury may cause an inflammatory response, resulting in atherosclerotic lesions (1). By the early 1900s investigators had proposed a correlation among the degree of atheroscle-rotic lesions, acute myocardial infarction (AMI)*, and stroke (2). The prevention and treatment of coronary artery atherogenesis is a major public health concern today (3).