Introduction
At UNM Hospital, ~50% of patients are admitted to the Internal Medicine (IM) service. Significant delays occur at the time of admission. These delays contribute to numerous downstream consequences, including poor patient care, increased hospital complication rates, decreased patient and provider satisfaction, and increased patient length of stay. IM admission times are calculated as the time between the ED “Consult to Inpt Medicine” order and the IM “Admit/Observation Order” (for which the IM “Bed Request” can serve as a surrogate). Median and average admission times are 4 hours 42 minutes and 5 hours 50 minutes, respectively. According to Hospital Compare, UNM is a one star facility. Admission delays contribute to this poor rating under “Timely and Effective Care” sub-category. By 8/1/2020, this project aims to decrease the time between the EM “Consult to Inpt Medicine” and IM admission order set to less than 2 hours on average.
Intervention
The Internal Medicine department staffed a new Triage Hospitalist position on eight days between November 1st and December 31st 2019. The Triage Hospitalists are responsible for the expedited evaluation and admission of ED patients, the clinical care of ED patients awaiting admission to IM, the evaluation and transfer of patients from critical care and surgical services to IM, and the distribution of new patients and transfers to the different IM services. Qualitative feedback on pilot program strengths and weaknesses was collected from ED and IM clinicians throughout the pilot via REDCap. On pilot days, the Triage Hospitalist recorded multiple data points using REDCap, including patient name, MRN, patient arrival time, “Consult to Inpt Medicine” order timestamp, start time of attending to attending handoff, estimated duration of attending to attending handoff, final admission decision, and “Bed Request” order timestamp. Retrospective chart review identified “Admit/Observation” timestamp, “Discharge Patient” timestamp, and recidivism. Adhering to the Plan-Do-Study-Act framework, data prompted continuous pilot improvement. Exemplar changes include requiring an attending to attending handoff for admissions, requiring the “Consult to Inpt Medicine” order being placed before the attending to attending handoff starts, and integration of TigerConnect into the ED IM communication pathway. Now fully implemented, the triage hospitalist position will be staffed by an IM attending physician from 7am-10pm between January 1st and June 30th, and 24 hours per day thereafter.
Results
75 patients were evaluated by the Triage Hospitalist during the 8 pilot shifts. The “Consult to Inpt Medicine” order was placed by the ED 28.6% of the time. Maximum delay between “Consult to Inpt Medicine” order timestamp and start time of attending to attending handoff was 7 minutes. Average duration of the attending to attending handoff was 3.41 minutes. Attending to attending handoff occurred at the patient’s bedside 60.7% of the time. Average time from ED’s “Consult to Inpt Medicine” order to IM “Bed Request” order was 40 minutes. Median and average time between IM “Bed Request” and the IM “Admit/Observation Order” was 1 hour 50 minutes and 2 hours 22 minutes, respectively. 56 (75.7%) patients were admitted to IM and 16 (24.3%) patients were dispositioned elsewhere. 5 patients (6.7%) were discharged from IM the following day. 1 patient (1.3%) was transferred to another service following admission to IM. 1 patient (1.3%) was re-admitted within 72 hours of discharge from IM. Qualitative feedback from ED and IM clinicians was overwhelmingly positive
