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Making Room
A Hospitalist-led program at Bayview shows how better bed management can keep patients—and ambulances—coming.

blank Ed Bessman and Eric Howell oversee “active bed management.”
Ed Bessman and Eric Howell oversee “active bed management.”

In the not-so-old days, a frail nursing home resident could stay as long as eight hours in the Emergency Department at Johns Hopkins Bayview Medical Center and see several physicians before being assigned a hospital bed. At other times, poor communication about available beds in the intensive care unit caused intubated patients to wait in the ED unnecessarily, while ambulances that would normally take cases to Bayview were diverted to other hospitals.

When Emergency Department
Director Ed Bessman and hospitalist Eric Howell saw how overcrowding was delaying care and sending some patients elsewhere, they developed a solution called “active bed management.” This hospitalist-led strategy aims to find room for patients admitted from the ED by closely monitoring and managing bed usage across several units.

As they detailed in a report that appeared last December in the Annals of Internal Medicine, their approach quickly made an impact. In the first four months after the program was launched in October 2006, the average time that ED patients waited for a bed dropped by 98 minutes. As of December, the average wait time had dropped from 7 hours, 30 minutes to 5 hours, 13 minutes—a decrease of about 30 percent. More dramatic is the reduction of ambulance diversions due to shortages of ICU beds: from 2,025 hours a year to 50 hours.

In the program, hospitalists take turns working 12-hour shifts, during which time their sole duty is to proactively monitor and manage the use of beds. Their activities include making twice-daily rounds in intensive care units, frequently visiting the ED to evaluate the congestion and flow of patients, and deciding the best clinical setting in the Department of Medicine for each patient requiring admission. If they need extra help, the hospitalist leader on call, known as the “bed director,” can assign medical admissions to beds outside the Department of Medicine and call in additional hospitalist staff. The program runs 24 hours, seven days a week.

An important part of the program is anticipating bed shortages in ICUs. “Prediversion” rounds, designed to prevent ambulance diversions, often open up beds by identifying patients who can be transferred to nonintensive care settings.

Implementing this system required an unusual degree of cooperation between the hospitalists and health care providers in Bayview’s two intensive care units, the intermediate care unit, the cardiac and pulmonary units and four large general medicine units.

The cultural shift required at Bayview developed gradually. In 2000, hospitalists implemented a system of direct telephone triage to the ED that helped relieve the congestion and decrease the throughput time to the general medicine service during the day. Howell and Bessman convinced the administration to build on the service, include other units, and make it around the clock in October 2006.

“Each of the divisions had to cede authority to Eric to make decisions as to where patients should go,” Bessman says. “It took slow and steady pressure to change when no one else had done it.”

Bayview’s ED handled roughly 58,000 patients last year. Of those, about a quarter were admitted, a population that formed roughly 60 percent of the hospital’s overall admissions.

Howell figures that active bed management has saved the medical center at least $2 million from decreased ambulance diversion; each hour of diversion means at least $1,000 of lost revenue. (Those benefits are partially offset by the salary and benefits for the two and a half additional hospitalist positions needed to run the program. Howell estimates those costs “generously” at $500,000.) Improved patient flow has also brought roughly 3,000 more patients a year to the ED.

“We are victims of our own success,” Howell says. “Increasing the efficiency of the hospital means more ambulances, along with more patients. It used to be we couldn’t get patients up fast enough. Now that we can, the hospital’s capacity has reached its limit.”

But this time, he says, the problem is making room for more beds.           

—Linell Smith



Johns Hopkins Medicine

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