The Development and Implementation of a Direct Admission System at a Tertiary Care Hospital

Abstract

Health care reform and changes in the levels and models of reimbursement have resulted in hospitals focusing on effi ciency and examining patient fl ow, especially in emergency departments (EDs). Improving the throughput of patients in the ED has been addressed in various ways, including the development of direct admission systems in which patients needing admission but not emergent care can bypass the ED altogether. The development process of such systems has not been addressed in the medical literature. We review the development and implementation of a direct admission system at a tertiary care hospital, including a review of existing direct admission systems. Our new direct admission system replaced a confusing, ill-defi ned process that was a perceived and later survey-confi rmed source of frustration for all involved and a source of resource waste and delays in care. This study also highlights a collaborative process among hospital personnel, including hospitalists, to address hospital effi ciency in a meaningful way. The described process can be generalized to other hospitals.Hospitals are under increasing pressure to improve the effi ciency of health care delivery, 1 especially in light of national health care reform 2 and its impact on hospital reimbursement, 3 notably a de-emphasis on fee-for-service payment and a movement toward payment based on the quality of the care provided rather than on the quantity of care provided. 4 The emphasis on effi ciency has necessitated an assessment of hospital admission and occupancy patterns in an effort to optimize patient fl ow (movement of patients into, between, and out of hospital departments and/or units). 5,6 Enhancing patient fl ow is of particular importance to emergency departments (EDs), where patient overcrowding has been recognized as a signifi cant problem diminishing ED care delivery capabilities 7 and decreasing patient satisfaction. 8,9 Patients in the ED awaiting admission reduce overall ED throughput. 10,11 This is being addressed in a variety of ways, including streamlining admission procedures with the creation of innovative admission protocols 12,13 and new hospital units such as observation units 14,15 and "fast-track" units. 16,17 However, there is a paucity of literature describing the development and use of a process to improve patient fl ow in the ED by the direct admission of patients to the inpatient setting, bypassing the ED entirely.Our hospital recognized an opportunity to optimize a portion of patient fl ow by creating a formalized system for the direct admission of patients to the inpatient setting. The opportunity for improvement became apparent from anecdotal direct admission process concerns voiced by ED and referring physicians and from a survey of referring physicians, who acknowledged that many patients felt to need admission but not emergent care were unnecessarily being sent to the ED.The objective of our quality improvement study was to design and implement a direct admission system to improve patient fl ow and referring phy...

Before the Flood

“…One such strategy is the use of a central call center to gather clinical data and triage patients referred to pediatric medical centers (7). Additionally, call centers provide an opportunity to coordinate discussions between multiple subspecialists at the onset of the transfer process, allowing them to develop clinical care plans and address logistics of transfer.…”

Pediatric ED Saves: Analyzing the ED Screen of Direct Admissions

“…Standard of care practice should be to obtain and document a patient’s chief complaint, vital signs, physical examination, and given interventions when accepting and evaluating a patient. 10,11,17 Although this was not part of this study’s aim, comparing this documentation to a patient’s evaluation upon ED arrival would be a helpful assessment of clinical deterioration before admission and the need for immediate intervention or PICU care.…”

Improving Direct Admissions to Internal Medicine Services

“…6,7 Of the available research, there have been only a handful of studies focused on quality improvement initiatives for DAs. The studies had varying process interventions including implementing a call center, 8 creating a standardized process that included communication with a designated medical admitting resident, 9 and creating a DA module to gather intake information, 10 with modest improvements in physician satisfaction and patient safety measures. More work is needed to evaluate and guide DAs, especially encompassing handoffs and communication that can be broadly implemented in complex care settings.…”