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Improving Patient Care |

Active Bed Management by Hospitalists and Emergency Department Throughput

Eric Howell, MD; Edward Bessman, MD; Steven Kravet, MD, MBA; Ken Kolodner, ScD; Robert Marshall, MBA; and Scott Wright, MD
[+] Article and Author Information

From Johns Hopkins Bayview Medical Center and Johns Hopkins University School of Medicine, Baltimore, Maryland.


Acknowledgment: The authors thank Ms. Cheri Smith, Ms. Regina Landis, Mr. Angel Sampedro, Dr. Roy Ziegelstein, and all the hospitalists and emergency physicians at Johns Hopkins Bayview Medical Center for their involvement in this project.

Financial Support: Dr. Wright is an Arnold P. Gold Foundation Professor of Medicine, and Drs. Kravet and Wright receive support as Miller-Coulson Family Scholars through the Johns Hopkins Center for Innovative Medicine.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Wright (e-mail, swright@jhmi.edu).

Requests for Single Reprints: Eric Howell, MD, Johns Hopkins Bayview Medical Center, Collaborative Inpatient Medicine Service, 4940 Eastern Avenue, Baltimore, MD 21224; e-mail, ehowell@jhmi.edu.

Current Author Addresses: Drs. Howell, Bessman, Kravet, Kolodner, and Wright and Mr. Marshall: Johns Hopkins Bayview Medical Center, Collaborative Inpatient Medicine Service, 4940 Eastern Avenue, Baltimore, MD 21224.

Author Contributions: Conception and design: E. Bessman, S. Kravet.

Analysis and interpretation of the data: E. Howell, E. Bessman, S. Kravet, K. Kolodner, R. Marshall, S. Wright.

Drafting of the article: E. Howell, E. Bessman, K. Kolodner, R. Marshall, S. Wright.

Critical revision of the article for important intellectual content: E. Howell, E. Bessman, S. Kravet, K. Kolodner, R. Marshall, S. Wright.

Final approval of the article: E. Howell, E. Bessman, R. Marshall, S. Wright.

Statistical expertise: E. Howell, K. Kolodner, S. Wright.

Administrative, technical, or logistic support: E. Howell, R. Marshall, S. Wright.

Collection and assembly of data: E. Howell, E. Bessman, R. Marshall, S. Wright.


Ann Intern Med. 2008;149(11):804-810. doi:10.7326/0003-4819-149-11-200812020-00006
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The emergency department and hospital cared for more patients in the intervention period than in the same months for the previous year (Table). Both the emergency department census and the number of hospital admissions increased, such that about 25% of patients presenting to the emergency department were admitted during both periods. Sex and mean age of patients visiting the emergency department were similar in the 2 study periods (Table). The 7 most frequent primary diagnoses among patients who were hospitalized were also the same during the 2 periods: chest pain, congestive heart failure, pneumonia, obstructive chronic bronchitis with acute exacerbation, alcohol withdrawal, acute renal failure, and acute respiratory failure.

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Figure 1.
Study flow diagram.

JHBMC = Johns Hopkins Bayview Medical Center.

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Consequences of active bed management for residents
Posted on December 10, 2008
Sumant R Ranji
University of California San Francisco
Conflict of Interest: None Declared

The active bed management system described by Howell et al appears to significantly reduce residents' opportunities to evaluate and triage patients independently, as an attending physician evaluates all admissions initially. This appears to be a fundamental change in the nature of residency training, but the effect of the bed management system on resident education is not discussed. How did internal medicine residents perceive the system, and was introduction of the system associated with detrimental educational effects?

Conflict of Interest:

None declared

Doctors as Bed Managers Inappropriate Use of Resources
Posted on March 7, 2009
Paul D Bunge
Madigan Army Medical Center
Conflict of Interest: None Declared

In the December 2 Annals, Howell et al present their case for "active bed management." In the intervention, they had hospitalists take turns doing twelve-hour shifts as bed manager, a position usually filled by a senior nurse (1). The bed manager typically coordinates the placement of the new patients from the emergency room and clinics onto the appropriate available ward. This person also tracks patients as they go in and out of the ICU and other units. The bed manager must keep track of all available beds, and negotiate as needed when beds, patients, and staff must be shuffled around to make room. Note that in the intervention, the hospitalists did not do any patient care while they filled this role.

I am not surprised at the result reported: The patients moved around the hospital more efficiently. The time that the patient remained waiting in the ER was shortened (a quality and hospital efficiency goal). The major problem with this intervention is not the result, but the cost: Whatever the possible short-term cost savings to the hospital and short-term benefit to patient comfort, the overall cost to the health care system must be factored in, which is essentially the huge cost of pulling 1/4 of the hospitalist staff out of direct patient care.

I am afraid that I must regard this intervention as both unethical and ridiculous. Unethical ecause "pressure from administration" lead to inappropriately removing doctors from patient care to achieve a financially-motivated efficiency goal. It is the doctor's esponsibility to call foul when the administrator crosses a line and refuses the patient appropriate care. Yet in this intervention, the patients were left to the mid-level providers and others while the doctor was making phone calls.

This intervention is ridiculous in that it is already a waste that so much senior nursing time goes to administrative duties, including the role of bed manager. Are we to have the doctors do this job that would more appropriately be performed by a clerk? When the movement of patients around the hospital is dysfunctional, that is a leadership problem, not a clinical problem.

This article is an unfortunate illustration of some very important points:

1. We have strayed far away from our job, our profession, our calling: patient care. We have left it to a few weary, brave soles who we now call "primary care managers." The rest of us, with no apparent limit, gather specialty or hospitalist status, and make as clean a break as we can from the whole mess. Shame on us! And shame on us for blaming others (the government, the economy, the payment system).

2. We need to question the current band-wagon thinking that there is a shortage of physicians in this country. When our highest levels of medical learning can advocate using doctors as bed managers, we may actually have the opposite problem: an illness of too much. (see Shannon Brownlee's article for a look at this topic: http://www.theatlantic.com/doc/200712/health-care)

3. Common sense needs to find its way back into the hospital. In the days of Oryx measures and JCAHO rules and sub-rules, the doctors of the world must be the ones to bring some wisdom to the table to question quality measures that may actually decrease quality, the multiplication of pointless paperwork, and other like challenges.

Once as a young physician on the way to work, I stopped my car at thescene of an accident. I told the ambulance crew my credentials and asked if they needed my help. One wise EMT told me quite simply: "sir, it probably would be more helpful if you made your way to the hospital where you are needed and see the patients there. We can handle this part." I did just that. Perhaps more of us should do the same.

References

1. Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, and Scott Wright Active Bed Management by Hospitalists and Emergency Department Throughput Ann Intern Med 2008; 149: 804-810

Conflict of Interest:

None declared

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