Journal of Hospital & Medical Management

Keywords

Geographic localization; Hospital admissions

Commentary

The Department of Medicine of the UNC School of Medicine has 12 inpatient services. Some are teaching services, staffed by a faculty attending and internal medicine residents. The Department also has services staffed only by hospitalists. To optimize team-based care with nursing and other ancillary staff and to maximize efficiency, all services in the Department have a designated geographic home on 1-2 wards in the hospital. Traditionally patients have been admitted to these services by using a centralized hospital bed control centre.

We found that at a census of 80% or lower, the centralized bed control centre was able to assign patients to preserve geographic localization. However, when the census was over 80%, services had patients dispersed throughout the hospital in up to 7 different locations.

The untoward effects were predictable. There was a significant extension of rounding time and lack of coordination with nursing and other ward personnel. Also, discharges were occurring late in the day. For our teaching services with resident work hour limits, this meant that residents were not doing initial workups and were missing teaching conferences.

As we tracked our census data over the last year, we observed that the census norm was 90% or greater and only rarely dropped below 80%. With this realization, the Department of Medicine decided to internalize the admitting and discharge processes rather than rely on the centralized hospital bed control centre. Our belief was that personnel focusing solely on the needs of our patients and staff would create geographic localization with all of its benefits even at constantly high patient censuses. This report describes this process and the outcomes for our department.

The Medical Admitting Officer (MAO)

The Department developed a position designated the Medical Admitting Officer (MAO). The initial MAO was hired from our pool of nursing supervisors. Her experience gave her significant understanding of the working process of admissions, including the challenges of the traditional hospital-based system. To begin, the MAO worked weekdays from 8AM to 5PM.

Her charge was to direct admissions for the Department of Medicine. All physicians, both faculty and residents, were instructed to contact the MAO for all admissions and transfers. Because a significant number of admissions come through the Emergency Room, the ER staff received the same request.

The MAO was also charged with working with inpatient teams to facilitate discharges and to communicate with the hospital bed control centre.

The MAO began at the beginning of an academic year. At that time, the inpatient teams were only 50% geographically localized. Almost immediately the percent regionalization began to improve and by the end of the first month reached 80% for all inpatient teams, both teaching and non-teaching service.

During those months we tracked times of admission and discharge. The average time for both admission and discharge was improved to peaks between 1-3PM daily. In surveying our attending’s and residents we heard repeatedly how much improved the admitting process had become. We also received positive feedback from the ER attending’s and staff. Most importantly our patients voiced appreciation for the facility gained in admission and discharge processes.

Discussion

Recognition of the complexity of the admitting process led us to put in place a designated admitting officer called the medical admitting officer (MAO). In developing this position we considered a number of factors. Perhaps most important was the skill set required. We considered whether a resident or attending physician could function in this role, and we concluded that a resident would have mixed feelings as he/she would be assigning patients to peers. The same could be said for attending physicians. Furthermore, residents and attending’s may not be familiar with the specific roles other personnel like nursing supervisors, bed control staff, and environmental services staff, play in the admitting and discharge processes.

Our choice of an experienced senior nursing supervisor contributed greatly to the success of the position. Her familiarity with all aspects of the admitting process led to a quick acceptance and appreciation of her role. On weekends and nights, the lack of an MAO was striking. We therefore expanded the role to a total of 5 other individuals with similar backgrounds to provide 24- hour coverage 7 days a week.

Initially the MAO was focused on the staff from the Department of Medicine. Within a few months we appreciated the importance of a liaison role with the Emergency Room staff and our hospital logistics centre. The MAO now meets daily with the staff from these two areas. An unplanned for but critical role for the MAO has been related to the Covid pandemic. Like many departments, we assumed responsibility for the care of many Covid 19 patients. The MAO has been an integral part of the Covid team, coordinating admissions, transfers, and discharge planning for these patients.

The cost of the MAO has been born by the Department of Medicine using revenue from clinical activity. We believe that the significant improvements in patient care and staff wellness more than justify the funding of this position. We would suggest that other departments consider such a position.