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Instead of adding beds, one can also add a hospitalist to
focus on bed management, as per the study from Johns
Hopkins (41). Having a hospitalist in this role decreased the
throughput
time for admissions by 100 minutes, and also
resulted in a decrease in ambulance diversion.
Another potential solution is to place a provider in triage.
The cost versus benefit analysis, however, is unclear and
would need to be explored prior to implementation (42).
Analyzing
throughput
and ensuring that staff are scheduled
appropriately is another potential solution. Optimizing
staffing to ensure that the department is appropriately
resourced at the times when patient flow is highest is a
common-sense solution to flow and resource issues. This
applies to physician providers as well as nursing staff (43).
B. Solutions external to the ED
Effective solutions are measured by their ability to increase
capacity. The most established of these is smoothing of
elective cases, early discharge of inpatients, and enhanced
weekend discharges. There must also be a plan which maxi-
mizes patient safety during times of over-capacity.
Smoothing of elective cases
In general, improvement of capacity will reduce boarding.
A variety of mechanisms, including smoothing of elective
admissions and early discharge, will improve boarding. Much
work has been done on the impact of elective scheduling of
surgical admissions, demonstrating a profoundly negative
impact on overall flow and boarding (see data from the Insti-
tute of Healthcare Optimization:
http://www.ihoptimize.org).
Smoothing of elective cases has led to a substantial decrease
in boarding and diversion, and improved availability of both
floor and ICU beds. The impact of smoothing has raised the
question of whether inadequate capacity is actually a real
problem, or an artificial one driven by the vagaries of the
elective schedule, in conjunction with the limited services
available and lack of discharges on weekends. Rathlev, et
al., demonstrated the impact of elective scheduling on
boarding and flow in the ED (44). Early discharge of inpatients
According to one study, early discharge would decrease
boarding by 96% (45) In most institutions, the result would
likely not reach that magnitude however it would make a
big different in bed access during peak times of admissions
from the ED. At New York Univeristy, increasing the number
of patients discharged before 12pm resulted in an overall
decreased LOS. Their efforts were driven by the finding that
admitted patients who made it to the inpatient unit before
noon had an average LOS 0.6 days shorter than those arriving
after noon. Insofar as early discharge results in early move-
ment of admitted boarders to the inpatient unit, the ED will
have greater capacity to treat patients as flow increases later
in the day.
Increasing weekend discharges
As noted above, the decreased number of admissions on
weekends is offset by the decreased number of discharges.
Increasing weekend discharges can substantially increase
available capacity as the week begins. Insofar as this may
require resources often not available on weekends, such as
echo, MRI, and stress testing, increasing services on week-
ends means less demand during the week. As such, this
can be accomplished not by additional staff, but simply by
redistributing some to the weekends.
Full capacity protocol
Financial needs dictate that hospitals must run at near full
capacity. As such, one should expect that capacity can be
exceeded on a fairly regular basis. Thus, some kind of full
capacity protocol (FCP) is needed. One such solution is to
move ED hallway patients to inpatient hallways.
Viccellio, et al., published one institution’s experience with
2000 patients placed on inpatient units in hallways, and
concluded that the practice is safe (46).
A subsequent study from Stony Brook University (pending
publication) documented that close to 90% of patients
who actually experienced placement in both ED and inpa-
tient corridors preferred the inpatient hallway rather than
remaining in the ED. A study from the University of Penn-
sylvania correlated an inverse relationship between overall
patient satisfaction and overcrowding. In a survey study,
Garson, et al., also demonstrated a strong patient prefer-
ence for being on the inpatient service rather than boarding
in the ED (48)
Processes that do not improve capacity
There are a multitude of smaller process improvement
opportunities within the ED, and within the institution.
Examples include improving nursing report, rapid bed
cleaning and turnaround, etc. Although these have value,
institutions often choose to focus on the “low hanging
fruit” which ultimately do nothing to improve the problems
patients face from boarding, but distract from the funda-
mental problem.
It is also important to note that the smoothing of elective
admissions, early discharge, and weekend discharge, by
improving flow and capacity, make it safer for the patient,
easier on the staff, and better for the financial bottom line.
These solutions do not require that anyone work harder, but
it does require that they work differently.
[EMERGENCY DEPARTMENT (ED) OVERCROWDING: EVIDENCE-BASED ANSWERS TO FREQUENTLY ASKED QUESTIONS -Salway RJ MD et al]