The first time an ED director hears it, he'll think it is heresy. Many leaders concerned with patient flow, like Michael Hill, MD, of EMPATH, a consulting firm specializing in change management in the ED, observed, “If you are not looking for solutions to ED patient flow on the inpatient side, then you are not looking in the right places.”
For many ED directors, this is uncharted territory. Most emergency physicians concerned with quality improvement have used data to improve ED processes and operations, providing data to health care providers through feedback loops. Most involved in this work have had success, but have focused overwhelmingly on the ED and its processes. It has not been part of the culture to consider that crowding and patient flow could be addressed from the inpatient side of the hospital as well.
How do you know if you have crowding and flow problems? Certainly you know it when you see it, but there are measures and markers for crowding. The General Accountability Office used these markers: hours on diversion, boarding patients in the ED, and patients leaving before treatment was complete. (Report to the Ranking Minority Member, Committee on Finance, U.S. Senate, “Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities,” GAO Report 2003.)
Other markers include capacity and parking. According to the Institute for Healthcare Improvement, if more than two percent of admitted patients are parked at least 50 percent of the day, the hospital is crowded. (Institute for Healthcare Improvement. “Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings.” Innovation Series 2003.) And if the midnight census is 90 percent or more, there also is great risk for crowding. (See table above.)
The exact arrival time, acuity, resources, and admission rate present us with clinical variability and flow variability. Providers vary in their ability to care for these diverse clinical pictures. The only way this variation can be controlled is if all patients had the same clinical problem and acuity, patients arrived at the same rate every hour, and all providers were exactly the same.
The way patients arrive presents us with random variability that cannot be controlled, reduced, or eliminated. It can be predicted, however, and many centers are building models to do just that. On the other hand, there is nonrandom variability that not only cannot be managed but cannot be eliminated. Surgical schedules, for example, frequently are aligned for surgeon's operating preferences and can be managed to eliminate nonrandom variability. In addition, discharges and flow into the community can be better managed to eliminate variation.
Some innovative facilities study the variability from all sources and control what they can. For instance, the operating room schedule can be adapted to accommodate the ED in several ways. Some facilities hold one OR open for emergencies, especially if the facility is a trauma center. Others schedule only 90 percent of OR time.
If more than 10 percent of a hospital's surgeries are emergent, this is absolutely necessary. According to Kirk Jensen of the Institute for Healthcare Improvement, the ability of a system to function in response to variation is exceeded when the system is operating at above 90 percent capacity. (See figure below.)
Another innovation being used is appointing an inpatient bed czar and an ED patient flow coordinator. The bed czar manages and ensures timely movement of patients to inpatient beds and movement out of the facility to chronic care beds, and coordinates transfers (the open inpatient bed is rapidly turned over and filled by an ED or ICU patient).
Similarly on the ED side, the patient flow coordinator monitors flow in the ED. This is a new role for the charge nurse who trades clinical duties for monitoring patient flow and identifying bottlenecks and delays. Both the bed czar and the patient flow coordinator have been associated with increased efficiency. (Urgent Matters. “Best Practices: Redesigning the Charge Nurse Role to Manage Patient Flow.” 2005;2; www.urgentmatters.org/enewsletter/vol2_issue2/BP_pfc.asp.)
The movement of patients out of the hospital also has been facilitated by a number of creative processes. The development of discharge teams and discharge units has a positive effect on flow in some settings. Patients vacate their rooms to go to a lounge where discharge specialists review plans for follow-up, review medications, and contact family members.
The day-ahead discharge protocols also help expedite discharge. Some institutions mandate 11 a.m. discharge, and have doctors anticipate and write discharge orders the day before. Some hospitals also are changing rounds to focus on potential discharges, and yet others offer incentives to physicians for early discharges.
According to the GAO, 69 percent of hospital EDs were overcapacity at some time in 2001, and the data were even worse for urban hospitals and trauma centers. When there are more patients than beds in the ED and some of these beds hold admitted patients, certain medical centers (Stonybrook, Duke, and Beaumont, to name a few) are exercising what has been dubbed the full-capacity protocol.
This plan involves transporting patients to inpatient hallways for admission. (www.viccellio.com/overcrowding.htm.) This policy is gaining national attention and support because it clearly helps patient flow in the ED. Its popularity is being fueled by the unexpected finding that patients admitted to hallway beds instead of ED beds have lengths of stay a full day shorter than those held in ED hallways.
An even newer and more exciting concept is the possibility of extending the chain of flow improvement into the community. Some institutions are working to smooth the transfer of chronic ventilator patients off the unit. In one case, a nursing home opened a ventilator unit staffed by the hospital's intensivists. Another innovation has been called open access, in which discharged patients are given timely follow-up in doctors' offices after an inpatient stay.
In short, patient flow can be approached two ways in the ED: by improving ED processes and operations for maximum efficiency and by studying every ED interface within the institution and changing inpatient processes to improve flow into the hospital. These solutions will be new to many emergency physicians, but should be enthusiastically embraced.
Inpatient Flow Initiatives
- ▪ Adaptive OR schedule
- ▪ Open OR for emergency surgeries
- ▪ Bed czar
- ▪ Discharge services: teams, lounges
- ▪ Coordinated transfers
- ▪ Day-ahead discharges
- ▪ Mandatory 11 a.m. discharge
- ▪ Targeted discharge rounds
- ▪ Open access scheduling
- ▪ Chronic care discharge planning
Markers for Crowding
- ▪ Days on diversion
- ▪ Boarding (days in the ED)
- ▪ Parking more than two percent of admitted patients more than half the time
- ▪ Midnight census greater than 90 percent
- ▪ Left before treatment complete (more than 2%)
Source: „Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities,“ General Accounting Office Report 2003.)