Emergency Medicine News:
Welch, Shari J. MD
Part 1 in a Two-Part Series
For decades, hotels have managed their rooms using information technology to the fullest, employing efficient models for room turnover. Though unscheduled hotel stays are not as frequent as unscheduled patients presenting to the ED, their operational model has something to say to the emergency department and the hospital at large.
While providing the most advanced care in the world, health care delivery consists of layer upon layer of inefficient and poorly articulated processes. Even today, many large hospitals have little IT support for bed management. In fact, at many sites, bed management still consists of a person, frequently a nurse, with a whiteboard and a clipboard in a windowless room. This bed controller may troll the wards looking for unreported empty beds. Compare this with the hotel industry with its up-to-the-minute and increasingly granular data on checkouts, housekeeping status, and room occupancy.
According to the Emergency Department Benchmarking Alliance (EDBA; www.edbenchmarking.org), almost 80 percent of EDs spend part of every day over capacity. Several years of research to define crowding scales and crowding measures have given way to an approach that instead looks for solutions to the problem. Most frontline practitioners agree that the definition of crowding is, like pornography, that you know it when you see it. No measurements are required. But undoubtedly the clearest cause of crowding is boarding admitted patients in the ED. Currently more patients are admitted through the emergency department than from any other patient stream. Sixty-six percent of patients occupying inpatient hospital beds nationwide were admitted through the ED. As more and more communities go to a hospitalist model for inpatient care, the patient's health care journey will increasingly begin in the ED.
When emergency departments are forced to board admitted patients, a number of unintended and dangerous consequences are observed. The Centers for Disease Control and Prevention found that more than 10 percent of patients waited more than an hour to be seen when the ED was crowded due to boarding. With so many diagnoses on the clock in terms of optimum care, this is not an acceptable constraint for emergency departments. Boarding increases patient walkouts and lengthens stay by a full day for the patient eventually admitted. Critical care patients who spend more than six hours in the ED show an increased length of stay and higher mortality rates. When boarding causes crowding, everything increases: ambulance diversion, medical liability cases, financial losses to hospitals and physicians, and medical errors.
Getting a patient admitted involves a team of people doing coordinated tasks, usually in series rather than in parallel. Consider the steps involved and who is responsible for each, and you can see the lack of coordination for these tasks in most hospitals: Find an attending (EP); request a bed (ED flow coordinator or charge nurse); bed assignment and management (bed czar); clean room (Housekeeping); admission paperwork and packet (Registration); report to floor (patient care nurse to floor nurse); admission orders (admitting physician); and transport (transport team).
Look at the sheer number of steps in the admission process. Is it any wonder that it is fraught with waits and delays? And remember that the handoff is one of the most dangerous things that will happen to a patient. Do any of these people involved in the process communicate with one another? Can you imagine a coordinated and seamless process?
At Caesar's Palace in Las Vegas, an electronic tracker follows room turnover. Checkouts from the front desk are cued on the tracker to alert housekeeping that rooms may be cleaned. Each housekeeper dials in at the start of servicing a room, and logs out when the work is finished, providing a granular database about these services and allowing for accountability by housekeeping staff. (By the way, to resolve communication and language barriers, Caesar's uses a laminated photograph book to show the housekeepers exactly how to arrange the towels, coffee station, and drapes for uniform room appearance.) By comparison, ED admission processes are seldom as standardized, and the full incorporation of technology into the process is just starting across the country. Inefficiencies in the admission process are all compounded by having to reach an attending for admission orders, by the archaic practice of having residents perform workups in the ED, and by the need for paperwork to be processed at almost every step in the game.
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