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Quality Matters

Quality Matters: Innovative Solutions Banish ED Boarding

Welch, Shari J. MD

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Emergency Medicine News: June 2010 - Volume 32 - Issue 6 - p 6
doi: 10.1097/01.EEM.0000381471.61414.b4

    Hospital bed management has a significant effect on the emergency department, with great potential to cause boarding and crowding, but as I noted last month, the hotel industry provides lessons for managing beds. All it takes are some innovative strategies for expediting admissions from the ED.

    As part of a more systematic and comprehensive bed management strategy, Bed Czars are increasingly being assigned to manage bed control. The Bed Czar is empowered to walk the hospital looking for “hidden beds” and to hold the floor charge nurses accountable. When beds are very tight, Bed Rounds can be made to let everyone in the facility know the situation on each unit. Progressive organizations are holding Bed Rounds in the morning so the leadership team can be aware of the status for the day. In extreme cases, surgeries may need to be canceled and procedures delayed. Hospitals also are moving to automated bed management with IT support to help identify open beds and cue housekeeping and transport appropriately.

    One of the most controversial ideas being trialed around the country is the “timed out order.” Some innovative EDs have crafted service-specific generic holding orders that allow a patient to be admitted upstairs without waiting for an attending to leave his office or surgery to write orders. Typically these orders are superficial, time-limited order sets, and offer just enough detail to get the patient upstairs. The best designed sets are approved by the medical executive committee and chiefs of respective services, and become the standard of care for the institution. A number of EDs in the ED Innovation Community at the Institute for Healthcare Improvement trialed this practice with great results. The orders expedited the admission of subsets of patients while allowing attendings a few-hour grace period to get to the hospital and see the patient. It tends to generate good will among the medical staff; they appreciate the attempt to accommodate the work they are doing in their offices or the OR.

    There is no question that hospitalist programs improve patient flow and expedite admissions. The hospitalist, by virtue of being in house, can be more readily reached and therefore can streamline admissions. In the best-run organizations, the hospitalists and the emergency physicians work together to craft flow strategies and guidelines for care.

    Typically, preadmission activities are more clerical and less clinical. By the time a patient is ready to be admitted, the intense diagnostic and therapeutic phase of the ED visit is over. The patient need not continue to occupy an ED bed, and utilize those precious bed minutes that can be put to better use seeing a new patient. As an alternative, some departments have designed an Express Admission Unit. This is a space where multiple patients can be held until the eight steps in the admission process are completed. Staffed by a tech who reports to a nurse if there are any difficulties, the unit is a place to hold patients while clerical tasks are done and the room is readied. This really makes sense and is part of the broader notion of patient segmentation. Patients need different levels of care and different services during an ED stay, and the Express Admission Unit is a nod to those changing needs.

    Another innovation, the Full Capacity Protocol, shows that patients can be safely boarded in hallways upstairs with excellent results when all hospital beds are full. A patient with a hip fracture would be boarded on the orthopedics floor, a TIA patient would be boarded on a neurology floor, and so forth. Peter Viccellio, MD, at the State University of New York at Stony Brook has written several articles demonstrating that there is no increase in the mortality rate and that length of stay is shortened when patients are boarded upstairs instead of the ED. (Many of Dr. Viccellio's articles are available on; type “Viccellio” in the search box.)

    Patients actually spend very little time in the hallways upstairs; somehow the system finds a bed for them. Boarding on the floor is usually done with the patient occupying an actual hospital bed. It is quieter than the ED, and patient satisfaction improves with the adoption of the policy and procedure. A copy of the full capacity protocol is available on Dr. Viccellio's web site (

    Another cause of delays is patients occupying beds waiting for a resident workup. Just say “no!” It might be possible to allow this practice in an Express Admission Unit, but admitted patients must not occupy precious ED beds for the convenience of the house staff.

    Boarding admitted patients in the ED is bad for patients, bad for departments, bad for the community, considering the direct connection between boarding and diversion. Low-acuity patients at your door have little to do with the solutions to boarding. Boarding relates to flow, and is a system problem with system solutions. Improving admission operations is the one thing you cannot fix in a vacuum. Start by educating the leadership of your organization about the bad outcomes associated with boarding. Introduce them to data-driven solutions that are system solutions. Show them the compelling data on the subject. Above all, be vigilant about ED bed minute utilization. ED bed minutes are for diagnosing and treating patients, not boarding them!

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    Dr. Welch
    Dr. Welch:
    is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
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