Emergency department (ED) overcrowding is a commonly encountered challenge and is associated with adverse events and poor patient satisfaction. One of the factors that can contribute to ED overcrowding is the boarding of admitted patients in the ED. Various methods have been implemented to improve this issue with limited success.
Purpose:
A collaborative workgroup of Hospital Medicine (HM) and Emergency Medicine (EM) service lines was developed to reduce ED boarding of admitted patients and improve throughput with the hope of improving quality, efficiency, and patient experience.
This workgroup aimed to 1) investigate best practices at each site, 2) standardize admission process where possible, 3) propose site specific recommendations, 4) create minimum workup requirements for common diagnoses to expedite admission process, 5) analyze staffing and align with demand, and 6) create a joint EM/HM dashboard to measure performance and metrics.
Description:
Our workgroup included teams from five different hospitals within our Health System. Hospitalists and EM physicians from each hospital took leadership roles at their respective sites and directed the team to evaluate current practices and make practice improvement recommendations. A project manager and a data analyst were involved to document workplan and evaluate metrics. Metrics that were targeted were minutes from ED registration to decision to admit, ED disposition to ED departure, and ED disposition to inpatient orders.
Teams across the five hospitals attended biweekly teleconference meetings to provide status updates and implement action plans. The ground team at each hospital included attending physicians, residents, nurses, and members from admitting and bed management. A process map of the current admission process at each site was created with a focus to reduce handoffs, expedite admissions, improve communication between staff, and to improve joint EM/HM metrics. At our site, action plans were designed to improve communication between providers and bed management to facilitate movement out of the ED, to develop mutually agreed upon minimum admission requirements for common diagnoses to eliminate clinically unnecessary “admission” testing, to initiate pre-emptive bed requests, and to align staffing with volume. All action plans have been implemented at our site with subjective positive reviews with plans to evaluate effects on the ED throughput.
Conclusions:
Hospital throughput and ED boarding of admitted patients is a commonly encountered issue. Establishing a collaborative workgroup of both HM and EM service lines to understand site specific barriers and implement improvements can reduce inefficiencies and improve hospital throughput, all while improving collegiality between hospitalists and EM physicians. Next steps of our workgroup include standardization of best practices across multiple hospitals and continued evaluation of metrics to gauge the level of success.