Background: A large academic safety-net hospital has experienced surges in hospital patient volumes resulting in inpatient strain. Strain is defined as a mismatch between supply and demand of hospital resources1. Inpatient strain led to a growing number of admitted patients boarding in the Emergency Department (ED) for several days, physically distant from their inpatient providers and with suboptimal nursing ratios. The initial response was to spend tremendous resources to increase bed capacity, which did not significantly alleviate wait-times. Thus, we developed an Inpatient Lean Team (ILT) to address these challenges with a multi-pronged approach.
Purpose: The purpose of the ILT was to decrease inpatient strain by leveraging interdisciplinary expertise. A group of physicians, hospital administrators, and nursing leadership identified key process and outcome measures. The main outcome measure was the weekly average of admitted medicine patients boarding in the ED and the primary goal was to decrease that average by 75% in 6 months.
Description: The ILT focused on the following areas: repatriation process for transfers, administratively blocked beds, and management of bed assignments. Pre-intervention is 3/1/24 to 2/28/25 and post-intervention is 3/1/25 to 10/31/25. The ILT developed a formal protocol for transferred patients to repatriate to their original hospital after completing specialty care. The ILT utilized return-transfers per month as a process measure. Monthly return-transfers increased from 26 to 54 and average transfer length of stay decreased in the intervention period (Figure 1).Inpatient rooms with two bed capacity can have one bed ‘blocked’ for infectious isolation, patient behavioral issues, or facilities repair. The ILT identified that some blocks lasted longer than indicated and developed an improved workflow to ensure consistent standards and timely removal of blocked status. The ILT used monthly average of blocked beds as a process measure, and this decreased from 36 to 18 after intervention.ILT created the position of ‘Nursing Director of Bed Movement’ to help facilitate bed assignments. Nursing administration developed a pathway to expedite handoffs and transitions of care between ED and inpatient medicine. Progress was tracked using the process measure of Percent of ED admissions reaching medicine beds within one hour; this averaged 31% pre-intervention, and rose steadily to over 60% post-intervention (Figure 2). This process measure was likely influenced by efforts to standardize telemetry orders to address long wait times for telemetry beds. To ensure appropriate utilization, guidelines were included in the telemetry order-set. Prior to ILT, 45 medicine patients boarded in the ED each midnight. This decreased by 89% to 5 patients per midnight in 6 months after intervention. Notably, the monthly average of admissions to the medicine service was stable throughout the pre- and post-intervention periods (1027 and 1051 admissions).
Conclusions: A decrease in patients boarding in the ED suggests that our ILT interventions lessened inpatient strain, despite a stable admission volume. Next steps include assessing the economic impact of ILT’s interventions. We believe that utilizing a multi-pronged, interdisciplinary approach can be an efficient model to reduce inpatient strain in similar healthcare settings.
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