By Joe Twanmoh, MD
Hospitals across the country are experiencing high levels of patient boarding in the ED, even though ED patient volume has not fully returned to levels typically seen prior to the COVID-19 pandemic. If most hospitals have not yet returned to 100% of their pre-pandemic levels for ED volume, why are so many EDs still crowded? The reasons are multifactorial, but the solution comes down to fixing your patient flow.
ED boarding is the start of a vicious cycle. Boarding patients ties up ED beds, creating waits and longer lengths of stay for all other ED patients. Boarding also impacts clinical outcomes, since boarders experience higher morbidity and mortality rates and higher inpatient LOS than nonboarders. Longer stays place a higher demand on inpatient beds, reducing functional bed capacity. Additionally, longer inpatient stays cost hospitals more money. Lastly, boarders typically report lower HCAHPS scores, further eroding the bottom line.
The Perfect Climate for a Perfect Storm
The likely confluence of events that created this perfect storm include:
- Pent-up demand. The elective surgery backlog has been a major contributor to ED boarding and long wait times. Once elective surgeries were no longer on hold, the influx of cases placed a greater demand on inpatient beds. Increased ED admission rates and acuityhas been another factor. One health system reported overall admission rates across its EDs have increased from 16% to more than 20%.
- Lack of nurses.During the COVID-related downturn in volume, many hospitals had to lay off nursing staff, while others left the industry due to health fears. This created a nursing shortage. In response, traveler nursing rates rose exponentially, dramatically increasing costs for hospitals. In addition to the added cost, calling in traveler nurses as needed compounds the problem. If you wait to call in staff after the patient has arrived, you create unnecessary waits, increase LOS and add to boarding.
- Patient segmentation.Hospitals created separate units to treat COVID patients. While this made sense from an infection-control standpoint, increasing segmentation results in load-leveling challenges and inefficiencies. While one unit is overwhelmed, another is under capacity. Similarly, higher volume EDs tend to be subsegmented into a main ED and a lower-acuity/fast track area, where patient load-leveling can also be a problem.
- Inefficient ED admission and inpatient discharge processes. Many hospitals struggled with these processes pre-COVID-19, so it’s no surprise that a public health crisis didn’t improve the situation. Even without boarding, many hospitals are challenged to get patients admitted from the ED in less than an hour from bed request to depart time.
Righting the Patient Flow Ship
Here are a few ways to address the inefficiencies described above:
- Employ demand-to-capacity staffing based on both volume and acuity.Determining staffing based on hourly patient arrivals alone is ineffective because that one number fails to fully capture patient acuity. Obviously, a sprained ankle takes much less time and fewer resources than a critical care case, but if you’re only counting patient volume, you’re overlooking half of the demand component. In addition to acuity, factors to consider when making staffing decisions include emergency severity index triage criteria, evaluation and management billing codes and facility billing codes.
- Space out surgical scheduling. Spreading elective OR cases across the week—also known as surgical smoothing—reduces competition between the ED and OR for inpatient beds, reduces ED crowding and improves OR utilization.
- Streamline processes to eliminate unnecessary wait and waste.Hospitals are full of inefficient processes. Just ask any patient how many times they are asked the same question by different providers or ask an ED nurse how many phone calls are needed to reach an inpatient nurse. These repetitive actions take time and wasting time on non-value-added activities distracts you from more useful tasks.
- Reduce performance variability.The nature of being human is that we don’t all do things at the same rate but, from a healthcare delivery perspective, variation needs to be reduced and mitigated as much as possible. Reigning in outliers when it comes to performance̶—whether related to lab/radiology turnaround time, time to see new patients, or time to assess a patient and make a disposition—will go a long way in improving overall throughput.
With improved patient flow, patients experience lower morbidity and mortality, and report higher satisfaction. Staff are less frustrated and experience greater job satisfaction with a more even and predictable workload and workflow. And hospitals benefit from shorter lengths of stay, increased patient satisfaction, and reduced staff turnover—all of which improve the bottom line.
Similar to losing weight, improving patient flow is not achieved by some gimmick or fad diet. It takes a methodical approach based on science and data. By applying lean concepts, queuing theory, theory of constraints and change management strategy, your hospital can quickly respond to ebbs and flows in patient volumes.
Joe Twanmoh, MD, is president and founder of Queue Management, based in the Washington D.C./Baltimore area, and an ACHE Member (firstname.lastname@example.org).