Emergency departments across the country are crowded with patients waiting hours to be seen and admitted patients boarding in the ED for additional hours or even days. Yet many EDs are not back to pre-pandemic volumes. So why all the crowding?
Even though patient volume may not be back to pre-pandemic levels, acuity is up. One health system reported that overall admission rates across its EDs have increased from 16% to more than 20%. That was before the Delta variant surge in COVID cases. Patient demand, or workload, is a combination of both volume and acuity. If a resurgence of COVID requires PPE for every patient and donning and doffing takes 5 minutes/patient, a physician seeing an average of 2 patients/hour will have her productivity drop to 1.7. EDs that have not returned to pre-pandemic staffing levels are most likely understaffed due to the acuity change. This creates a domino effect: increased waiting times, overworked and overstressed staff, burnout, and staff turnover. Particularly during the current nursing shortage, staff retention is critically important.
Higher volume emergency departments often have separate treatment areas for patients with lower acuity. When an ED is overrun with high acuity patients, these low acuity areas may be used inefficiently. Underutilization, where beds are not used due to a lack of appropriate patients, or acuity creep, where sicker patients are placed in the low acuity area due to lack of beds in the main ED, can occur. With underutilization, valuable space and staff sit idle, whereas with acuity creep, a treatment area may not be adequately resourced to care for these sicker patients, resulting in longer length of stay and bed gridlock. Both scenarios result in ED crowding, longer waits, frustrated staff, and dissatisfied patients.
Righting the Patient Flow Ship
The solution to the inefficiencies described above is to improve patient flow.
Employ demand-to-capacity staffing based on both volume and acuity. Looking at only hourly patient arrivals to determine staffing, misses half of the demand component. Obviously, a sprained ankle takes much less time and fewer resources than a critical care case. But if you’re only counting patients, each counts equally as one. Failure to factor in acuity results in an understaffed ED, which ensures long waits and crowding.
Space out surgical scheduling. Also known as surgical smoothing, spreading elective OR cases across the week reduces competition between the ED and OR for inpatient beds, eases 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 staff members or ask an ED nurse how many phone calls are needed to reach an inpatient nurse to give report. These repetitive actions waste time on non-value-added activities that distracts your team from more useful and necessary tasks.
Reduce performance variability. Delivering care relies heavily on human capital. The nature of being human is that we all don’t do things at the same rate. Someone comes in first and someone comes in last in any race. But from a healthcare delivery perspective, the last person can’t come in days after the first. Reigning in outlier performance̶ whether lab or radiology turnaround times, time to see new patients, or time from assessment to patient 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.
However, like 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 (joe@queuemgmt.com). To find out more go to https://www.queuemgmt.com/
Sources
Handel DA, Hilton JA, Ward MJ, Rabin E, Zwemer FL Jr, Pines JM. Emergency department throughput, crowding, and financial outcomes for hospitals. Acad Emerg Med. 2010 Aug;17(8):840-7. doi: 10.1111/j.1553-2712.2010.00814.x. PMID: 20670321.
Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009 Sep;54(3):381-5. doi: 10.1016/j.annemergmed.2009.02.001. Epub 2009 Mar 20. PMID: 19303168.
Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008 Sep;15(9):825-31. doi: 10.1111/j.1553-2712.2008.00200.x. PMID: 19244633.
Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011 Dec;18(12):1324-9. doi: 10.1111/j.1553-2712.2011.01236.x. PMID: 22168198.
Twanmoh J. (2012, October 9). ED boarding affects quality, length of stay, and patient satisfaction [PowerPoint slides]. Presented to Medical Executive Committee, Saint Agnes Hospital, Baltimore, MD.
Twanmoh J. (2020-2021). Informal survey with physician management groups, health systems, independent emergency physicians, and academic medical directors.
White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013 Jan;44(1):230-5. doi: 10.1016/j.jemermed.2012.05.007. Epub 2012 Jul 4. PMID: 22766404.