Increasing and sustaining discharges by noon - a multi-year process improvement project

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Utilizing an emergency medicine stabilization team to provide critical care in a rural health system

INTRODUCTION

Over the past decade, Emergency Department (ED) patient volumes have increased more than available hospital ICU capacity. This has led to increased boarding and crowding in EDs, requiring new methods of providing intensive care. Many hospitals nationwide have developed ICU boarding mitigation strategies at the hospital and ED level or implemented ED-based resuscitative care units to improve patient care and disposition. However, these have been described in the setting of larger medical centers without broader application to rural, community ED environments. The authors herein have created an ED model utilizing a physician and nurse on-call team to provide improved care to critically ill patients requiring resuscitation when an ICU bed is not immediately available.

GOALS

The goal of this paper is to describe a novel approach to providing critical care in a rural health system. A community health system-based resuscitation team named Emergency Medicine Stabilization Team, or EMSTAT, was developed as a mobile team consisting of one emergency physician and one emergency or critical care nurse. The authors present data from the first 12 months of the program including diagnoses, procedures, temporal trends, and lengths of stay.

RESULTS

Over the course of twelve months, EMSTAT was contacted for 195 patients and ultimately traveled to bedside for 131 cases. The three most common diagnoses seen were sepsis, respiratory failure, and diabetic emergencies. 99 documented procedures were performed; the most common were central venous catheters, arterial lines, and intubations. 104 patients were admitted to the intensive care unit, while the other 27 were either downgraded to a lower level of care, discharged, transitioned to palliative care, or died.

DISCUSSION

Over a twelve-month period, the authors describe a novel rural community-based mobile critical care team. This team demonstrated the ability to quickly arrive at bedside, continue resuscitation, acquire a disposition, and provide individualized critical are. This model serves as a roadmap for developing similar community based-resuscitation programs.

Enhancing Hospital-Wide Patient Flow to Reduce Emergency Department Crowding and Boarding

INTRODUCTION

ED overcrowding and boarding is a global phenomenon that negatively affects patients, hospital staff, and hospital-wide operations. Poor patient flow has been identified as a major contributing factor to ED overcrowding and boarding, which is directly linked to negative patient outcomes. This project implemented a multidisciplinary rounding team that addressed barriers to patient flow in real time. By reducing the inpatient length of stay bed capacity will improve, which in turn will help alleviate ED boarding and overcrowding.

METHODS

This before-and-after process improvement project took place on a 30-bed, inpatient medicine floor of a level-I trauma, tertiary, regional transfer center. Multidisciplinary rounding was used to improve care team communication and collaboration. Concepts from a Real-Time Demand Capacity model were used in this project to help develop a plan for capacity issues regarding bed supply and demand. Outcome variables included inpatient length of stay and ED boarding hours.

RESULTS

Implementation of multidisciplinary rounding resulted in a statistically significant reduction of 0.83 days in the length of stay for patients on this floor. By increasing inpatient bed capacity, ED boarding hours for patients targeted to the 3000-medicine floor was reduced by an average of 8.83 hours per month, a reduction > 50% from baseline.

DISCUSSION

Increasing inpatient bed capacity helps decrease ED access block, and contributes to reducing ED overcrowding. Implementing a daily multidisciplinary rounding structure on the inpatient floor helped hospital throughput by expediting discharges, which in turn created inpatient bed capacity.

Level-loading a health system by transferring emergency department patients to a community hospital: Prospective cohort study

BACKGROUND

Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction.

OBJECTIVE

We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes.

METHODS

A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center.

RESULTS

79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p < 0.0001), ED length of stay (10.5 vs 16.1 h, p < 0.0001), and hospital length of stay (3.5 vs 5.7 days, p < 0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred.

CONCLUSION

We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

Emergency department staff perceptions about the care of children with mental health conditions

OBJECTIVE

The number of children with mental health (MH) conditions who present to the emergency department (ED) is increasing. This study aimed to gain insight into the lived experiences of ED staff caring for children with MH conditions and to understand perceptions of current ED resources and what is needed to optimize care.

METHODS

This was a qualitative study informed by complexity science theory utilizing a phenomenological approach. We used purposeful sampling from urban and nonurban EDs with varying pediatric volume. Participants were pediatric emergency care coordinators and other ED staff. Semi-structured interviews were completed. The initial codebook was created using a concept driven approach. Constant comparative analysis and deductive reasoning was employed for thematic analysis.

RESULTS

Thematic saturation by consensus was achieved with 24 interviews. Analysis found an overarching theme of moral distress of ED staff, compounded by frustration with barriers to care and perceptions of negative impact on care of other ED patients. Participants suggested the need for creation of patient, caregiver, ED staff, and ED leadership resources to enhance care.

CONCLUSIONS

ED staff perceive children with MH conditions experience significant barriers to optimal care in the ED, which causes ED provider moral distress. Additionally, other ED patients are perceived to be subsequently negatively impacted. Our findings highlight urgency for funding for more resources that are dedicated to children in the ED setting to ensure both safe, patient-centered care, and to reduce the distress described by ED staff who care for them.

Evaluation of the risk factors associated with emergency department boarding: A retrospective cross-sectional study

PURPOSE

Boarding is a common problem in the emergency department (ED) and is associated with poor health care and outcome. Imam Khomeini Hospital is the main healthcare center in Urmia, a metropolis in the northwest of Iran. Due to the overcrowding and high patient load, we aim to characterize the rate, cause and consequence of boarding in the ED of this center.

METHODS

All medical records of patients who presented to the ED of Imam Khomeini Hospital from August 1, 2017 to August 1, 2018 were retrospectively analyzed. Patients with uncompleted records were excluded. Boarding was defined as the inability to transfer the admitted ED patients to a downstream ward in ≥2 h after the admission order. Demographic data, boarding rate, mortality and triage levels (1-5) assessed by emergency severity index were collected and analyzed. The first present time of patients was classified into 4 ranges as 0:00-5:59, 6:00-11:59, 12:00-17:59 and 18:00-23:59. Descriptive, parametric and non-parametric statistical tests were performed and the risk of boarding was determined by Pearson Chi-square test.

RESULTS

Demographic data analysis showed that 941 (58.5%) male and 667 (41.5%) female, altogether 1608 patients were included in this study. Five patients (0.3%) died. The distribution of patients with the triage levels 1-5 was respectively 79 (4.9%), 1150 (71.5%), 374 (23.3%), 4 (0.2%) and 0 (0%). Most patients were of level 2. Only 75 (4.7%) patients required intensive care. The majority of patients (84.2%) were presented at weekdays. The maximum patient load was observed between 12:00-17:59. Of the 1608 patients, 340 (21.1%) experienced boarding within a mean admission time of 13.70 h. Among the 340-boarded patients, 20.1% belonged to surgery, 12.1% to orthopedics, 10.9% to neurosurgery and 10.3% to neurology. The boarding rate was higher in females, patients requiring intensive care and those with low triage levels. Compared with the non-boarded, the boarded patients had a higher mean age.

CONCLUSION

The boarding rate is higher in the older and female patients. Moreover, boarding is dependent on the downstream ward sections: patients requiring surgical management experience the maximum boarding rate.