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Internal and Emergency Medicine

, Volume 13, Issue 6, pp 923–931 | Cite as

Emergency department throughput: an intervention

  • Nowreen Haq
  • Rona Stewart-Corral
  • Eric Hamrock
  • Jamie Perin
  • Waseem KhaliqEmail author
EM - ORIGINAL

Abstract

Shortening emergency department (ED) boarding time and managing hospital bed capacity by expediting the inpatient discharge process have been challenging for hospitals nationwide. The objective of this study is was to explore the effect of an innovative prospective intervention on hospital workflow, specifically on early inpatient discharges and the ED boarding time. The intervention consisted of a structured nursing “admission discharge transfer” (ADT) protocol receiving new admissions from the ED and helping out floor nursing with early discharges. ADT intervention was implemented in a 38-bed hospitalist run inpatient unit at an academic hospital. The study population consisted of 4486 patients (including inpatient and observation admissions) who were hospitalized to the medicine unit from March 2013–March 2014. Of these hospitalizations, 2259 patients received the ADT intervention. Patients’ demographics, discharge and ED boarding data were collected for from March 4, 2013 to March 31, 2014 for both intervention and control groups (28 weeks each). Chi-square and unpaired t tests were utilized to compare population characteristics. Poisson regression analysis was conducted to estimate the association between intervention and hospital length of stay adjusted for differences in patient demographics. Mean age of the study population was 58.6 years, 23% were African Americans and 55% were women. A significant reduction in ED boarding time (p < 0.001) and improvement in early (before 2 PM) hospital discharges (p = 0.01) were noticed among patients in the intervention groups. There was a slight but significant reduction in hospital length of stay for observation patients in the intervention group; however, no such difference was noted for inpatient admissions. Our study showed that dedicating nursing resources towards ED-boarded patients and early inpatient discharges can significantly improve hospital workflow and reduce hospital length of stay.

Keywords

Hospital workflow Early hospital discharges ED boarding time Hospital length of stay 

Notes

Acknowledgements

This work would not be possible without the efforts of the ADT nursing team (Christine Barton, RN, CMSRN, MSN, Leilani Turman, RN, CMSRN, Jonathan Espenancia, RN, CMSRN, Shahida Khan, RN, CMSRN, Sol Marte, RN, BSN).

Funding

None.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.

References

  1. 1.
    Pines JM, Hilton JA, Weber EJ et al (2011) International perspectives on emergency department crowding. Acad Emerg Med 18(12):1358–1370CrossRefPubMedGoogle Scholar
  2. 2.
    Di Somma S, Paladino L, Vaughan L et al (2015) Overcrowding in emergency department: an international issue. Intern Emerg Med 10(2):171–175CrossRefPubMedGoogle Scholar
  3. 3.
    Press Ganey Associates, Inc. (2010) Emergency Department Pulse Report 2010 patient perspectives on american health care. South Bend. http://helpandtraining.pressganey.com/Documents_secure/Pulse%20Reports/2010_ED_Pulse_Report.pdf. Accessed 17 Nov 2017
  4. 4.
    Stang AS, Crotts J, Johnson DW, Hartling L, Guttmann A (2015) Crowding measures associated with the quality of emergency department care: a systematic review. Am J Emerg Med 22(6):643–656Google Scholar
  5. 5.
    Clark K, Normile LB (2002) Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-atlantic states. J Emerg Nurs 28:489–495CrossRefPubMedGoogle Scholar
  6. 6.
    Singer AJ, Thode HC Jr, Viccellio P, Pines JM (2011) The association between length of emergency department boarding and mortality. Acad Emerg Med 18(12):1324–1329CrossRefPubMedGoogle Scholar
  7. 7.
    Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti ML, Rowe BH, Dreyer J, Bell R, Schull M (2016) Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf 25(7):489–498CrossRefPubMedGoogle Scholar
  8. 8.
    Bernstein SL, Aronsky D, Duseja R, Epstein S et al (2009) Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 16(1):1–10CrossRefPubMedGoogle Scholar
  9. 9.
    Rabin E, Kocher K, McClelland M et al (2012) Solutions to emergency department ‘boarding’ and crowding are underused and may need to be legislated. Health Aff 31(8):1757–1766CrossRefGoogle Scholar
  10. 10.
    Afilalo M, Soucy N, Xue X et al (2015) Hospital stay on acute care units for non-acute reasons: effects of patient pre-hospitalization and admission factors. Healthc Manag Forum 28:134–139CrossRefGoogle Scholar
  11. 11.
    Mullins PM, Pines JM (2014) National ED crowding and hospital quality: results from the 2013 Hospital Compare data. Am J Emerg Med 32(6):634–639CrossRefPubMedGoogle Scholar
  12. 12.
    Huang Q, Thind A, Dreyer JF et al (2010) The impact of delays to admission from the emergency department on inpatient outcomes. BMC Emerg Med 10:16CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    White BA, Biddinger PD, Chang Y et al (2013) Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med 44(1):230–235CrossRefPubMedGoogle Scholar
  14. 14.
    Curley C, McEachern JE, Speroff T et al (1998) A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Med Care 36(8 Suppl):AS4–AS12PubMedGoogle Scholar
  15. 15.
  16. 16.
  17. 17.
  18. 18.
    Spiva L, Johnson D (2012) Improving nursing satisfaction and quality through the creation of admission and discharge nurse team. J Nurs Care Qual 27(1):89–93CrossRefPubMedGoogle Scholar
  19. 19.
    Lane BS, Jackson J, Odom SE et al (2009) Nurse satisfaction and creation of an admission, discharge, and teaching nurse position. J Nurs Care Qual 24(2):148–152CrossRefPubMedGoogle Scholar
  20. 20.
    Siehoff A, Gancarz B, Wise C (2009) Improving patient admissions with dedicated admission nurses. J Nurs Adm 39(1):11–13CrossRefPubMedGoogle Scholar
  21. 21.
    Patterson J, Dutterer L, Rutt M et al (2007) Bridging orders and a dedicated admission nurse decreases emergency department turnaround times while increasing patient satisfaction. Ann Emerg Med 50(3):351–352CrossRefPubMedGoogle Scholar
  22. 22.
    Morgan R (2007) Turning around the turnarounds: improving ED throughput processes. J Emerg Nurs 33(6):530–536CrossRefPubMedGoogle Scholar
  23. 23.
    Kravet SJ, Levine RB, Rubin HR, Wright SM (2007) Discharging patients earlier in the day: a concept worth evaluating. Health Care Manag 26(2):142–146Google Scholar
  24. 24.
    Salter M (2001) Planning for a smooth discharge. Nurs Times 97(34):32–34PubMedGoogle Scholar
  25. 25.
    Coleman EA (2003) Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 51(4):549–555CrossRefPubMedGoogle Scholar
  26. 26.
    Quinn R (2011) Aggressive bed management increases capacity and revenue-generating opportunities without added costs. Hospitalist 15(10):136–138Google Scholar
  27. 27.
    Litvak E, Bisognano M (2011) More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Aff 30(1):76–80CrossRefGoogle Scholar
  28. 28.
    Howell E, Bessman E, Kravet S (2008) Active bed management by hospitalists and emergency department throughput. Ann Int Med 149(11):804–811CrossRefPubMedGoogle Scholar
  29. 29.
    Gregory D, Baigelman W, Wilson IB (2003) Hospital economics of the hospitalist. Health Serv Res 38(3):905–918CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Colwell J (2014) Length of stay: timing it right. Strategies for achieving efficient, high-quality care. ACP Hosp http://www.acphospitalist.org/archives/2014/10/los.htm. Accessed 17 Nov 2017
  31. 31.
    Vom Eigen KA, Walker JD, Edgman-Levitan S et al (1999) Carepartner experiences with hospital care. Med Care 37(1):33–38CrossRefPubMedGoogle Scholar
  32. 32.
    Wachter RM, Katz P, Showstack J (1998) et al reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA 279(19):1560–1565CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2018

Authors and Affiliations

  • Nowreen Haq
    • 1
  • Rona Stewart-Corral
    • 2
  • Eric Hamrock
    • 3
  • Jamie Perin
    • 4
  • Waseem Khaliq
    • 1
    Email author
  1. 1.Division of Hospital Medicine, Department of Medicine, Johns Hopkins Bayview Medical CenterJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Johns Hopkins Bayview Medical CenterJohns Hopkins University, School of NursingBaltimoreUSA
  3. 3.Department of Operations IntegrationJohns Hopkins Health SystemBaltimoreUSA
  4. 4.Johns Hopkins Bloomberg School of Public Health, Department of International HealthBaltimoreUSA

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