Hospital-Based Emergency Care At the Breaking Point (2007) / Chapter Skim
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4 Improving the Efficiency of Hospital-Based Emergency Care
4 Improving the Efficiency of Hospital-Based Emergency Care
Pages 129-164
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From page 129... ...
There is little that emergency care providers and advocates can do to alter such environmental factors as growing use of the emergency department (ED) by the uninsured; the increasing age and number of chronic conditions of patients; staffing shortages in many key areas, especially nurses and on-call specialists; malpractice insurance rates that grew on average more than 50 percent between 2002 and 2003 (AMA, 2003)
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From page 130... ...
As a result, innovations that have swept through other sectors of the economy, including banking, airlines, and manufacturing, have failed to take hold in health care delivery -- a sector of the economy that now consumes 16 percent of the nation's gross domestic product and is growing at twice the rate of inflation. Health care information technology has advanced considerably in the last decade, but mainly in the administrative and financial arenas, as opposed to the core processes of delivering clinical services (NAE and IOM, 2005)
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From page 131... ...
Indeed, that is what often happens. UNDERSTANDING PATIENT FLOW THROUGH THE HOSPITAL SYSTEM Crowding in the nation's EDs poses a serious threat to the quality, safety, and timeliness of emergency care.
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From page 132... ...
Human factors research has been widely used across industries and has had many recent applica Hospital administrators and policy makers have at their disposal a number of promising options for identifying and resolving the patient flow problems that contribute to ED crowding and its consequences. But these leaders must first be compelled to take action, something that will occur only when the causes of ED crowding are clearly understood, and administrators realize that the strategies required to address the problem go well beyond the ED itself.
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From page 133... ...
model of patient care, based on engineering principles from queuing theory and compartmental models of flow, applies operations management concepts to patient flow within the acute care system (see Figure 4-1)
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From page 134... ...
ACUTE CARE SYSTEM FIGURE 4-1 Input/throughput/output model. SOURCE: Reprinted from Asplin et al., 2003, with permission from the American College of Emergency Physicians.
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From page 135... ...
. Under the I/T/O model, ED input, or demand, comprises three distinct categories of care: emergency care (treatment of seriously ill or injured patients)
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From page 136... ...
EDs are not designed to provide privacy to hallway boarders, and staff are often too busy to meet an admitted patient's needs in a timely manner. Moreover, boarding is the primary cause of ambulance diversion, a practice that delays access to emergency care and can send inbound patients to a hospital where the medical staff does not know them and has no access to their medical records.
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From page 137... ...
. Whether complex or routine, the timely administration of these ancillary services and the prompt availability of test results are imperative for smooth hospital operations and efficient patient flow.
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From page 138... ...
. It should be noted, however, that it is difficult to quantify the increment over and above appropriate evaluation in emergency care that constitutes "defensive medicine." Staffing Requirements In contrast to the strict nurse-to-patient ratios on many inpatient units and ICUs, most hospitals have declined to adopt nurse-to-patient ratios for the ED.
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From page 139... ...
STRATEGIES FOR OPTIMIZING EFFICIENCY A number of initiatives now under way are aimed at improving patient flow in order to reduce ED crowding and its related effects. These include Urgent Matters, a $6.4 million, 10-hospital campaign supported by The Robert Wood Johnson Foundation that aims to eliminate ED crowding and improve public understanding of challenges facing the health care safety net; the IHI IMPACT Network, which, through its Improving Flow Learning and Innovation Community, seeks to increase patient throughput and minimize delays while ensuring that high performance in flow is not achieved at the expense of quality; and the University HealthSystem Consortium (UHC)
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From page 140... ...
. By smoothing the inherent peaks and valleys of patient flow and eliminating the artificial variabilities that unnecessarily impair that flow, hospitals can minimize the occurrence of queues and improve safety and quality while simultaneously reducing hospital waste and costs (Litvak and Long, 2000)
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From page 141... ...
. Many of the hospitals participating in the Urgent Matters, IHI, and UHC patient flow initiatives have undertaken systematic reviews and revamping of OR scheduling as a way of improving patient flow; enhancing the quality, safety, and timeliness of emergency care; reducing unnecessary costs; and increasing surgical revenue.
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From page 142... ...
HOSPITAL-BASED EMERGENCY CARE BOX 4-3 Case Study: Boston Medical Center, Boston, Massachusetts Boston Medical Center (BMC) is a private, nonprofit academic medical center that serves as the primary teaching affiliate for the Boston University School of Medicine.
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From page 143... ...
. Clinical Decision Units (CDUs)
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From page 144... ...
. Today, observation units are used most frequently for the efficient management of patients with complaints of chest pain, abdominal pain, back pain, dehydration, congestive heart failure, asthma, and shortness of breath (Hostetler et al., 2002; Ross et al., 2003)
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From page 145... ...
. CDUs offer the potential to alleviate crowding in EDs and add elements of continuity to patient care.
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In this way, the CDU aids the hospital in managing patient flow and reducing crowding while at the same time contributing to the smooth functioning of the ambulatory care system.
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From page 147... ...
rates and not listed separately. Many groups, including the Society for Academic Emergency Medicine (SAEM)
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From page 148... ...
. Coordinated Patient Discharge One of the most widely recognized bottlenecks in patient flow is the discharge process.
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From page 149... ...
It also frees non–fast track ED resources to care for the most seriously ill and injured patients, moving them quickly into appropriate inpatient units. In this way, fast tracks can reduce delays in care for both urgent and nonurgent patients, thereby improving patient flow across the ED.
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From page 150... ...
Some EDs are divided into separate areas -- for example, pediatrics, obstetrics, and psychiatry -- and triage is used to direct patients to the appropriate setting. Computer-enhanced triage is also being adopted by some hospitals to improve the reliability of triage decisions and expedite patient flow.
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From page 151... ...
A number of other institutions have adopted the practice, which is currently promoted by the New York State Department of Health. Admission/Discharge Units An admission/discharge unit separate from the ED area has the potential to improve coordination of emergency patients and enhance patient flow.
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From page 152... ...
The challenges to improving the efficiency of hospital-based emergency care are multiple, and the demands on physicians and administrators should not be taken lightly, particularly in light of the many other demands they face -- for example, interdepartmental battles for resources, cost and revenue management, community relations, and a bewildering assortment of potential threats and opportunities. Despite the best intentions, hospitals face an uphill battle to focus sufficient attention on emergency care in the face of these other demands.
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From page 153... ...
They must be willing to send a strong, consistent message that improving patient flow is a hospital priority. And they must back up those words with specific, demonstrable actions, including personal involvement in the development, implementation, and evaluation of patient flow improvement strategies.
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From page 154... ...
Using the I/T/O model, hospitals can identify key performance indicators for evaluating patient flow performance. Examples of such indicators used successfully by hospitals participating in the Urgent Matters initiative are time from inpatient bed assignment to bed placement, inpatient bed turnaround time, total ED throughput time, and time to thrombolysis for cardiac patients (Wilson et al., 2005)
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From page 155... ...
Such an approach also includes timely collection and analysis of data at multiple points across several hospital settings to enable Sample Team Structure Chief Operating Officer STEERING COMMITTEE Vice President for Nursing Chief Medical Office Chief of Emergency Medicine EMERGENCY INPATIENT TEAM DEPARTMENT TEAM Vice President for Nursing Chief of Emergency Medicine Chief Medical Officer Director, Emergency Care Services Nursing Director Information Systems Coordinator Nurse Manager Clinical Manager Housekeeping Supervisor Clinical Supervisor Admitting Director Quality Management Inpatient Attending Clinical Nurse Specialist Inpatient Medical Director Business Analyst Director fo Patient Access Services Asst. Medical Director FIGURE 4-2 Sample hospital team structure.
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From page 156... ...
The strategies discussed above have the potential to improve patient flow significantly; enhance the quality, safety, and timeliness of emergency care; and produce related cost savings. Yet history has demonstrated that little progress will be made toward achieving these goals unless hospitals are held accountable through regulatory and incentive-based policies.
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From page 157... ...
Therefore, the committee recommends that the Joint Commission on Accreditation of Healthcare Organizations reinstate strong standards designed to sharply reduce and ultimately eliminate emergency department crowding, boarding, and diversion (4.4)
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From page 158... ...
provide inpatient care at no additional cost to the hospital, while the elective patient gets the bed. Giving the ED admission priority over the elective one forfeits that advantage.
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From page 159... ...
Therefore, the committee recommends that hospitals end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards (4.5)
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From page 160... ...
4.5: Hospitals should end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards.
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From page 161... ...
emergency departments. Academic Emergency Medicine 8(2)
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From page 162... ...
2001. Overcrowding in America's emergency departments: Inpatient wards replace emergency care.
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From page 163... ...
1998. Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population: A randomized trial of health status outcome and cost.
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From page 164... ...
2004. Bursting at the Seams: Improing Patient Flow to Help America's Emergency Departments.
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