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A Necessity, Not an Option: Rethinking ED Systems

Eric Bachenheimer, for HealthLeaders Media, December 18, 2008

The December 4, 2008, edition of QualityLeaders addressed the need for a third option to ease emergency department overcrowding instead of resorting to boarding patients in EDs or placing them in inpatient hallways.

Emergency departments nationwide deserve gold stars for their creativity in mitigating the effects of overcrowding by making processes more efficient through quick registration, provider in triage, bedside registration, standing orders, and the use of fast track and sub-waiting areas, to name a few. For some, there is simply no more bandwidth to utilize, no other efficiencies to be gained outside of changes intended to reduce bottlenecking for getting admitted patients to inpatient beds quickly.

Patient satisfaction surveys have shown that patients seeking care in the emergency department primarily want two things: good medical care and reasonable wait times. Boarding of inpatients in the ED inhibits the ability of ED staff to achieve both of these goals.

While growing in popularity, retail health clinics do not appear to be part of the answer, as surveys conducted by MinuteClinic have shown the bulk of patients utilizing such centers would have otherwise sought care at a physician office or urgent care center (95%), not an emergency department (only 5% of respondents).

Many point to urgent care centers or freestanding emergency departments as a model of the future, because they are not equipped to provide inpatient care and must transfer the patients to a hospital setting and are therefore immune to the ED boarding problem. But arranging transportation for a hospital admission effectively moves the admission bottleneck right back to the hospital and likely results in the patient waiting in the hospital ED, effectively doing little to solve the boarding problem but allowing some time to identify a bed. So regardless of the proliferation of urgent care centers, hospitals will still need to address the complex "admission process."

The third option that will solve this problem is to re-engineer the traditional systems that still dominate the majority of hospitals today so that there is minimal waiting for care in the ED and transportation to a clean available bed on an inpatient unit. This is a formidable challenge, as it requires the following:

  • Simplify the hospital admission process. The process to admit an emergency department patient to an inpatient bed is a complex one. Once the ED physician has made a decision to admit the patient, it can often be a challenge to get some hospital services to accept a patient, let alone provide a timely consultation to evaluate the patient. This can take hours. Once this hurdle has been cleared, then there's the issue of completing the required electronic and/or paper forms, creation of an inpatient chart, and identification of an available bed. If a patient is fortunate enough to have a bed identified, the chances that it is clean, the inpatient floor nurse is available to accept the report, and transportation is available to whisk the patient to his or her inpatient bed are slim to none. Even when the hospital is not at full census, the multitude of steps and subprocesses involved requires significant coordination among the ED, inpatient floor, housekeeping, transportation, patient access, and the admitting physician. Phone calls are not promptly returned. Change of shift personnel require briefing/reporting, which adds further delays. Ultimately, coordinating all the resources involved requires a consensus among stakeholders with competing priorities—hardly a simple task.

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