Emergency departments often "board" patients so higher-paying elective cases scheduled for admission get beds first.
But a study that tested smarter management strategies finds that hospitals can reduce boarding time and bring $3.6 million more in net revenue a year at just one hospital.
The added revenue would come from caring for patients who otherwise would leave without being seen, and for treating patients transported by ambulances that otherwise would divert them to other hospitals, according to the study, published this week in the Annals of Emergency Medicine.
Revenue would also come from avoiding costly complications that are much more likely in patients who are boarded for six hours or more, says Jesse M. Pines, MD, lead author of the study and the director of the Center for Healthcare Quality at George Washington University in Washington, D.C. "There are multiple papers showing clear associations between longer boarding times and higher rates of complications," Pines said.
Pines adds that his study, done with researchers from the Hospital of the University of Pennsylvania and the Wharton School, is the first of its kind to assess the trade-off between potential lost revenue when patients leave or are diverted, and "debunks the conventional wisdom that boarding ED patients in the ER maximizes hospital profits."
Cutting just one hour off the boarding time results in better care for the patients and higher profits for the hospital, he says. Nationally, 10% to 15% of the time patients spend in an emergency room is spent waiting for a room after they are admitted, or "boarding," Pines says.
Additionally, ED boarding time, total time spent in the ED, left-without-being-seen rates, and other quality metrics specific to emergency room performance will soon be posted on Hospital Compare, giving patients another basis on which to choose where they get their care.
To streamline ED flow, however, research by Pines shows that hospital teams would have to agree to place some patients on units that they wouldn't ordinarily go to. For example, there might be a general medicine unit bed available, but the physician wants the patient to go to a GI floor, a practice that means the patient has to wait longer, boarding in the ED. Hospital teams might also have to agree to remove limits or thresholds on the number of hospital beds reserved for ED patients.
It also would mean that on occasion, hospitals would postpone a few elective surgeries – roughly about 5% – or reduce scheduling on certain days of the week when ED volume is usually highest, such as on Mondays and Tuesdays. Physicians may not like that, he acknowledges, but "you'd have to have an understanding among physicians and certain management that certain cases might be cancelled and patients inconvenienced."
Not scheduling those procedures in the first place on those days would resolve some of the crunch.
The research was done as a simulation exercise at a sample inner city teaching hospital with 118,000 ED visits, from which 22% were admitted over two years, and 7% left without being seen.