Emergency department (ED) overcrowding and diurnal patterns in patient flow affects patient safety and experience outcomes, which puts increased pressured on hospitalists and inpatient staff to discharge earlier in day.
In a 2007 study in the Annals of Emergency Medicine (Fee, et.al.) highlighted the effect on time to antibiotic administration for patients diagnosed with community-acquired pneumonia. They demonstrated that for every additional patient in the emergency room, the likelihood of antibiotic administration within 4 hours decreased by 4%.
Similar associations are seen with the management of patients with non-ST segment elevation myocardial infarctions. Several studies in the emergency medicine literature also highlight delays in pain assessment and treatment with high ED census and number of boarders (patients admitted but awaiting an inpatient bed in the ED). More recent studies highlight an association between length of ED boarding and mortality.
In this chapter, we will discuss ways in which you can address throughput as an individual, as a part of an inpatient unit, and as a champion for a hospital-wide initiative.
II. Identify the Goal Behavior.
The hospitalist will view patient throughput as a serious issue that has efficiency, experience and safety implications. Furthermore, the hospitalist will understand and describe the complexity of this issue, which is typically impacted by a wide array of stakeholders and competing incentives. Patient throughput can be achieved with engagement and concerted communication among physicians, advanced practitioners, nursing, social work and case management, and other ancillary staff. Additionally, coordination of care must be done seamlessly at time of discharge.
III. Describe a Step-by-Step approach/method to this problem.
The first steps in this process fall under the umbrella of “Individual Responsibility.”
As a hospitalist, improving the throughput begins by anticipating barriers to discharge. Close collaboration with other disciplines is needed, including social workers, case managers, nurses, and physical therapists on various medical units. This usually takes the form of daily interdisciplinary rounds, and they are efficient and critical for early discharge planning.
Assessing the patient’s ability to ambulate and take care of activities of daily living are important for identifying a need for a post-acute care facility. This requires preparation days in advance with a formal physical therapy consult and communication with a social worker and case manage. Certain medical diagnoses may require support services at home, including home nursing and physical therapy. Some patients require the presence of a home health aide with them at time of transport or when they arrive home. These will need carefully planning to achieve early and safe discharge.
Certain tasks are helpful to complete the day prior to discharge, to avoid hurried preparations in the morning. Follow up appointments, medication reconciliation, prescriptions, and discharge summaries need to be prepared the day before to prevent early morning delays. Keep in mind that many offices, agencies and pharmacies do not open until 8 or 9 am.
Timely and goaldirected communication with consultants is crucial. Because of other obligations, consultants often see patients late in the day, and nonurgent consults are seen the following day. Call consultants quickly when needed, both in the context of the hospitalization and in the time of day. The question should be directed with a targeted goal for discharge – “Could you assess patient for her asthma exacerbation. If she continues to improve I am hoping to coordinate discharge by Wednesday morning, pending your recommendations.”
In addition to discussing with other care providers, a careful discussion with the patient allows for safe and speedy discharge. A general plan for length of stay should be discussed on admission (“I think that if we treat you with antibiotics and monitor for 48h, I hope to get you home safe unless there are complications”). The day prior to discharge, a clear plan for the following morning must be addressed. For example, “Pending the discussion with your pulmonologist today, and tomorrow’s morning blood tests look improved, we hope to get you discharged from the hospital by 11am.” At this point, it is important to discuss post-discharge follow-up plans, including new medications, potential signs and symptoms to watch out for, and ways to reach providers in case of questions. Addressing questions and concerns at this time will prevent any last minute hold-ups.
Testing and treatment decisions play an important role in throughput. Practicing high value care can prove helpful for both the patient and health system. Testing that is indicated for an outpatient work up, such as a routine ultrasound in patients with chronic kidney disease, is best done as an outpatient. The ultrasound not only affects the waiting time for other patients (e.g., the patient waiting for the same ultrasound in ED), but it also increases the likelihood of errors and incidental findings that may require further workup in the hospital. Avoiding low value tests are critical for timely discharge. The practice of routine daily morning labs, especially on the day of discharge, should be reexamined. Daily phlebotomy has been associated with hospital induced anemia and worsening of preexisting anemia. This may lead to unnecessary anemia. Lab errors such as “pseudohyperkalemia” can lead to further testing and unnecessary treatments. When labs are done for low value reasons on the day of discharge, these issues may needlessly delay discharges and cause disruptions in patient care.
The mode of transportation for the patient is an added layer of complexity. If it is an arranged transportation by the social worker or case manager (such as ambulance, ambulette, taxi), then it requires close communication the day prior and morning of the discharge. Confirming or canceling at least an hour prior to the planned time of transport is helpful for the social worker’s, case manager’s, and nurse’s workflow. Discharge orders and prescriptions should be finalized to prevent delays.
If the patient wishes to arrange his own transportation home, that must be arranged ahead of time by the family. A planned time for the morning is crucial for an early discharge. “Please call your son to come and pick you up here at 11am.”
On the morning of discharge, plan to round on the planned discharges early. By this time, all preparations for discharge should be ready or pended. After seeing the patient and communicating the plan for discharge, the discharge order should be placed quickly and communication to the social worker/case manager and the nurse with a proposed time should be communicated clearly.
The remaining steps will focus on unit and hospital-wide principles that a hospitalist can be a part of.
More recently, hospitals are focusing on the discharge-before-noon metric (DBN) to improve patient throughput. The target time should be dependent on each hospital’s patient flow patterns, and the goal is set to help discharge patients earlier in the day in order to relieve patient census in the ED. A 2015 study in the Journal of Hospital Medicine by Wertheimer et.al. demonstrated that a sustained DBN rate of 35% on two medicine units led to a statistically significant change of one hour in median arrival to the floor from the emergency department.
Interventions targeting morning discharges require significant effort to maintain. The same Wertheimer study employed a multifaceted intervention including afternoon interdisciplinary rounds, a discharge checklist for front-line staff, a standardized electronic communication tool, and daily feedback. This also highlights the importance of a multidisciplinary, coordinated effort.
A handful of hospital-wide initiatives have been shown to improve hospital throughput: boarding patients in inpatient hallways (moving patients from the ED to inpatient hallways after they have been admitted); full-capacity protocol (a systematic method of distributing boarded patients beyond the ED); and surgical schedule “smoothing” (which involves a more considered approach to scheduling surgeries during the week). Wagner et.al. showed in Health Affairs in 2015 that while some hospitals are adopting such interventions, many with the most crowded emergency departments still have not.
Opportunities exist for hospitalists to participate in large-scale projects. Hospitalists can function as a “bed czar,” or “active bed manager,” a role that can take on several forms.
A study at Johns Hopkins Bayview Medical Center utilized a hospitalist around-the-clock to triage admissions to the department, manage resources of the department, and quickly reach out to more senior administrative officials to respond to more critical throughput issues. They saw a decrease of 98 minutes of ED throughput time along with a decrease in the hours the hospital was on ambulance diversion.
Hospitalists can play an active role in throughput in other ways, including helping to identify patients inappropriately triaged to a telemetry floor (not every patient with atrial fibrillation needs to be on telemetry). The creation and utilization of an observation unit, or a “low risk chest pain” unit, has typically been within the realm of emergency medicine, but some hospitals are more heavily relying on hospitalists to staff and manage these units, with promising results.
IV. Common Pitfalls.
In considering novel interventions to improve patient throughput in the hospital, one must be aware of potential pitfalls that lurk behind the promise of decreased throughput times or decreased length of stay.
For example, in an effort to ensure more patients are discharged in the morning, providers may incidentally be incentivized to keep patients an additional day, rather than discharging them in the afternoon. A retrospective analysis from UCSF reviewed patients discharged before noon on medical and surgical services and found an association between increased length of stay and earlier discharge. While this does not confirm a causal relationship, it highlights the difficulties we all face in juggling various throughput metrics.
Active participation by hospitalists in determining programs targeting throughput is also an important opportunity to ensure the workload and responsibility of the issue is distributed equally amongst all players. Though the emergency department arguably feels the brunt of overcrowding, initiatives do not focus on the ED alone. In the same way, as hospitalists are proving to be adept at improving patient flow, one must be cautious not to overburden the system. A higher patient census for a hospitalist (greater than 15 patients) is associated with increased lengths of stay, along with increased utilization of consultants.
When considering interventions, it is important to identify process metrics such as length of stay, and readmission rate, as well as patient and provider satisfaction.
This chapter is only a starting point for any discussion highlighting interventions targeting patient throughput. Of the many initiatives laid out above, one takeaway exists: effective management of hospital throughput requires effective collaboration amongst many stakeholders.
V. National Standards, Core Indicators and Quality Measures.
While metrics like LOS can be considered throughput metrics, most hospitals will focus on measures beyond LOS such as:
ER wait times
ER to inpatient bed times
Discharge before noon rate
Average time of discharge
There are no agreed upon national standards, quantifiable core indicators or quality measures that reflect patient throughput. Most benchmarks for patient throughput are based upon ER metrics. The 30-minute arrival to provider time has been emphasized by the American Hospital Association's Hospitals in Pursuit of Excellence program.
VI. What's the evidence?
Schafermeyer, RW, Asplin, BR. "Hospital and emergency department crowding in the United States". Emergency Medicine. vol. 15. 2003. pp. 22-27.
George, JA, Fox, DR, Canvin, RW. "A Hospital Throughput Model in the Context of Long Waiting Lists". The Journal of the Operational Research Society. vol. 34. Jan 1983. pp. 27-35.
Elliott, DJ, Young, RS, Brice, J, Aguiar, R, Kolm, P. "Effect of hospitalist workload on the quality and efficiency of car". JAMA internal medicine. vol. 174. 2014. pp. 786-793.
Fee, C, Weber, EJ, Maak, CA, Bacchetti, P. "Effect of Emergency Department Crowding on Time to Antibiotics in Patients Admitted With Community-Acquired Pneumonia". Annals of Emergency Medicine. vol. 50. 2007. pp. 501-509.e501.
Howell, E, Bessman, E, Kravet, S, Kolodner, K, Marshall, R, Wright, S. "Active bed management by hospitalists and emergency department throughput". Ann Intern Med. vol. 149. 2008. pp. 804-811.
Pines, JM, Hollander, JE. "Emergency department crowding is associated with poor care for patients with severe pain". Ann Emerg Med. vol. 51. 2008. pp. 1-5.
Singer, AJ, Thode, HC, Viccellio, P, Pines, JM. "The association between length of emergency department boarding and mortality". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. vol. 18. 2011. pp. 1324-1329.
Warner, LS, Pines, JM, Chambers, JG, Schuur, JD. "The Most Crowded US Hospital Emergency Departments Did Not Adopt Effective Interventions To Improve Flow, 2007-10". Health affairs (Project Hope). vol. 34. 2015. pp. 2151-2159.
Wertheimer, B, Jacobs, RE, Bailey, M. "Discharge before noon: an achievable hospital goal". J Hosp Med. vol. 9. 2014. pp. 210-214.
Wertheimer, B, Jacobs, RE, Iturrate, E, Bailey, M, Hochman, K. "Discharge before noon: Effect on throughput and sustainability". J Hosp Med. vol. 10. 2015. pp. 664-669.
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