ED to Wards: Beating the Boarding Problem

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.