Many hospitals in the country operate at capacity, and many patients are boarded in the emergency department. Although there are many ED-based flow initiatives, virtually none of these address the most significant impediment to flow: boarding of admitted patients in the emergency department due to lack of inpatient beds. Only a few interventions really have any lasting and significant impact on boarding and capacity.

This is one of a series of interviews that highlight dramatically effective interventions to reduce boarding and crowding. Early-morning discharges can have a strong impact on capacity, virtually eliminate boarding, and also decrease the length of stay. I recently sat down with Katherine Hochman, MD, to discuss NYU Langone Medical Center’s efforts to increase capacity by discharging patients earlier in the day.

Participants

• Peter Viccellio, MD, FACEP, is vice chairman of the department of emergency medicine and associate chief medical officer for the Health Sciences Center at Stony Brook University in New York.
• Katherine Hochman, MD, is assistant professor and associate chair for quality of care in department of medicine at NYU Langone Medical Center in New York City.

PV: Welcome and thank you for joining me to discuss another issue related to hospital overcrowding and flow. As you know, this is a major issue for emergency medicine, hospitals, and patient safety. Previous literature has suggested that early discharge could really have a dramatic impact on hospital capacity and on hospital flow. You have been a leader in some major initiatives at NYU in order to improve early discharge.

KH: Thanks very much for having me. The major metric that changed how we viewed early discharge was the fact that patients who came up to the floor after 1 p.m. stayed an average of 0.6 days longer even after you adjusted for all the different diagnoses compared with those patients who physically arrived on the floor before 1 p.m. This was a major eye-opener for us; the metric that really changed it all was that 0.6 increase in length of stay.

PV: There are five or six articles that looked at length of stay as a function of boarding, and the punchline was that there was roughly a day increase in stay if you boarded patients in the emergency department. When we initiated the full-capacity protocol, we reversed that. We were always curious as to why. If you admit and board a patient in the emergency department, they are going to get their antibiotics and their CT scans, but they’re not going to get care management, social work, and other inpatient services. If you don’t get them up in the morning, they lose that day.