EL: Boston Medical Center is a Level I trauma center. Their emergency department was constantly overloaded. After surgical smoothing, their ambulance diversion decreased by 20 percent. Their waiting time dropped to 2.8 hours compared to five plus hours at other academic hospitals in Boston. Improvement in the emergency department overcrowding was not at the expense of the surgeon. Due to their nature of being a Level I trauma center, their cases were frequently bumped by the emergent surgeries with gunshots, etc. The number of cancelled or rescheduled cases dropped by 99.5 percent, from the average of 700 a year to about six a year.
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
PV: What are the upsides and the downsides?
EL: Ottawa Hospital is a large academic hospital. They reported a $9 million margin improvement, and they reported 40 lives were saved in the first year. Why? Because they documented that when the hospital is overcrowded and the operating rooms are overcrowded, the waiting time to get emergent or urgent surgery could become prohibitive, resulting in an increased mortality rate.
PV: Hospitals are doing so many different things to address crowding. Few have been effective or sustained. Would you consider this intervention just one of many on the list of things that hospitals can do?
EL: As long as we have those peaks, we are going nowhere. Let me give you another example from 2009 publication in Critical Care Medicine. At the Johns Hopkins neurological ICU, authors found that during peaks in admissions, the hospital readmission rate increased by 500 percent. What does that mean? I believe that [the Centers for Medicare & Medicaid Services] suggest that there should be a 20 percent reduction in the hospital readmission. If you do not smooth, you could report a success, with 400 percent instead of 500 readmission rate during those peak days. When I say that Cincinnati Children’s was able to improve their margin by $100 million a year, hospitals of similar size that do not do that will waste $100 million a year. In terms of safety, cost, readmission rates, and mortality rates, it’s dangerous to the patient and the financial well-being of the hospital to ignore these peaks and troughs. I consider this an absolutely essential part of any effort to address crowding. Without it, you will not solve your problem.
PV: In summary, you have found that smoothing improves the hospital’s available capacity to decrease emergency department boarding of admitted patients, and you’re going to have steadier nurse-patient ratios without peaks and valleys. It’s going to be safer for the patients, it’s going to be better for the hospital’s financial line, and it’s going to actually be better for the doctors, particularly those that are doing elective surgery, because they don’t get their cases bumped, their patients are placed in the preferred rooms, and one can run the elective operating room with a higher capacity because it’s much more predictable.