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The Contested Admission: Tips to Reduce Harmful Admission Delays

By Shari Welch, MD, FACEP | on May 18, 2018 | 1 Comment
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The Contested Admission: Tips to Reduce Harmful Admission Delays
ILLUSTRATION: Chris Whissen PHOTOS: shutterstock.com

As emergency departments have struggled with inefficient admission processes, a new domain called the ED-inpatient interface (EDii) has been identified. In the December 2017 issue of Emergency Medicine Australasia, Staib et al discussed and characterized the importance of this interface.1

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ACEP Now: Vol 37 – No 05 – May 2018

Meanwhile, in emergency departments across the country, the term “contested admissions” has been used to depict the problem of getting patients with an increasing number of comorbid conditions admitted. The contested admission refers to any discussions, testing, or consultations that delay the admission process—in other words, any answer but “yes” to the admission call.

The contested admission contributes to ED boarding, and a robust body of literature describes the ill effects produced by boarding (see the sidebar, “The Badness of Boarding”). So how are facilities are reducing admission inefficiencies in general and contested admissions delays?

Three Areas of Inefficiency

Hospitals intensely focused on admission efficiency have discovered there are three areas in which inefficiencies can occur. First, bed assignment has been a source of delay, particularly in the current era of inpatient geography (ie, services with strict unit assignments) and in facilities that employ capping (ie, strict numbers of admissions allowed by services). However, many facilities have streamlined these processes with tele-tracking products and performance improvement initiatives. The admit-decision-to-departure Centers for Medicare and Medicaid Services metric currently measures the time from the admission order or bed request to departure.

Hospital services such as housekeeping and transport services can also contribute to delay. Many facilities staff environmental services (EVS) heavily on the day shift, but hospital discharges often peak in the late afternoon or early evening. This demand-capacity mismatch ensures terminal room cleaning takes more time than the 30-minute industry standard. In addition, housekeeping and transporters often lack a systematic deployment scheme, and time is wasted walking between medical center towers. Improved deployment strategies can improve both housekeeping room turnaround and transport times.

The area that currently accounts for the longest delays, however, is the time from the call to the admitting team until the admission is accepted. Emergency departments often get pushback from various services and requests for further testing and consultations. This contested admissions phenomenon at the EDii gives the impression services are trying to avoid patient admissions.

To obtain an idea of the problem’s magnitude, an informal and unpublished survey of academic emergency medicine chairs was completed. Half of the academic programs that responded to the survey were working on the problem, according to Bruce Adams, MD, chairman of emergency medicine at the University of Texas Health Science Center at San Antonio. Another unpublished study conducted at Virginia Commonwealth University showed 39 percent of admissions were contested, which added three hours to patients’ ED length of stay.

Pages: 1 2 3 4 | Single Page

Topics: BoardingContested AdmissionsOperationsPractice Management

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About the Author

Shari Welch, MD, FACEP

Shari Welch, MD, FACEP, is a practicing emergency physician with Utah Emergency Physicians and a research fellow at the Intermountain Institute for Health Care Delivery Research. She has written numerous articles and three books on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting, and her expertise is in ED operations.

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One Response to “The Contested Admission: Tips to Reduce Harmful Admission Delays”

  1. June 7, 2018

    Matthew Vrobel Reply

    Is there a way to see the shared metrics policy at the University of South Carolina?

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