Incentives for residents: The UMass Memorial Medical Center in Worcester used cafeteria vouchers to incentivize residents to increase the number of patients discharged by noon, which would open up beds for admitted ED patients.
Data surrounding contested admissions will soon be at our fingertips. Most tracking systems can now track the time from the first consultation called on admitted patients, which might be a better proxy than admission order or bed request. The time interval between that time stamp and the admission order or bed request will more accurately capture the pain of the contested admission. That data will drive process changes.
By tackling the contested admission problem as a hospital, medical center, or medical school, we can improve quality, safety, efficiency, and the experience of care. Why not address your contested admissions using some of these cutting-edge strategies?
The Badness of Boarding
Studies show boarding can produce many negatives:
- The quality of care for patients with multiple conditions suffers from boarding in the emergency department.3,4
- Delays getting patients to inpatient beds have been associated with a variety of adverse events.5
- Boarding is associated with increased in-hospital death rates.6–8
- Outcomes of patients with pneumonia, acute myocardial infarction, sepsis, and trauma are less favorable when patients are boarded in the emergency department.9,10
- As boarding time increases, inpatient length of stay increases, and waits and delays of ambulatory discharged patients also occur.11,12
- Admitted patients boarding in the emergency department experience delays in medication administration and missed orders.13–15
- Patient experience suffers when patients are boarded in the emergency department; patients would prefer to be boarded in inpatient hallways.16,17
- Staib A, Sullivan C, Prins JB, et al. Uniting emergency and inpatient clinicians across the ED-inpatient interface: the last frontier? Emerg Med Australas. 2017;29(6):740-745.
- Writing admission and transition orders. ACEP website. Accessed Dec. 14, 2017.
- Liu SW, Chang Y, Weissman JS, et al. An empirical assessment of boarding and quality of care: delays in care among chest pain, pneumonia, and cellulitis patients. Acad Emerg Med. 2011;18(12):1339-1348.
- Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10.
- Sri-On J, Chang Y, Curley DP, et al. Boarding is associated with higher rates of medication delays and adverse events but fewer laboratory-related delays. Am J Emerg Med. 2014;32(9):1033-1036.
- Raviv B, Israelit SH. Increased mortality of delayed patients in the emergency department of a tertiary medical center. Harefuah. 2015;154(11):697-700, 743, 742.
- Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212.
- Singer AJ, Thode HC Jr, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emer Med. 2011;18(12):1324-1329.
- Fee C, Weber EJ, Maak CA, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50(5):501-509.
- Schull MJ, Vermeulen M, Slaughter G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44(6):577-585.
- Derose SF, Gabayan GZ, Chiu VY, et al. Emergency department crowding predicts admission length-of-stay but not mortality in a large health system. Med Care. 2014;52(7):602-611.
- Krall SP, Guardiola J, Richman PB. Increased door to admission time is associated with prolonged throughput for ED patients discharged home. Am J Emerg Med. 2016;34(9):1783-1787.
- Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J. 2011;33(1):39-54.
- Leisman D, Huang V, Zhou Q, et al. Delayed second dose antibiotics for patients admitted from the emergency department with sepsis: prevalence, risk factors and outcomes. Crit Care Med. 2017;45(6):956-965.
- Coil CJ, Flood JD, Belyeu BM, et al. The effect of emergency department boarding on order completion. Ann Emerg Med. 2016;67(6):730-736.
- Pines JM, Iver S, Disbot M, et al. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831.
- Viccellio P, Zito JA, Savage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.