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
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.
Services outside the emergency department often report that additional testing is faster in the emergency department. However, Penn State Health Milton S. Hershey Medical Center’s imaging department studied the time it takes to obtain imaging studies and found studies were obtained only 15 minutes faster in the emergency department. This finding argues against holding patients in the emergency department for additional diagnostics.
To improve delays related to contested admissions in your facility, considering employing the following tactics:
Admission agreements: The first set of admission agreements we know of were the Stanford Admission Rules drafted in 2004. They were presented in a matrix and provide basic agreements for admissions to different services. Admission agreements can take months to years to draft and still do not anticipate every possible scenario. I recently witnessed a case of a patient on warfarin with a head injury who was neurologically intact. The ED workup revealed a ST-elevation myocardial infarction and an ischemic foot. More than four hours were spent determining the admitting service. Areas of contention included orthopedics and medicine, neurology, and neurosurgery.
Bridging orders: Bridging orders should be short-term and timed-out, allowing patients to be admitted from the emergency department to the floor while the admitting service finishes clinical or surgical work.2 These orders have always been endorsed by the Institute for Healthcare Improvement (IHI). They are useful in smaller facilities but can have a place in busier facilities and academia, too.
No-refusal policies: Many organizations have adopted no-refusal policies, which may be applied on the physician side and the nursing side. Such policies mean when a bed is available and a service identified for admission, there is no answer but yes. The emergency department is empowered to determine the admitting service. This model has been applied at Brown University, Washington University, Brigham and Women’s Hospital, and Carolinas Medical Center. Some sites have taken an additional step of allowing a service to refuse a patient as long as it then finds an alternative arrangement for the patient.
Shared metrics: According to Edward Jauch, MD, MS, professor and director of the division of emergency medicine at the Medical University of South Carolina, his institution has implemented shared metrics for admitted patients for the emergency department and admitting services. Shared metrics include a goal of one hour for admission to the surgical ICU. This policy originated in the C-suite and puts income at risk for not meeting shared metrics, including length of stay. It also requires professionalism and courtesy. When this policy went live, it produced a profound effect on patient flow.
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.