Over the past six months, Nationwide Children’s Hospital has seen an 82% drop in patients boarding in the emergency department.
That progress stems from a targeted initiative to identify and eliminate barriers in moving patients to inpatient units after care teams determine they require admission, according to Lee Ann Wallace, MSN, RN, chief nursing officer of the Columbus-based pediatric health system.
Roughly a year ago, emergency and inpatient teams came together to pinpoint common bottlenecks in the admission process. Their analysis revealed one persistent, internal issue: admissions were often delayed as inpatient teams debated the most appropriate placement for patients or asked ED staff to hold a patient because their unit was in the middle of a shift change.
“There’s all this sort of negotiation and finagling that goes on. In the meantime, the patient’s sitting in the emergency room,” Ms. Wallace said.
At the time, the hospital had patients boarding upwards of 5% to 6% of the time — meaning a patient who had been admitted was still waiting in the ED at least four hours later. The Joint Commission considers boarding a patient safety risk and recommends it not exceed four hours.
“We really took the time to look and see what is the actual data telling us about why patients don’t get up there? And the vast majority of it was our own internal, behind-the-scenes pushback on getting that patient up,” Ms. Wallace said.
After identifying barriers, ED and inpatient teams came to a shared decision that 60 minutes is a reasonable expectation for getting patients to an inpatient unit after a decision to admit is made. To support that goal, they evaluated several placement algorithms designed to help inpatient units more quickly determine where patients should be admitted and ultimately agreed on a single algorithm.
Since putting the change into practice, the boarding rate has fallen to below 3%.
The improvement has also led to fewer ED patients leaving before receiving care, Ms. Wallace said.
“Our left-without-being-seen rate is now below 2%, even in the winter,” Ms. Wallace said. “That’s pretty amazing.”
These types of patient flow improvements are increasingly important as hospitals navigate sustained high occupancy rates. Capacity strain is especially acute for children’s hospitals, many of which routinely operate near their limits caring for high-acuity patients. Over the years, a growing number of general acute care hospitals have closed their pediatric units, often citing financial pressures and low patient volumes. Between 2008 and 2022, U.S. hospitals closed nearly 30% of inpatient pediatric units. As a result, children’s hospitals are absorbing more demand, making efficient patient flow even more critical to ensure timely care.
“This is a great example of how, when we all stack hands and try to do the right thing, that creates more capacity in the ED and gives patients a bed when they need to be in a bed,” she said.
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