What's the Holdup? Overcoming the Costly Delays in Admissions and Throughput

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The American College of Emergency Physicians reports that the average emergency department boarding time — where patients who are ready for hospital admission are kept in the ED until space becomes available in other departments — is about four hours. Meanwhile, a CDC and UMass report indicates that the chances for a medical mistakes increase with longer boarding times.

CNN, Forbes and Hospitals & Health Networks outline the strong link between low wait times and high patient satisfaction scores. And, The Annals of Emergency Medicine indicates that even small reductions in the average emergency department boarding time could result in millions of additional dollars per year in revenue for hospitals that implement active bed management strategies. What all this data means is that, now more than ever, patient satisfaction and hospital revenue are more closely linked than ever. Increasing ED volume doesn't increase bottom lines the way it used to; in today's facilities it can actually mean the opposite. The most successful EDs are the ones that are eliminating gridlock, cutting down on wait times and streamlining their admissions process. MarkHamm

Here are five reasons that hospitals may have growing wait times and shrinking reimbursement:

1. There is just too much gridlock in the ED. Long wait times create frustration for patients and lower satisfaction scores. The ED is now the "front door" of the hospital, where patients first enter, so bottlenecks tend to ensue. A busy, overflowing ED is no longer an indication of profitability. While overcrowding in the ED may seem to be an obvious link to increasing wait times, it is possible to accommodate growing volume while decreasing wait times. When that happens, ED volume increases shift from a positive to a negative for a healthcare facility. More patients are treated more quickly, more efficiently and more effectively.  Patient satisfaction scores actually can grow along with the volume.

2. There are no empty beds. ED boarding time can also take several hours. These are patients who likely already know that they're being admitted to the hospital, but are waylaid in the emergency room until a vacant bed can be found for them. This can also have a negative impact on patient satisfaction metrics. So if there's a patient in every room of the inpatient unit, it's not necessarily a good sign.

3. There is too much finger pointing between departments. The ED physicians "can't reach" the hospitalists to facilitate an admission. The hospitalists are too busy on the inpatient floor to "drop everything" and run to the ED every fifteen minutes. Resentments between the disparate departments ensue.

4. There is too little agreement between departments. What constitutes a case severe enough for a hospital admission can be highly subjective. If the doctors can't agree, care will be very disjointed, disorganized and patients continue to wait while the physicians hash it all out.

5. All of the required orders and forms are being filled out by hand. There's no need to resort to jokes about the poor legibility of physicians' handwriting. But in the age of automation, point-and-click documentation software and pre-population for forms, having physicians hand-write orders can slow down the physicians and flummox the readers.

All of these challenges can be overcome — through tools, technology and various communication techniques. Even hospitals that are performing above the afore-mentioned national averages may seek to improve further. There are few metrics that can't be improved. And in the era of value-based purchasing, those metrics are more important than ever.

One such facility that sought to improve on its "better-than-average" metrics was TriStar StoneCrest Medical Center, a 109-bed HCA facility in Smyrna, Tenn. The hospital was reporting about 46,000 annual ED visits. By focusing on throughput and wait times, they were able to increase their ED volume by 15 percent — which in this case, is a positive increase, because wait times were simultaneously reduced. Which means, the TriStar StoneCrest ED can now treat more patients in less time than it used to, without any degradation in quality of care. Their Left Without Being Seen rate was reduced by 35 percent. Their boarding time dropped from 210 minutes down to 80 minutes.

The improvements have been jaw-dropping, and they didn't take very long to achieve. The hospital attained these amazing results by addressing the some of the following challenges:

  • Improving the time it took to move patients from the ED to the inpatient unit. At the time that process was taking about three and a half hours. This had a negative effect in their ED, often causing some bottlenecks and gridlock.

  • Discharging patients more efficiently: patients who were scheduled for discharge in the morning were often still occupying inpatient beds well into the afternoon. This can further stymie new admissions.

  • Ineffective communications and poor handoffs, which can waste valuable time and effort, were determined to further slow down the admitting and discharge processes.

They decided to focus on improving communications between departments, streamline the admissions process and enhance efficiency of their discharge protocols. They were able to achieve some great results in all of these goals through the use of EmCare's Door-to-Discharge solution; our proprietary software tool for rapid admissions, RAP&GO; a proven communication solution; and willingness on behalf of their excellent staff to built new protocols and break down the silos that had hampered patient flow.

With the new attitudes, the new processes and new technology platforms, TriStar StoneCrest saw the following improvements:

  • Boarding times dropped from about 210 minutes to 80 minutes. Those results were almost instantaneous, according to the hospital administration.

  • ED volume grew from 38,940 to 46,043. Reduced boarding times meant there was more opportunity to treat patients in the ED.

  • Left Without Being Seen rate fell from 0.99 percent to 0.64 percent.


The successes achieved by TriStar Stonecrest have boosted alignment of the ED and hospitalist groups even further. The physicians report that they appreciate not having to hand-write their orders any longer. The emergency physicians enjoy the escalated notification systems for the hospitalists, because  the emergency department isn’t wasting time or energy "tracking down" the hospitalists for admission approvals.

Reducing wait times isn't going to fix healthcare in the U.S. But it can improve flow, throughput and quality of care throughout the entire hospital. The right combination of tools, technology and talent can get healthcare moving in the right direction.

Mark Hamm is CEO for EmCare Hospital Medicine. He has an extensive background in the management of hospitalist programs, including developing and executing strategic plans, day-to-day operations and practice growth. Prior to joining EmCare, Mr. Hamm served as vice president of hospital medicine and emergency physician operations at HCA Physician Services. He has also served as a senior vice president of operations in TeamHealth’s hospital medicine division and their emergency medicine division.

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