Some of the most enduring images of the pandemic will surely be those of severely ill patients lined up on gurneys, waiting for hours, even days, for a critical care or inpatient bed.
Delays in patient transfer were getting longer before COVID, but the coronavirus turned them into a deadly crisis. Dramatic expansion of emergency departments, acute care and critical care units have all failed to solve the underlying problems of patient flow through hospitals.
What’s needed is an entirely new approach to how acute care medicine is delivered. Instead of building new hospitals or acquiring facilities or systems, we should invest in the people, processes and technology that can optimize patient flow and improve quality.
According to the Institute for Healthcare Improvement (IHI), blockages in patient flow have hospital-wide causes, including inefficient processes for transferring patients among units and discharging them. Factor in today’s stunning rise in behavioral health patients occupying ED and inpatient beds, and you see why there are new capacity constraints for hospitals and suboptimal utilization of scarce resources.
Having established patient transfer policies as a hospital medical leader, I can attest to the urgent need for filling gaps in coverage that can cause catastrophic delays in getting critically ill patients the right care at the right time in the right setting by the right providers. As the CEO of a telehealth company that has spent the past decade building a team of world-class intensivists, I can also attest to the enormous potential for change that widespread adoption of virtual care can have in this process.
Almost two decades ago, the IHI recommended three simple rules to provide a focus for achieving hospital-wide patient flow:
- Put patients on the appropriate clinical unit with the clinical team that has disease- or condition-specific expertise
- Allow no delays greater than two hours in patient progression from one hospital unit or clinical area to another, based on medical readiness criteria
- Ensure each unit or clinical area has some capacity at the beginning of each day
In the years immediately following that report, the volume of ICU admissions from the ED increased by almost 50%, with demand often exceeding available capacity in many hospitals around the country, leading to admission of patients who were either too well or too ill to benefit, while squeezing out patients who would otherwise be accepted to the ICU, leading to increased hospital mortality.
The rise in ICU admissions has sparked a companion 32% increase in ED length of stay for critically ill patients.[i] These “boarding delays” are more striking for patients being treated in higher volume and/or metropolitan area EDs, with up to 87% of all patients having an admission delay of greater than two hours. ED crowding and ICU capacity strain have been associated with longer ED and inpatient lengths of stay. In addition, critically ill patients waiting in the ED for ICU beds have a proportional increase in their mortality directly correlated with the length of their wait for an ICU bed.[ii]
According to the American College of Healthcare Executives (ACHE), as ED volumes have grown, the number and sophistication of patient streams have increased and often include:
- Fast track (for the least sick moved quickly in and out of treatment spaces)
- Mid-track or vertical model (for moderately sick patients often treated in a chair)
- Major care or acute care (for severely ill patients treated in a bed)
- Critical care (for very ill sick or injured trauma patients)
- Admission holding area (for boarded patients who are stable waiting for a bed)
Much clinical research has shown the effectiveness of this sorting strategy. The most effective departments, ACHE says, staffed these areas with medical teams, had internal waiting rooms to optimize the use of treatment spaces and a physician in triage in charge of the complicated patient-sorting process.
Importantly, the ACHE added: “ED leaders should be thinking about how patients can be screened without provider contact, managed virtually with telehealth.”
As the healthcare world begins to dust itself off and look to the post-pandemic future, wasteful processes that cost every stakeholder will no longer be standard operating procedure. Patient flow isn’t just about getting people into a hospital bed in a reasonable period of time; it is a key to operational efficiency that saves time, keeps patients safe and results in better care outcomes.
At each care transition, a growing body of evidence says the most effective strategy for most hospitals is to call on a physician with the most relevant experience possible, a strategy made possible by increasingly frictionless telehealth services.
Corey Scurlock, MD, MBA, is CEO of Equum Medical, which delivers acute specialty care services virtually, reducing delays in needed transfers and more accurately targeting care interventions, allowing care providers to serve a larger number of patients; improve patient care; and deliver positive clinical, operational and financial results.
[i] Kusum S, Mathews, KS, Durst, M, et al. Effect of Emergency Department and Intensive Care Unit occupancy on admission decisions and outcomes for critically ill patients. Crit Care Med. 2018 May 46(5): 720–727
[ii] Groenland CNL, Temorshuizen F, Rietdijk WJR, et al. Emergency Department to ICU Time is Associated with Hospital Mortality: A Registry Analysis of 14,788 Patients from Six University Hospitals in the Netherlands. Crit Care Med. 2019 Nov 47(11): 1564-1571.