Patient access attacks ED problem 'on many fronts'

You can't control root causes, but you can have impact

If your hospital is like most, patients admitted through the emergency department are being held, possibly in hallways, for hours and even days. It's a complicated problem that the patient access department isn't responsible for and can't control. Still, you bear the brunt of the poor customer service scores that result from this situation.

"Patients waiting for an inpatient bed perceive this wait to be part of the admission wait time," explains Pam Carlisle, corporate director of patient access services at OhioHealth in Dublin.

"Not only are patient access staff rated on this issue by patients, which is out of their control, but they are also held accountable for this score on their customer service scorecards," she adds.

In contrast to bedside registration, which ensures privacy and confidentiality, the patient's privacy is potentially compromised by being interviewed in the hallway, says Carlisle. "Patients may rate the customer service of patient access staff lower because the patient's overall treatment time in the ED did not meet their expectation," she says. "Either they waited too long to see the physician or they waited too long for a bed on the floor."

As with most hospitals today, Ohio Health is forced to hold patients in its ED who are being admitted and waiting for inpatient beds to open. The issue, says Carlisle, is a result of numerous patient throughput issues — not just a shortage of staffed inpatient beds.

For example, patients scheduled for discharge may be waiting for family to arrive to pick them up, or nursing units may plan to discharge patients but are kept waiting for several hours for the discharge order to be written.

"We believe that although we do not control the elements, we can have an impact around the outcomes," says Carlisle. "At this time, we are attacking the problem on many fronts."

Here are some things that have been done:

• Patient access has worked with clinical staff to make the inpatient units more aware of the time delays.

"We have set into place some process steps to make each unit more accountable for those delays," says Carlisle. "We are hoping that this will decrease the wait time to be admitted."

Registration staff help round with the ED patients during long wait times.

"This keeps the patients informed of what's going on, and also helps with customer service scores," says Carlisle.

• Volunteers visit with all ED patients experiencing an excessive wait for a bed.

The volunteers keep the patient and families informed of where and when a bed is expected to open. They also provide food, drinks, and blankets.

• Patient access enlisted the help of the hospital's process excellence team to work on a project related to patient throughput.

"This project involves all patients and is not just looking at ED patients," notes Carlisle.

• Some low-acuity patients who require only basic treatment are seen by the physician in the triage area and are discharged from triage without ever being registered.

"These new 'fast-track' patients require patient access to redesign their process to accommodate the patient flow improvement," says Carlisle. "It is a good design for the patients, so we have to find a way to make it work!"

• A goal was set to discharge patients by noon each day.

"Most discharges are known early enough to get the patient out by noon," says Carlisle.

"Crowding has increased our wait times for lower acuity patients," reports Patricia Kunz Howard, PhD, RN, CEN, operations manager of emergency and trauma services at University of Kentucky Chandler Medical Center in Lexington.

"Boarding does impact access and increase waiting times, as well as ED length of stay," says Howard. "Our facility has been very proactive. We have implemented many changes to address crowding and patient access."

The hospital's "capacity management" staff use electronic bed boards to track available beds, and patient transfer facilitators were added to ensure timely access for patients. Patients who need observation can be moved to the clinical decision unit to free up ED treatment space.

The hospital also uses a "Full Capacity Protocol," which converts pre-determined private rooms into semiprivate rooms, to move patients out of the ED.

"When we are experiencing crowding, we utilize a pre-divert meeting with the capacity management staff, the hospital operations administrator, and the ED charge nurse to try and push some patients out of the ED," says Howard.

[For more information, contact:

Pam Carlisle, corporate director, patient access services, OhioHealth, 5350 Frantz Road, Dublin, OH 43016-4259. Phone: (614) 544-6099. E-mail:

Patricia Kunz Howard, PhD, RN, CEN, operations manager, emergency and trauma services, University of Kentucky Chandler Medical Center, H 113B, 800 Rose Street, Lexington, KY 40536-0293. Phone: (859) 323-6618. Fax: (859) 257-2814. E-mail:]