Crowded and inefficient EDs are a perennial concern for hospitals, and it’s becoming more clear than ever before that there is a direct effect on quality of care and patient safety. Particular strategies are known to work, but some hospitals still can’t fix their ED problems.
The more important lesson is that fixing ED issues requires looking beyond the confines of the ED.
When surveyed about a set of interventions proven to improve ED operations, hospitals in 2015 had on average adopted only half of them, according to research by Jesse Pines, MD, MBA, professor of emergency medicine, health policy, and management at the George Washington University School of Public Health in Washington, DC. (An abstract of the study is available online at: http://bit.ly/2z9Q7Jr.)
The inclusion of ED throughput in the Medicare Star Ratings has driven more attention to the issue in recent years, Pines says.
“There are a number of reasons hospitals are not addressing throughput in the emergency department as effectively as they could be, even though there are strategies out there that they could implement,” Pines says. “Some are more difficult than others because the emergency department is a complex environment in which to do quality improvement. There are so many interactions with other parts of the hospital that having an efficient emergency department requires not only that it perform well, but that hospital services such as laboratory, admitting, [and] bed management … perform well.”
It is not uncommon for a hospital to look at all areas that need attention and realize that fixing the ED is too complex and requires too much effort in disparate areas, Pines says. Hospital leaders may opt instead to address the low-hanging fruit that can yield faster and more concrete results, he says.
Demonstrate Quality Commitment
Research has indicated that certain ED interventions work, but more important is a commitment to quality improvement, he says. That commitment hinges on four criteria, he says.
“The first is a dynamic leader in the emergency department, either a physician or a nurse who is committed to making improving the flow of the emergency department their passion,” he says. “The second is an administration that invests resources and makes improving the emergency department a priority. Without those two, any intervention is going to be unsuccessful.”
Next comes the availability of data and the ability to analyze it, Pines says. The fourth criterion is long-term commitment.
“Some hospitals are looking for a silver bullet, like adding more ED beds, and they hope that doing that one thing will solve their problems,” Pines says. “A lot of studies have shown that is not always effective and often is a very expensive short-term fix. Unless you fix the broader problems across the hospital that affect the ED, you’re just going to stack more patients in the ED without really improving care or efficiency.”
Interventions for boarding can be particularly challenging because they must involve all the other inpatient services, which are themselves complex organizations, Pines says.
If those four criteria are met, a hospital can look to interventions that have been proven to improve the functioning of an emergency department. Some of those interventions include streamlining the triage process, providing express service for some patients who do not need complex care, improving transitions from the ED to inpatient units, and using software to anticipate patient volume.
But whatever intervention is attempted, some challenges are inevitable, Pines says. With so many ED issues related to the function of other hospital departments, many interventions can be stymied by what happens, or doesn’t happen, elsewhere.
“Generally, the more services involved or the more people who have to come to the table to agree to something, the harder it is to do,” Pines says. “Non-participation by other service lines can be a real barrier. They may feel like they are functioning just fine, so to address the issues you have in the ED you have to convince [them] that they need to make it a priority to improve.”
Another challenge is deciding what intervention to address first. Pines suggests looking at the research indicating the potential interventions and remembering that there is not likely to be any one intervention that will solve your problems. Study your own data to determine the primary problems in your ED and look for interventions that might work together to address root causes, he suggests.
Data Analysis Is Key
No matter what interventions you use, make measurement and data analysis fundamental parts of the program, Pines says.
“Quality improvement is about trying things and measuring progress over time, working your way through different interventions in a stepwise way,” he says. “You may have success in an area and move on to the next intervention, but you still need to measure that first intervention to see if the improvement is holding up. They may have slipped back to the old way of doing things and you’ve lost your gains with that intervention.”
Remember that ED performance is about more than efficiency and cost control, Pines says. Multiple studies have demonstrated that quality of care suffers in overcrowded and inefficient EDs, he says.
“There is a clear quality rationale that says if you address crowding, quality will improve,” Pines says.
Clear Link With Quality
Numerous quality measures can be affected by ED overcrowding and other ED issues, says Benjamin Sun, MD, MPP, FACEP, professor with tenure in the Department of Emergency Medicine at Oregon Health and Science University in Portland, and director of its emergency medicine research fellowship. He has conducted extensive research on ED crowding and its relationship to quality.
“There is very consistent literature showing that the higher the level of ED crowding, the worse a hospital performs on other process measures like time to pain medication for broken bones, antibiotics for pneumonia, and patient satisfaction,” he says. “More importantly, there is literature showing a correlation between ED crowding and mortality.”
Sun’s most recent research identified four key strategies to reduce overcrowding in EDs, concluding that an engaged executive should be combined with a data-driven approach and coordination across the hospital at all levels. (An abstract of the study is available online at: http://bit.ly/2zb8r4J.)
The study identified groups of hospitals categorized as low-, high-, or highest-improving in terms of lengths of stay and boarding times (the length of time an admitted patient must wait for an inpatient bed), as measured through statistics provided by 2,619 U.S. hospitals to CMS. The authors picked a representative sample of four hospitals in each of the three categories of performance, then systematically interviewed a broad range of stakeholders including nurses, ED directors, directors of inpatient services, chief medical officers, and other executive officers.
Previous research by Sun and his colleagues indicated that there is a great deal of variation among hospitals on the Medicare ED crowding metrics, but Sun says some of that is attributable to factors beyond an individual hospital’s control, such as community demographics and size. But even after adjusting for those factors, there still was significant variation.
“We found that there are some hospitals that have figured out how to do a good job, and other places that still have poor performance,” Sun says. “That led to our most recent research where we identified the factors that define high-performing hospitals, and they are factors that are within the control of the hospital.”
No Single Strategy Works Best
Sun says he and his colleagues were hoping to identify specific forms of intervention that are most effective, but those were elusive.
“To our surprise, we didn’t find that any specific form of intervention … tied to a higher performance level. We were hoping there would be evidence that if you would only do X, Y, and Z interventions, your problems would go away,” Sun says. “We didn’t see that. We found that across all levels of performance, they were using the same words and doing essentially the same things. They all had a provider in triage, used lean quality improvement methods, and [employed] other common interventions.”
So, particular interventions were not the discriminating factors. Instead, they identified four broader approaches that were common to those hospitals best addressing the efficiency of the ED and performance on quality measures:
- Involvement of executive leadership. Executive leaders in high-performing hospitals identified hospital crowding as a top priority complete with clear goals and resources to achieve those goals. “In contrast, low-performing hospital executive leadership did not prioritize crowding initiatives, despite acknowledging the causes,” the authors wrote. “Emergency department leadership often felt isolated in their struggle with significant boarding and lengths of stay.”
- Hospitalwide coordinated strategies. High-performing hospitals performed as a cohesive system across departments to alleviate crowding, in contrast to low-performing hospitals that operated in silos. For example, one executive at a high-performing hospital developed strategies for improving bed turnaround times on inpatient rooms. “Instead of waiting for the room to go from dirty to clean and then to book transportation for a patient to come, we started doing things in parallel so that we would cut down on waiting time,” the executive wrote in the report.
- Data-driven management. High-performing hospitals gathered and used data to adjust operations in real time, provided immediate feedback to key personnel, and predicted patterns of flow in the ED and hospital, matching resources to meet expected demand. “In contrast, at low-performing hospitals, data were most often available only retrospectively, and, if the data were used, they were discussed by executive leadership at monthly or quarterly meetings,” the authors wrote.
- Performance accountability. High-performing hospitals held staff accountable and problems were addressed immediately to reduce crowding.
Leaders More Receptive
One good finding from that research is that hospital leaders have come a long way in the past 10 or 15 years, acknowledging that ED crowding is not just a function of how the ED itself operates, but driven mostly by inpatient crowding and inefficiencies throughout the hospital. That was not common wisdom until recent years, Sun says.
“You have to have hospital leadership make ED crowding top priority, and they have to understand that it requires more than just telling the ED director to fix it. Having your hospital leadership understand the breadth of the problem is a big first step in improving the metrics,” Sun says. “That facilitates addressing cross-department initiatives, which is key to making any improvements with this problem.”
One hospital executive at a top-performing hospital told the researchers that they used ED crowding as a global metric of hospital efficiency overall, Sun recalls. Any problems with the lab, environmental, surgical, or intensive care services would eventually manifest in the form of ED overcrowding, he said.
Sun, an emergency physician, recalls working in a 20-bed hospital with an inpatient boarding challenge, and on some days every ED bed was occupied by someone waiting for an inpatient bed. No matter how efficient he and the ED staff were, they could not free up ED beds until inpatients were available.
“We were scrounging for anywhere to treat a patient — in the hallways, closets, anywhere we could put them,” Suns says. “It illustrates that when you have a very severe boarding problem, just focusing on the ED operations is addressing only a tiny part of the whole issue.”
- Jesse Pines, MD, MBA, MSCE, Director, GW Center for Healthcare Innovation and Policy Research, George Washington University School of Medicine & Health Sciences, Washington, DC. Email: firstname.lastname@example.org.
- Benjamin Sun, MD, MPP, FACEP, Professor with Tenure, Department of Emergency Medicine, Oregon Health and Science University, Portland. Phone: (503) 494-1193. Email: email@example.com.