Reducing ED stays for admitted patients

The Clockwork ED Series on Eliminating Bottlenecks and Delays from the Washington, DC-based Clinical Initiatives Center had the following key findings:

• Given continuity of care concerns, most hospitals mandate the attending physician, or a physician from the admitting service, to write admitting orders for patients. Delays here are common and stem from physician time to get to the ED, length of subsequent exam, and, in some cases, additional test ordering. To avoid delays in physician arrival to the ED, some community hospitals are extending responsibility of hospitalists to include writing admitting orders.

• For academic medical centers, strong disincentives for residents to assume new patients often result in unnecessary handoffs between services and lengthy work-ups. That leads to granting ultimate admission authority to ED physicians.

• The result of successful reduction in admission decision process is earlier initiation of the bed placement process. Rather than confront political and operational challenges of speeding admission decision, some hospitals are achieving the same end by starting the decision and bed placement processes simultaneously.

• At many hospitals, admitting patients from the ED is cumbersome, requiring nine steps, at least five communications, and often taking 90 minutes. Some hospitals are trying to streamline the process by reducing necessary communications and removing bed control as the go-between for the ED nurse and the inpatient nurse.

• The biggest problem is inpatient nurse disincentives to assume new patients. All information needed for the admission process to move forward — namely, bed occupancy, bed availability, and the floor’s readiness to accept the patient — rely on inpatient nurse reporting and responsiveness.

• A few leading hospitals are attacking the problem in two ways. The first: Give ED nurses authority to send patients to a ready bed, regardless of floor nurse responsiveness. The second: Limit floor nurses’ role in providing bed readiness information. Hospitals use housekeeping to flag "patient-ready" and "ready to be cleaned" beds and use technology to inform necessary staff.