Flow in the emergency department (ED) is both a product of and contributor to the flow of patients and processes in the entire hospital. The process of patient flow begins when the patient crosses the threshold into the ED and does not end until the patient leaves the hospital. For most patients, the ED is part of the entire patient experience and should not be considered separate from the rest of the hospital. When addressing the flow problems in the ED an approach that views the ED as an entity independent from the hospital as a whole is not a viable approach.
Bottlenecks in the ED, operating room (OR), and the postanesthesia care unit (PACU); issues with availability of telemetry beds; longer lengths of stay (LOS); complications and “adverse events”; and poor satisfaction of patients, physicians, and staff may all be manifestations of poor patient flow in the hospital. Contributing factors to poor patient flow include
- Peaks and valleys in the inpatient census driven by the elective schedules of the operating room, catheterization lab, and other procedural areas of the hospital (variable demand)
- Staffing and scheduling preferences with little or no correlation to clinical need of patients (demand-capacity mismatch)
- Poor admission and discharge practices
- Variable ED volume
- Lack of coordinated care
- Lack of availability of long-term care and psychiatric beds
In addition, the variability of ancillary services availability also presents significant flow problems for both inpatients and the ED. The notion that hospitals are (fully) staffed and function at full capacity 24 × 7 × 365 is just not reality. This variability causes ancillary services, such as like nuclear medicine, physical therapy, case management, and some imaging capabilities, to have decreased availability on weekends and after hours. This decreased capacity results in longer LOS when these services are needed, but unavailable.
Improving patient flow requires collaboration and a multidisciplinary effort. When making decisions about change, it is necessary to first gather data to drive decisions and create a foundation of collaboration among physicians, nurses, and hospital leadership. These decisions must be based on relevant, recent, and actionable data as well as a commitment by the hospital and physicians to hold each other accountable and to continue to improve.
Some of the ways hospitals can drive patient flow improvement include
- Matching demand-capacity
- Smoothing the flow of elective admissions
- Addressing the drivers of admission and discharge efficiency for inpatients
- Creating effective dashboards by which to measure success
Experience with hospital-wide flow committees has shown that 3 key issues commonly emerge1:
Selected improvement projects are often not aimed at the true patient flow bottlenecks.
Changes, which result from those selected projects, may improve flow only in part of the system, but may not optimize flow in other parts of the system.
Many hospitals lack the resources, will, and ability to execute the changes needed ...