Expanding ED Capacity Alone May Increase Crowding
It is argued that endemic boarding signifies the need to expand capacity. However, accessing the required capital and financing personnel costs are not feasible in tight economic times. Furthermore, expansion of ED capacity often simply reduces the ED's pressure on the inpatient services and ironically leads to more ED beds filled with boarding inpatients and longer ED LOS and more crowding.45
An observation unit, ideally run by the ED, may be an exception to expansion causing more crowding. An observation unit can unload the ED and, because of its 24/7 operational mentality, move patients through the system faster and more efficiently.46-48
Hospital Solutions to Crowding
The “full capacity protocol” is a straightforward solution to crowding that has proven to be safe and effective.49,50 By this protocol, when the ED and hospital are at capacity, appropriate (non-ICU) patients are sent to the inpatient floor to wait for the bed to be available. Basically, instead of the patient waiting (boarding) in the ED, the patient waits (boards) on the inpatient floor. Nursing ratios are often worse in the ED than on the inpatient floor when patients are distributed throughout the hospital.
Smoothing of elective admissions, particularly elective surgery, has demonstrated some of the greatest improvements in capacity. To some degree, effective smoothing calls into question whether there is a true capacity problem or whether it is simply a scheduling problem51 (see Chapter 40). Many services in the hospital are only available Monday through Friday, encouraging the practice of admitting the majority of elective patients early in the week; this asymmetry in flow drives lack of capacity early in the week and excess capacity late in the week and over the weekend. When elective surgical services are more evenly distributed over a full 5-day (or even a 7-day) schedule, inpatient and ICU capacity are increased, and overall throughput improved, with demonstrably decreased boarding in the ED.
Early Inpatient Discharges
In some regards, hospitals have a hotel-like function, turning over beds to the next patient. However, unlike hotels, hospitals may not have a “checkout” time. Hospitals that efficiently discharge patients early in the day, with a goal of 80% discharges out by noon, are less likely to board patients.45
EDs can improve their own flow to increase access. Beginning at triage, bedside registration, and bypassing triage when beds are available can save valuable minutes and improve flow. Moving nonemergent patients to a fast track or utilizing a “split-flow” process isolates low-acuity, low-resource intensive patients from the crowded conditions and improves flow for these patients. Increasingly, patients undergo extensive testing and imaging prior to admission. Determining clear expectations for turnaround times for these tests and monitoring performance can reduce wait times. Protocols and order sets, often initiated in triage, can reduce the time spent waiting for results.
In a paper-based system, fully 20% of a physician's time is spent writing on the chart.44 That time may be even longer with some computer-based electronic systems, and thus can contribute to delays in care. Scribes can be used not only to eliminate this time but to also gather laboratory information and old records. Scribes may also be valuable for nonphysician providers.
Completion of Workup on Inpatient Unit
“Packaging” the patient often requires completion of nondeterminative tests in the ED, many of which could be completed on the inpatient unit. Consultation in the ED can be valuable, but the demands on specialists in both teaching and private settings can delay consultation response and therefore patient admission to an available bed. Protocols that bypass a specialty workup in the ED with direct admission to the service can save minutes to hours. Monitoring consult response time helps to decrease the wait.
When crowding is severe, some facilities have moved a physician into the triage area. This has been shown to decrease the number of patients who leave prior to medical screening examination (LPMSE) and to initiate treatment more quickly. In EDs with a large volume of nonemergent patients, flow can be improved by treating those patients without using a bed.52-54 However, in EDs without large nonemergent patient loads or without large numbers of patients who LPMSE, the practice simply adds the cost of an additional physician without income or operational improvements to offset it. In the appropriate setting, studies have shown that physicians in triage enhance throughput and reduce LOS.55-59 Combined, these 2 improvements reduce occupancy and, therefore, the need for resources.
Large public hospitals have begun to defer the care of patients after an initial screening examination. These programs perform a medical screening examination and then recommend that patient without an “emergency medical condition” seek care elsewhere. This effort has been directed mostly at uninsured patients, and the safety of such practices has not been clearly established. Unless there is a referral site for them, these patients may be left completely without care and ultimately their illnesses will progress, adding cost to society later.