Becker's Hospital Review

13 Executive Briefing Sponsored by: T he emergency department serves as the primary driver of admit volume in most hospitals, accounting for more than half of hospital admissions on average. If an ED fails to function efficiently — whether due to slow discharge processes, inefficient ED operations or ED staffing issues — some patients may leave without ever seeing a provider. "If people are coming to the ED, they want to be seen, and if they can't get in, [hospitals] lose revenue and potential admissions," explains Jody Crane, MD, TeamHealth's chief clinical officer of emergency medicine and co-author of The Definitive Guide to Emergency Department Operational Improvement. Comprising 20,000-plus clinicians, TeamHealth is a physician-led company offering staffing, administrative support and management services. Patients entering a hospital via the ED tend to report lower Hospital Consumer Assessment of Healthcare Providers and Systems scores compared to patients who are directly admitted, Dr. Crane continues. "Poor-performing EDs can really hinder ED revenue and inpatient revenue and utilization," Dr. Crane warns. Poor patient experiences can translate into bad HCAHPS scores, which affect hospitals' reimbursements in the value-based environment. Patient flow is a major component of well-functioning EDs, and smooth patient hand-off processes can have a ripple effect across department operations hospital-wide. As the "front door" of the hospital, the ED is intertwined with the hospital's clinical, operational and financial goals. Messy patient flow systems may negatively impact care, bottom lines, patient satisfaction scores, clinical quality and patient safety. Fortunately, there are several key steps hospital leaders can take to get their patient flow on the right track. ED challenges — overcrowding, boarding and closed inpatient beds The U.S. reports 141.4 million ED visits annually, according to the CDC/National Center for Health Statistics. A Press Ganey study of 1.5 million patients at 1,893 hospitals found patients who spent one hour to two hours in the ED reported an overall satisfaction rate of 89 percent. The satisfaction rate dropped to about 77 percent when patients spent six-plus hours in the ED. "The take-home point is: If you're efficient in the way you handle patients and you deliver reliable care, then patients are going to be almost uniformly satisfied," Dr. Crane says. "The best way to please patients is to provide them with a reliable experience that is better than what they expected." Besides lowering patient satisfaction scores, inefficient patient flow in the ED can negatively influence operations across the hospital system. Consider an ED that is over capacity daily. In this scenario, let's say a patient suffering from acute appendicitis walks through the door at 6 p.m. and is not seen until 3 a.m. The patient requires surgery at this point, but a surgeon is no longer onsite at such an early hour. Now, the hospital must call in staff to perform a surgery in the middle of the night. Ultimately, a weak patient flow system pushes volume into the overnight shift, when hospitals already have less staffing. "It you're not keeping up with your demands, that overnight hospitalist is going to be overwhelmed," says Dr. Crane. Additionally, Dr. Crane notes inefficiencies and constraints in other parts of the hospital can aggravate crowding in the ED and increase length of stay to roughly one day. This crowding may be due to closed inpatient beds. Strapped with cost constraints, hospitals are attempting to cut down on unnecessary spending, including closing inpatient beds not in use. Unfortunately, this has a ripple effect on ED patient flow. "We're encountering an unusual phenomenon of patients in the ED who are waiting to get upstairs, but there are closed beds upstairs," explains Dr. Crane. While boarding in the ED may seem like the most appropriate solution in the short-term, it can also inadvertently lead to poor care quality, decreased patient safety, delayed care and low patient satisfaction, according to the American College of Emergency Physicians. "It's not that we're running out of inpatient beds, but we're running out of resources to care for patients on the inpatient side," Dr. Crane says. "It's a big dilemma." Don't just 'go with the flow' How do ED leaders begin improving their patient flow systems? Improving patient flow within an ED requires trial and error and a deep-dive analysis. Dr. Crane suggests ED leaders first look at their metrics to pinpoint bottlenecks. Is the hold-up at the front door or is it a backend problem with transferring patients upstairs, for example? Next, investigate your ED's staffing efficiency to determine if the department has the appropriate mix of physicians and nurses at the appropriate times. Organizations don't want to land too high or too low on national benchmarks for staffing productivity, as each extreme indicates either an excess or dearth of resources. 'Unfreeze' your emergency department to enhance patient flow & satisfaction

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