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{ "pk": 18626, "title": "Reduced Time to Admit Emergency Department Patients to Inpatient Beds Using Outflow Barrier Analysis and Process Improvement", "subtitle": null, "abstract": "<p><strong>Objective: </strong>Because admitted emergency department (ED) patients waiting for an inpatient bed contribute to dangerous ED crowding, we conducted a patient flow investigation to discover and solve outflow delays. After solution implementation, we measured whether the time admitted ED patients waited to leave the ED was reduced.</p>\n<p><strong>Methods:</strong> In June 2022, a team using Lean Healthcare methodologies identified flow delays and underlying barriers in a Midwest, mid-sized hospital. We calculated barriers’ magnitudes of burden by the frequency of involvement in delays. During October–December 2022, solutions targeting barriers were implemented. In October 2023, we tested whether waiting time, defined as daily median time in minutes from admission disposition to departure (ADtoD), declined by conducting independent sample, single-tailed t-test comparing pre- to post-intervention time periods, January 1–September 30, 2022 (273 days) to January 1–September 30, 2023 (273 days). Additionally, we regressed ADtoD onto pre-/post period while controlling for ED volume (total daily admissions and ED daily encounters) and hospital occupancy. A run chart analysis of monthly median ADtoD assessed improvement sustainability.</p>\n<p><strong>Results: </strong>Process mapping revealed that three departments (ED, environmental services [EVS], and transport services) co-produced the outflow of admitted ED patients wherein 18 delays were identified. The EVS-clinical care collaboration failures explained 61% (11/18) of delays. Technology contributed to 78% (14/18) of delays primarily because staff’s technology did not display needed information, a condition we coined “digital blindness.” Comparing pre- and post-intervention days (3,144 patients admitted pre-intervention and 3,256 patients post), the median minutes a patient waited (ADtoD) significantly decreased (96.4 to 87.1 minutes, P = 0.04), even while daily ED encounter volume significantly increased (110.7 to 117.3 encounters per day, P < 0.001). After controlling in regression for other factors associated with waiting, the intervention reduced ADtoD by 12.7 minutes per patient (standard error 5.10, P = 0.01; 95% confidence interval −22.7, −2.7). We estimate that the intervention translated to ED staff avoiding 689 hours of admitted patient boarding over nine months (ADtoD coefficient [−12.7 minutes] multiplied by post-intervention ED admissions [3,256] and divided by 60). Run chart analysis substantiated the intervention’s sustainability over nine months.</p>\n<p><strong>Conclusion:</strong> After systemwide patient flow investigation, solutions resolving digital blindness and environmental services-clinical care collaboration failures significantly reduced ED admitted patient boarding. </p>", "language": null, "license": { "name": "Creative Commons Attribution-NonCommercial 4.0", "short_name": "CC BY-NC 4.0", "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNonCommercial — You may not use the material for commercial purposes.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.", "url": "https://creativecommons.org/licenses/by-nc/4.0" }, "keywords": [ { "word": "emergency department outflow" }, { "word": "boarding" }, { "word": "delays" }, { "word": "technology" } ], "section": "Emergency Department Operations", "is_remote": true, "remote_url": "https://escholarship.org/uc/item/3j1829kp", "frozenauthors": [ { "first_name": "Marjorie", "middle_name": "A.", "last_name": "Erdmann", "name_suffix": "", "institution": "Oklahoma State University, Spears School of Business, Center for Health Systems Innovation, Stillwater, Oklahoma", "department": "" }, { "first_name": "Ipe", "middle_name": "S.", "last_name": "Paramel", "name_suffix": "", "institution": "Oklahoma State University, Spears School of Business, Center for Health Systems Innovation, Stillwater, Oklahoma", "department": "None" }, { "first_name": "Cari", "middle_name": "", "last_name": "Marshall", "name_suffix": "", "institution": "Oklahoma State University, Spears School of Business, Center for Health Systems Innovation, Stillwater, Oklahoma", "department": "None" }, { "first_name": "Karissa", "middle_name": "", "last_name": "LeHew", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "" }, { "first_name": "Abigail", "middle_name": "", "last_name": "Kee", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Sarah", "middle_name": "", "last_name": "Soliman", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Monica", "middle_name": "", "last_name": "Vuong", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Sydney", "middle_name": "", "last_name": "Spillane", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Joshua", "middle_name": "", "last_name": "Baer", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Shania", "middle_name": "", "last_name": "Do", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Tiffany", "middle_name": "", "last_name": "Jones", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" }, { "first_name": "Derek", "middle_name": "", "last_name": "McGuire", "name_suffix": "", "institution": "Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, Tulsa, Oklahoma", "department": "None" } ], "date_submitted": "2023-12-12T23:27:52Z", "date_accepted": "2024-05-16T22:49:49.126000Z", "date_published": "2024-08-01T13:00:00Z", "render_galley": { "label": "Final Article", "type": "pdf", "path": "https://journalpub.escholarship.org/westjem/article/18626/galley/24593/download/" }, "galleys": [ { "label": "Layout", "type": "pdf", "path": "https://journalpub.escholarship.org/westjem/article/18626/galley/14991/download/" }, { "label": "Final Article", "type": "pdf", "path": "https://journalpub.escholarship.org/westjem/article/18626/galley/24593/download/" } ] }