ED boarding continues to be an issue for hospitals and health systems in the United States. Many organizations struggle to streamline the ED and admission processes to facilitate improved efficiency. To learn more about the various practices some organizations are adopting to improve their boarding times, HBI spoke with Dr. John D’Angelo, the executive director and senior vice president for emergency medicine at Northwell Health.
Q. How did you go about implementing improvement efforts within Northwell Health’s EDs?
Dr. D’Angelo: There isn’t a one-size-fits-all model for implementing quality improvement efforts. There are a lot of variables in the ED, so we looked at the input, throughput, and output across the patient journey for optimizing the operations.
We also focused on driving this culture that triage is a verb and not a noun. It’s frustrating for your patients to repeat their entire story to the triage nurse, registrar, nurse performing the primary assessment, and the provider. So, we established processes to bypass triage when we are pulling patients directly to beds, and resort to traditional triage only if our ED is packed, which enabled flexibility. We “pull until full” and then if we can leverage chairs or alternative areas in the ED, we keep on pulling; the last place we want our patient is the waiting room.
We also tried to put as many processes in parallel as possible with the goal of getting the patient and provider together early in the care process. We had the front-line staff map their typical processes and looked at opportunities where processes being done sequentially can be run in parallels, such as having the providers and the nurses in the room obtaining history simultaneously when possible. We reduced the action of triage to simply obtaining a chief complaint and assigning an acuity at many of our facilities. Then based on the pivot nurses’ intuition of “sick vs. not sick” we hand the patients off immediately to an intake provider or the ED team who complete what we historically termed triage as part of their intake of that patient, reducing redundancy and expediting door to first orders.
Q. What has Northwell Health specifically done to decrease the time that patients sit in the ED before the physician flagging them for admission?
Dr. D’Angelo: ED boarding is a hospital flow issue, and its resolution is a team effort that comes from the top down. Some strategies we implemented within our EDs include:
- Transitioning every admitted patient in the ED to the inpatient team within an hour of their admission.
- Collaborating with the health system’s Chief Experience Officer, we created a “Patient Experience Bundle” to reliably address the following four domains for every admitted patient who did not have an inpatient bed: Communication, Logistics, Basic Needs (Comfort), and Environment.
- Developing a high-capacity protocol to streamline hospital responses preemptively depending on the patient volume.
- Assembling our hospitalists and front-line providers in a room to try and come up with solutions to optimize our workflows keeping the patients’ needs at the center of every decision.
Understanding the challenges we face within our ED and the inpatient units helped us better serve our patients and manage volumes. For instance, one of our hospitals came up with an intervention they called “squeezing the sponge,” in which every hospitalist on duty reports to the ED in the last few hours of their shift to help with the work up admissions. This, compared to the prior model where all patients queued up waiting for a single admitting hospitalist, decompressed the change of shift work by around 80%, and the hospital cut down its ED boarders by around 50%.
Also, we worked on a preemptive bed request, in which when it was clear that a particular patient would require admission, the ED team gave a heads up to the hospitalist and bed board teams about patients they are going to receive before completion of the ED workup. This further helped the teams plan their future work and expedite the admission process when the patient was ultimately admitted.
Q. How did Northwell Health measure its effectiveness, and what were some of the outcomes after implementing these interventions?
Dr. D’Angelo: One of our busy tertiary hospitals piloted the use of cameras in a few units to track retrospectively the actual empty bed to occupy time – and we managed to cut that time down from 10 hours to about five hours.
As a system, we have had many hospitals successfully move the needle on this problem while some still struggle. Overall as a system, we cut our boarder patients that are over 24 hours down by about 40%, as well as our boarder patients over 12 hours down by 30% since March. We achieved this by creating real-time tools to track metrics, including admission length and patient holding more than two hours, six hours, 12 hours, and 24 hours. Having data at your hand 24/7 and understanding its impact on the results we’re trying to achieve is critical to ensure improvement.
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