January 27, 2013

Empty the Dishwasher

True story: a few months ago, I walked into my apartment, and noticed the sink was overflowing with dishes. My first reaction: The dishwasher must be full.

I had been taught a few years ago that the main cause of crowding in the ED is boarding of admitted patients: patients who came to the ED, got admitted, and are waiting for beds upstairs. It seemed a bit odd at first, but the explanation makes sense. There are 3 possible causes: input, throughput, and output. Either there are too many patients coming to the ED; patient time in the ED is too long; or, we can't get patients out of the ED.

While the mainstream media and many policy people who aren't fluent with the topic are quick to attribute crowding to armies of low-acuity patients clogging up EDs with sore throats and ankle sprains, empirical evidence shows that's just not the case.

And it makes sense. If an admitted patient sits in the ED for an extra 6 hours, that's the equivalent load as 6 low-acuity patients who each take an hour. They may not take up a lot of physician time (although they do use some) they require a nurse, and a space in a room (or hallway).

Same idea with throughput. Although some emerging evidence suggests that throughput is a bigger factor than we thought. But much of this is probably due to EDs doing more comprehensive workups in order to avoid admitting patients.

So why is boarding such a pervasive problem? The reasoning is that hospital administrators think that hospitals generate more revenue from elective, procedural admissions than from ED admits. Therefore, elective surgical schedules are kept full in order to bring as as much revenue as possible, and the ED patients will still get admitted (after waiting for a while). If hospitals cancelled elective admissions because the hospital was full, they would forgo that revenue.

However, there is some evidence that this calculation is mistaken, and hospitals actually lose revenue by filling up the hospital, forcing the ED to go on diversion, so that critically ill patients are lost (and they pay pretty well).

Oh, and keeping the ED crowded leads to all sorts of badness for the patients, not just longer wait times but worse care.

Further, lack of space in rehab and nursing facilities (and lack of payment by insurers) is another hospital-output problem, particularly for public hospitals.

In addition to dialing down elective procedures, hospitals can help with crowding in a number of ways. Overall, a lot of it is a matter of hospital operations (the business/admin stuff, not the surgical stuff. coincidence?) Simple things like automatically calling housekeeping to clean a room when an inpatient is discharged.

Perhaps the best plan, concocted by Peter Viccellio, is brilliantly simple. If all the admitted patients can wait in the ED hallways, why can't we spread them throughout the inpatient hallways? There are certainly a lot of hallways and nurses upstairs, too. It's been shown to be safe, preferred by patients, and, not surprisingly, places that institute inpatient hallway boarding "magically" find beds for half of the hallway boarders fairly quickly.

Yet EDs across the nation are still crowded, most of the time, pretty much everywhere. Perhaps if hospitals made better decisions, things would be better -- for revenue, for healthcare workers, and for patients.

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