DDBA 8561 Week 4 Emergency Flow Paper Example

Boarding, Not Arrivals: A Flow Paper Locating the Bottleneck in a Community Hospital's Emergency Department at Inpatient Bed Assignment, Evidenced Interval by Interval and Followed to Where the Pressure Would Go Next

Student Name

Walden University

DDBA 8561: Seminar in Managing Healthcare Delivery Systems

Instructor Name

Month Day, Year

Boarding, Not Arrivals: A Flow Paper Locating the Bottleneck in a Community Hospital's Emergency Department at Inpatient Bed Assignment, Evidenced Interval by Interval and Followed to Where the Pressure Would Go Next

Introduction

Emergency department crowding at Ridgeway Regional, a composite 310-bed community hospital in North Carolina, is usually blamed on volume: visits have grown about 4 percent a year, and staff describe waiting rooms full of patients who could have seen a primary care physician. The hospital's response has been to add a fast-track area for low-acuity patients.

This paper argues that boarding, not arrivals, governs flow through Ridgeway's department. Admitted patients waiting for inpatient beds occupy treatment spaces for hours, and that occupation, more than the number of people walking in, determines how long everyone else waits. If the evidence showed that most delay accrued before the decision to admit, or that boarding hours were small relative to other intervals, the thesis would be wrong.

Literature

Asplin et al. (2003) proposed a conceptual model of emergency department crowding in three parts: what flows in, meaning the demand for emergency care; what happens inside, meaning the work of evaluation and treatment; and what flows out, above all the transfer of admitted patients to ward beds. The model's value lies in showing that crowding can originate in any of the three, and that remedies aimed at one may fail if the cause lies in another.

Hoot and Aronsky (2008) systematically reviewed research on crowding and grouped causes into input, throughput and output factors. Input factors such as non-urgent visits and frequent visitors are often blamed, and they deserve a fair hearing: fast-track areas can shorten waits for low-acuity patients. But the review found that the output factors, particularly inpatient boarding and hospital bed shortages, were among the causes most consistently associated with crowding. Non-urgent patients use relatively few resources, so removing them does little for the treatment spaces that admitted patients occupy.

Evidence

Ridgeway's tracking system records four time stamps for each visit: arrival, first provider contact, decision to admit or discharge, and departure. The intervals between them follow the consensus definitions Welch et al. (2011) published, so they can be compared with other departments. For the most recent six months, median intervals were as follows.

[after]

Admitted patients spend a median of 5 hours 40 minutes in the department after the decision to admit. About 21 percent of visits end in admission, but because admitted patients stay so long after the decision, they account for roughly 40 percent of all treatment space hours. On a typical weekday at 3:00 p.m., 11 of the department's 32 treatment spaces hold boarders.

The effect on discharged patients follows. When boarders occupy a third of the spaces, arriving patients wait for a space to open. The arrival-to-provider interval for discharged patients is 48 minutes overall but 74 minutes on days when more than ten patients are boarding at 3:00 p.m., and 33 minutes on days with five or fewer.

Table 1

Median Intervals by Disposition, Six Months

Why the Bottleneck Is Bed Assignment

The decision-to-departure interval for admitted patients has three parts: bed request to bed assignment, assignment to bed ready and bed ready to departure. Ridgeway's bed management system shows that bed request to assignment accounts for a median of 3 hours 50 minutes, most of the boarding time. Beds are assigned when a discharge is confirmed on the inpatient unit, and discharges cluster in mid-afternoon. The bottleneck is not the emergency department's process but the inpatient side's timing.

Where the Pressure Would Go

If boarding eased, through earlier inpatient discharges or a dedicated admission unit, the emergency department would treat patients faster, but the pressure would land elsewhere. Inpatient units would receive admissions earlier in the day, when nurses are completing morning care; earlier discharges would require pharmacy, transport and post-acute partners to work earlier as well. The fast-track area, meanwhile, would continue to help low-acuity patients but would not touch the 5 hours 40 minutes.

Implications

The hospital's investment in fast-track addresses input, while the evidence points to output. The more useful work lies in the timing of inpatient discharges and bed assignment, which the emergency department cannot control alone.

Testing the Thesis Further

A sharper test would compare weeks when inpatient occupancy was unusually low, such as the week after a holiday, with ordinary weeks. If boarding governs flow, waits for discharged patients should fall in low-occupancy weeks even if arrivals do not.

Limits

Time stamps depend on staff entering them accurately. Six months may not capture winter respiratory surges, when input pressures rise.

References

Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A., Jr. (2003). A conceptual model of emergency department crowding. Annals of Emergency Medicine, 42(2), 173-180. https://doi.org/10.1067/mem.2003.302

Hoot, N. R., & Aronsky, D. (2008). Systematic review of emergency department crowding: Causes, effects, and solutions. Annals of Emergency Medicine, 52(2), 126-136. https://doi.org/10.1016/j.annemergmed.2008.03.014

Welch, S. J., Asplin, B. R., Stone-Griffith, S., Davidson, S. J., Augustine, J., & Schuur, J. (2011). Emergency department operational metrics, measures and definitions: Results of the Second Performance Measures and Benchmarking Summit. Annals of Emergency Medicine, 58(1), 33-40. https://doi.org/10.1016/j.annemergmed.2010.08.040