Two recent articles on ED boarding and patient flow highlight growing awareness of the importance of this issue and its impact on what emergency physicians do every day. But while both articles suggest some ways of dealing with ED boarding, neither addresses directly the key ingredient to ensuring those strategies succeed: correct framing enabled by a strong working partnership between the Emergency Department and the hospital administration and staff.
The first story published in the September ACEP News, “Many Ways to Be Waylaid Between ED and Inpatient Bed” echoed the already common notion that not only does ED boarding of admitted patients “[cost] hospitals money, reduce patient satisfaction, and has been shown ultimately to increase length of stay and mortality,” but that healthcare reform will lead to even greater ED patient volumes, at least in the near term, meaning hospitals will continue to deal with this problem.
The second article, “Hospitals Failing to Address Patient Boarding” outlined some tried and true techniques for improving hospital flow in such a way as to make it less likely for back-end flow issues to affect ED boarding.
It is easy to sit at home as an emergency physician reading ACEP News and not feel impacted by these types of articles. After all, they seem to involve so many facets of the hospital that emergency physicians lack control over. How are we supposed to fix a boarding problem if it is generally agreed that boarding is a back-end hospital congestion issue?
In the ACEP story, Dr. Jody Crane is quoted emphasizing three factors in improving patient flow: physician handoff, nursing handoff, and bed efficiency. The last two may seem out of the scope of practice for an ER doc, but if emergency physicians forge strong relationships with their nursing and inpatient counterparts they can have a great deal of influence on flow that may not traditionally be in their purview. As such, there is no reason why emergency physicians, regardless of their type of practice, shouldn’t be leading the way in teaching their departments and hospitals how best to deal with their flow issues.
Our emergency department at Meritus Medical Center has tackled and mastered this issue. Meritus is consistently meeting its goals of having a door to doctor time of less than 30 minutes and a left without being seen (LWBS) of less than once percent. This is due in large part because of a coordinated, hospital-wide effort to do what is best for our patients. This is the key. While we employed a number of suggestions outlined in Dr. Crane’s article, they would not have succeeded if they were not framed the right way. Perhaps the largest obstacle to change in a hospital setting is not a lack of resources but a lack of shared strength and fortitude. If everyone involved is committed to doing what is best for our patients then there is no choice but to succeed.
These articles should not seem distant and unfamiliar, goals unattainable. Dr. Amal Mattu believes that emergency physicians are, and rightly should be, the EKG experts. I believe we should also be the efficiency and flow experts. The key to implementing change is to shy away from discussing what is best for your department and instead talk about what is best for your patients; the secret, of course, being that they are one in the same.