To understand one reason why your hospital cares so much about patient throughput and discharging patients before noon, think of tables in a restaurant. A restaurant has a limited number of tables, and the more quickly they serve customers, the sooner they’re able to seat a new party. So by improving their throughput, they can serve more customers and increase profitability without having to add tables.
Of course, the more a restaurant pushes to increase throughput, the more it risks a decrease in the satisfaction of its customers. Too much focus on throughput could annoy customers so much that it puts them out of business (Seinfeld’s Soup Nazi is one notable exception).
Yet hospitals are likely to increase their customers’ satisfaction by improving “front-end” throughput from the ED to the inpatient unit. In fact, CMS added two new core measures (known as inpatient quality reporting, or IQR) that hospitals began reporting on Jan. 1:
- Median time from ED arrival to ED departure for admitted patients, and
- Admit decision time to ED departure for admitted patients.
You already knew about these, right? Although they don’t directly influence Medicare payments to your hospital now, there is a pretty good chance they could become part of the Hospital Value-Based Purchasing program in the future. So expect administrative leaders at your hospital to continue pestering you about ED throughput with even greater intensity.
I confess that improving throughput feels like one of the most difficult things for me to do, and I sweat when in meetings about it. Yet I know intellectually that we can do better. After all, it wasn’t that long ago that a patient could expect to wait hours to see an ED doctor, and shortening the wait seemed an impossible task. But EDs everywhere have done just that, and now lots of them post the current ED wait time (typically less than 10 or 15 minutes!) on the Internet or billboards. So if they can do it, then I’m sure hospitalists can, too.
I wrote about hospital throughput in my April 2009 and May 2010 columns, and included some strategies you might want to try. Here are a few more directed at ED-to-inpatient ward throughput.
The One-Admitter Approach
Most practices have no option other than a single admitter at night, but if your one admitter during daytime hours reliably gets behind, then you should have “rounders” help with admitting duties. While this is stressful for the rounder, and could sometimes delay the rounder’s ability to discharge patients early (more on that later), in most cases, the benefit will be worth the cost. In fact, I think the best arrangement is for all, or nearly all, daytime hospitalists to share admissions every day.
Remember, this approach will eliminate the admitter-to-rounder handoff from Day One to Day Two, resulting in a net increase in efficiency (and probably patient satisfaction). Plus, reduction handoff errors should decrease, because only one doctor, rather than two, will have to get to know the new patient.
Some hospitalists with inefficient work habits have an opportunity to become more efficient at taking a history and reviewing records, along with other steps in the admission process, without risking poor quality. But most are reasonably efficient at those tasks already and shouldn’t make them the focus of throughput efforts.
That said, most, or nearly all, hospitalists could shorten the time from when the ED pages on a new admission to when we appear in the ED to see the patient.
Here is one scenario that gives rise to the type of delay I’m talking about. The ED doctor pages a triage hospitalist, and the two finally speak directly 10 minutes later. After a five-minute conversation, the triage doctor pages the hospitalist who will actually admit the patient, waits 10 minutes for the return call, relays the information (possibly leaving out or misrepresenting some of what the ED doc said), and the admitting hospitalist heads to the ED 15 minutes later. Each person in this scenario acted reasonably promptly, but the clock starts with the first ED page. The hospitalist is already at 45 minutes when they arrive to see the patient!
You need to minimize “daisy chain” communication between the ED doctor and the hospitalist who will actually see the patient. In the scenario above, I think it would be best to eliminate the triage doctor entirely (see my December 2008 column for ideas about how to do this) so that the hospitalist who will actually admit the patient learns of the new referral quickly and speaks directly with the ED doctor.
Another reason for a poor “page from ED to hospitalist at patient’s bedside” time is that the admitting hospitalist just doesn’t make it a priority to get to the ED quickly. They might decide to round on two or three more patients before working on the new admission. Of course, we must triage and sometimes delay getting to the ED while attending to an unstable floor patient, but not too often, in my experience.
I’m not suggesting that others adopt my habit: I typically don’t call the ED back at all. Instead, I just head to the ED immediately after being paged, and usually arrive in less time than I would have spent on hold waiting for the ED doc to come to the phone.
When presented with several ED patients to admit at the same time or tied up with a critical patient on the floor, getting to the ED quickly isn’t possible.
Write Admission or “Holding” Orders and Move the Patient to His/Her Room
This is frustrating for the admitting hospitalist, because among other problems, families often leave when the patient moves to the inpatient ward, and additional tests likely will take longer to complete from the floor rather than ED. And while it is hard to quantify, I think this practice increases the risk of errors—though some studies have shown that long ED stays are associated with worse outcomes for the patient, too.
One of the marquee principles of ED medicine has historically been “ED doctors should never write admission orders.” Even so, I sense that this view is shifting, and many now see this as clinically reasonable, and in some cases necessary, to ensure good performance. Our ED docs have agreed to do this if there is concern that the hospitalist can’t finish writing orders within an hour of first being paged about the patient. Ask me in a year and I’ll let you know just how this is going.
And, of course, another option is for the admitting hospitalist to provide admission orders or “holding” orders by phone. I think this is safe for many patients, as long as it is followed by a bedside admission visit by the hospitalist before too long.
Next month: What about throughput at the discharge end of the hospital stay? And yes, improving throughput risks quality of care, yet we have to do it while maintaining or improving quality.
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm.