Why Your CEO Needs to Fix ED Holding

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bukata-mugIt’s bad for patients and it’s bad for business. Thankfully, there are more than a dozen ways to fight it, and plenty of research to back you up.

It’s bad for patients and it’s bad for business. Thankfully, there are more than a dozen ways to fight it, and plenty of research to back you up.  

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I am known for whining. On some topics I’m a dog with a bone. One of the topics on the list that raises my BP is CEOs who tolerate holding admitted patients in the ED. And yes, tolerate is the right word. To me, tolerate implies that somebody who can do something about a situation chooses not to. And that’s exactly how I feel about CEOs who don’t adequately address holding admitted patients in the ED.

Now, if your ED doesn’t hold admitted patients, or at least rarely does, congratulations. You can stop reading now.

But, if your ED is like most, you hold admitted patients routinely, and you’re extremely frustrated about it because it seems you are incapable of fixing the problem. And, in fact, you are incapable because this is largely a top-down problem. The people at the top need to be motivated to fix the problem, and, if they are not, you are baying at the moon.

So the question is should your CEO really care about this issue? Sure, they have lots of other challenges to deal with — the medical staff has got its knickers in a twist over something, the employees want to unionize, there is too much overtime, the hospital’s margins are too thin — you name it.

And, in fact, the ED has always been a mess and is easily viewed as a necessary evil. There are all of those uninsured and Medicaid patients. The hospital loses money even on the Medicare patients. The medical staff wants ridiculous stipends to take call, if they are willing to take call under any circumstances. And, of course, there all of those EMTALA risks, and the ED is a disproportionate source of complaints, medical errors and lawsuits. Who needs it?

Simply put, the ED is important, not because it generates head-turning revenue, but because, like Jeter was to the Yankees, it’s the face of the franchise. I wouldn’t be surprised if about half of all patients admitted to hospitals come through the ED.

That’s just one reason why your CEO needs to be on top of — and do something about — the ED holding issue. Here are some of the ideas that have been suggested to solve the problem:

  • Create a bed czar. 
  • Mandate discharges before noon (the medical staff may whine — but just do it).
  • Start a discharge lounge.
  • Empower medical directors of the ICU and CCU to help make decisions on who needs to be moved out.
  • Stop believing everyone needs a monitored bed.
  • Find the members of the medical staff who have the longest LOS and have Guido talk to them.
  • Spread out elective surgeries throughout the week rather than bunching them up early in the week.
  • Run your hospital 24/7 – the patients are just as sick after 5pm when most hospitals effectively shut down.
  • Get a good, motivated, knowledgeable hospitalist group (office-based physicians will make more money if they stick to office practice rather than trying to do inpatient and outpatient care).
  • Limit ICU/CCU privileges to specialists (or at least mandate consults) so that every Tom, Dick and Mary can’t screw around trying to be an intensivist.
  • Have dedicated intensivists.
  • Start an observation ward with your ED physicians and hospitalists.
  • Threaten to admit patients to the halls on the floor (they have nicer halls than in the ED) and don’t let anyone tell you it is against the fire code or the like unless they can prove it.
  • Try to narrow variability in clinician practice (this is really, really tough and needs medical staff champions).
  • Finally (and this should be at the top of the list) link the CEOs bonus to ED throughput metrics including the holding of ED patients. This would get the problem fixed in literally a few weeks – guaranteed.

Why move admitted patients out of the ED? I could make the case that it is just good business, but this doesn’t seem enough of a motivator. So let’s focus on why CMS has finally gotten its act together and is now interested in ED throughput metrics: It’s because it’s unsafe to run an ED that makes patients wait excessively; because it is unsafe to hold admitted patients in the ED (especially ICU-type patients).

The literature on this subject is compelling. Here are the conclusions of five articles from the EMA database to stir you, your medical staff, and most importantly, your CEO to fix your holding issues. Each article indicates the potential for increased mortality — not just length of hospital stay, not just increased charges, not just increased morbidity — but increased mortality that occurs when EDs are crowded and holding patients.

EFFECT OF EMERGENCY DEPARTMENT CROWDING ON OUTCOMES OF ADMITTED PATIENTS
Sun, B.C., et al, Ann Emerg Med 61(6):605, June 2013
CONCLUSIONS: This large study quantifies an excess in inpatient mortality, hospital length-of-stay and costs among patients admitted through the ED on days of high ED crowding, and supports implementation of a systematic strategy to address this important public health priority.
37 references (sunb@ohsu.edu – no reprints)
Copyright 2014 by Emergency Medical Abstracts – All Rights Reserved 1/14 – #10

INCREASE IN PATIENT MORTALITY AT 10 DAYS ASSOCIATED WITH EMERGENCY DEPARTMENT OVERCROWDING
Richardson, D.B., Med J Australia 184(5):213, March 6, 2006
CONCLUSIONS: The author feels that ED overcrowding may be associated with increased short-term inpatient mortality.
14 references (drew.richardson@act.gov.au)
Copyright 2006 by Emergency Medical Abstracts – All Rights Reserved 8/06 – #21

THE ASSOCIATION BETWEEN HOPITAL OVERCROWDING AND MORTALITY AMONG PATIENTS ADMITTED VIA WESTERN AUSTRALIAN EMERGENCY DEPARTMENTS
Sprivulis, P.C., et al, Med J Australia 184(5):208, March 6, 2006
CONCLUSIONS: These findings suggest that hospital and ED overcrowding is a source of increased mortality and represents a patient safety issue.
24 references (peter.sprivulis@uwa.edu.au)
Copyright 2006 by Emergency Medical Abstracts – All Rights Reserved 8/06 – #22

ASSOCIATION BETWEEN WAITING TIMES AND SHORT TERM MORTALITY AND HOSPITAL ADMISSION AFTER DEPARTURE FROM EMERGENCY DEPARTMENT: POPULATION BASED COHORT STUDY FROM ONTARIO, CANADA
Guttmann, A., et al, Br Med J 342:d2983, June 1, 2011
CONCLUSIONS: Rates of death and admission to hospital increased with increasing lengths of stay in these Canadian EDs, regardless of patient acuity levels.
34 references (astrid.guttmann@ices.on.ca – no reprints). Copyright 2014 by Emergency Medical Abstracts – All Rights Reserved 12/14 – #35

IMPACT OF DELAYED TRANSFER OF CRITICALLY ILL PATIENTS FROM THE EMERGENCY DEPARTMENT TO THE INTENSIVE CARE UNIT
Chalfin, D.B., et al, Crit Care Med 35(6):1477, June 2007
CONCLUSIONS: This large study documents an adverse effect of “boarding” of critically ill patients in the ED for six or more hours prior to transfer to the ICU.
33 references (dchalfin@applied-decision.com)
Copyright 2007 by Emergency Medical Abstracts – All Rights Reserved 11/07 – #16

I think there definitely has been an increased focus on improving ED throughput. Door-to-provider times really matter at many hospitals, and, in some locations, it is less than 30 minutes. In some subsets, it’s even shorter. Patient satisfaction scores, even with their acknowledged faults, are driving patient-focused care. But we still, as an industry, have a reputation for making patients wait while still charging concierge-level prices. It is, however, an entirely different matter when we allow our EDs to become dysfunctional to the point where patients suffer more than inconvenience, when our fixable dysfunction endangers their lives. If this doesn’t provide a wake-up call to the “suits,” nothing will.

Richard Bukata, MD is the editor of Emergency Medical Abstracts

 

2 Comments

  1. Tracy Mahoney on

    Nothing will fix the ER until CEOs realize that they need to hire more floor nurses and more ER nurses; also the nurse to patient ratio needs to be attainable; ex: yesterday our ER charge nurse had to take care 10 patients, yes 10 patients, who were on the wall because not enough room in the ER and not enough nurses upstairs to discharge pts and not enough beds available; you can’t make a floor nurse who already has 5 pts take care of more, just like the ER charge nurse is NOT supposed to have any pts; we almost missed a STEMI because of it.
    Floor nurses should not have more than 4 pts; DOU RNs should have 3, ICU RNs should have 2, ER RNs should have 3; but until the hospitals fork over the money to provide patients with the appropriate nurses, nothing is going to change…in fact it will probably get worse

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