When Addressing ED Throughput, Don't Forget To Check The Back Door

Yesterday's post covered the anticipated increase in ED visits for most hospitals because of the impact of healthcare reform. As hospitals prepare for this they will most certainly look to improve ED throughput, which is certainly what I would recommend. Many efforts I have seen hospitals attempt focus on the front door of the ED to get patients into the system faster. This is important but it is usually only part of the solution to faster throughput in the ED.

A number of approaches have been tried to get patients into the treatment cycle faster. Door to doc time or door to treatment time is a metric we all look at. Some innovative approaches have been used to shorten this. Some of them work and some of them don't. For example, hospitals have tried a policy of not using the waiting room unless absolutely necessary. The idea is to have enough treatment rooms in the ED to whisk new arrivals instantly into a room. This gives them the idea that treatment has begun. But the plan backfires when a patient waits an hour in a room without seeing anyone. Its like entering a crowded restaurant and immediately getting a table only to wait an hour for the waiter to show up. To improve throughput you need to begin service earlier.

But while many hospitals do effectively reduce waiting on the front end, fewer recognize the impact of the backlog on the back end of the ED. I'm talking about the patients waiting to be admitted upstairs. Disposition to Admit time is the metric to look at. Admit is defined as the patient has left the ED and is in an inpatient bed on a unit. Not all EDs recognize the significant impact this can have on ED throughput, patient satisfaction, ED productivity and ultimately new ED business.

The primary reason that ED patients who need admission remain in the department is the lack of available beds upstairs. We sometimes see a lack of cooperation from nursing staff to accept new patient in available beds, but usually its because the beds are full. And often they are full with patients who have been medically ready to be discharged for hours. They just haven't left yet. This is often because they are waiting on a family member who works or because the attending physician makes rounds late. These are both challenging issues but they can be addressed. We have helped many hospitals do it.

So when focusing on improving ED throughput, don't forget to address the inpatients lingering in the beds upstairs. Your ED bottleneck may well be bigger at the back door than it is at the front.

More on this later.

Mark Brodeur