A rapid admission protocol to reduce emergency department boarding times

Amarasingham, Ruben; Swanson, Timothy S.; Treichler, D B; AmaraSingham, Saha; Reed, William

doi:10.1136/qshc.2008.031641

Cited by 23 publications

(30 citation statements)

References 16 publications

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“…While the improvement in LOS observed in the current study was much greater (90 minutes), our study was conducted in a higher volume ED following a more comprehensive process change and intervention, which may explain this difference. A second rapid admission process study, reported by Amarasingham et al, used standardized admission holding orders to achieve significant reductions in ED boarding time (360 minutes vs. 270 minutes, p < 0.001) and in the time to admission order placement (210 minutes vs. 75 minutes, p < 0.001) . Howell and colleagues studied another unique intervention, a telephone‐based consultation between emergency physicians and in‐hospital hospitalists for admitted patients.…”

Section: Discussionmentioning

confidence: 99%

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay

Haydar

Strout

Baumann

2016

Academic Emergency Medicine

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Objective: The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients. Methods:We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior.Results: The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention. Conclusions:We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.ACADEMIC EMERGENCY MEDICINE 2016;23:776-785 © 2016 by the Society for Academic Emergency Medicine E mergency department (ED) crowding has taken center stage with growing emphasis now being placed on system-wide approaches to addressing issues related to health...

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Section: Discussionmentioning

confidence: 99%

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay

Haydar

Strout

Baumann

2016

Academic Emergency Medicine

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“…Other studies have shown that interventions alone are insufficient for achieving high quality improvement rates 25 26. A similar study on reducing emergency admission times applied Kotter's change management model 27. The rapid admission protocol used differs greatly from the Big Squeeze interventions, yet there is a remarkable similarity in their change management approach and engagement of clinician opinion leaders and multidisciplinary teams.…”

Section: Discussionmentioning

confidence: 99%

Using systematic change management to improve emergency patients' access to specialist care: the Big Squeeze

et al. 2012

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BackgroundDelayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality, and increased patient anxiety.Objectives(1) To provide timelier access to inpatient and urgent outpatient specialist care for emergency patients. (2) To influence multiple stakeholders to modify their traditional practices and sustain changes.SettingNational University Hospital of Singapore, an academic medical centre with 997 beds in Singapore and over 34 sub-specialties.MethodsA set of six interventions was implemented to meet three goals: (1) provide timely access to urgent outpatient specialist care requested by the emergency department ED; (2) increase early inpatient discharges (in order to better match timing of emergency admissions); and (3) provide earlier defined care by inpatient specialists at the ED. An eight-step organisational change management plan was implemented to ensure all specialties complied with the changes.ResultsThe goals were achieved. (1) Specialist outpatient appointments given within the timeframe requested by the ED doctor increased from 51.7% to 80.8%. (2) Early discharges increased from 11.9% to 26.6% and were sustained at 27.2%. (3) 84% of eligible patients received earlier defined specialist care at the ED. The change management achieved excellent clinician compliance rates ranging from 84% to 100%. However the median wait for admission remained unchanged.ConclusionThe interventions reduced the time for ED patients to access specialist outpatient and inpatient care. The systematic organisational change management approach resulted in sustained compliance.

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“…Although the practice of EPs writing holding orders has not been shown to improve patient safety, it has certainly been shown to reduce the length of stay in the ED. [12][13][14][15][16] We know from robust crowding literature that prolonged length of stay in the ED leads to poor outcomes in elderly, stroke, and critically ill patients. [17][18][19][20][21] Treatment delays lead to increased morbidity and mortality.…”

Section: Againstmentioning

confidence: 99%