Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay

Abstract

IntroductionPatient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients.MethodsThe BPPI was implemented at our system’s tertiary care, academic medical center, a high-volume, high-acuity hospital that serves as a regional referral center for western Massachusetts. The BPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goal alignment and communication of operational teams. It was organized to address critical aspects of a patient’s progress through his hospital stay and to create additional inpatient capacity. The specific goal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine service by optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients. Concurrently, we measured the effects on emergency department (ED) boarding hours per patient and walkout rates.ResultsThe BPPI engaged over 300 employed clinicians and non-clinicians in the work. We created increased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively address patient progress; during the 24 months, this resulted in a sustained rate of discharge orders written before noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: −0.014, 95% CI [−0.023, −0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness over the same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient: −0.09; 95% CI [−0.15, −0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [−0.7, −0.1] P= 0.01).ConclusionThe BPPI realized significant gains in patient progress for adult patients by promoting earlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient and walkout rates decreased.

Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review

“…Moreover, the turnaround time (TAT) decreased in the five studies that addressed it. Boarding time was only evaluated in four LH interventions, with better results in all of them [ 3 , 19 , 29 , 91 ].…”

“…Other important outcomes reported included the percentage of day of surgery cancellations [ 8 ], reduction in surgery times [ 94 ], reduction of time to surgery [ 95 ], reduction of unnecessary instruments delivered to the OR [ 94 , 96 ], and savings in nursing time [ 97 ]. Additional measures of efficiency after LH intervention included an increase in capacity for extra patients [ 97 ], additional ED bed hours per day [ 91 ], an increase in capacity of open beds per day [ 19 , 98 ], a reduction in transfer due to lack of beds [ 29 ], improved OR utilization [ 8 , 26 , 27 ], and an increase in surgical admissions receiving appropriate perioperative antibiotics [ 86 ]. Finally, mortality was measured in six studies, four of which reported no change after LH intervention [ 17 , 18 , 28 , 29 ], while two studies reported a decreased [ 87 , 98 ].…”

“…Interesting, when the main goal is to reduce infections within surgical units, LH contributed to reducing the LOS in two out of three studies [ 18 , 100 ], while one study [ 86 ] reported no change. Moreover, when LOS was reduced, other associated benefits were reported, such as cost reductions [ 17 , 95 , 99 , 100 ], a better return of investment [ 48 ], increased savings [ 47 , 90 , 93 , 98 , 102 ], or an earlier discharge order [ 3 , 19 ].…”

“…Commonly targeted processes are the discharge and admission processes, due to the fact that these processes are almost always unnecessarily long and can have a large impact on the throughput of patients [ 111 ]. For the admission process, we found that the boarding time decreased in all four studies [ 3 , 19 , 29 , 91 ], in which 2.1 h was the longest reduction time, resulting in a boarding time of 5.5 h [ 19 ]. In the literature, boarding times ranged from 2 h (or less) to 24 h (or more), with medical/surgical patients experiencing shorter boarding times and behavioral patients experiencing longer boarding times [ 120 ].…”

“…Some measures used in outpatient care include emergency department length of stay (LOS) [ 9 , 10 ], the waiting time to see a healthcare professional [ 11 , 12 ], the waiting time for treatment [ 13 ], the waiting time for triage [ 14 ], and patients left without being seen [ 15 , 16 ], among others. Conversely, some common indicators within inpatient care are the hospital length of stay (LOS) [ 17 , 18 ], boarding time [ 3 , 19 ], and discharge order time [ 19 , 20 ]. Likewise, major areas of inefficiency that hospitals are trying to reduce are present in the perioperative workflow [ 21 ].…”