Lessons from the Field: How One Hospital Curbs Boarding

At our institutions, we are down to minimal divert times and very little or no boarding time in the emergency department, with the exception of psychiatric patients.

Each hospital is unique and has different bottlenecks in different areas; in many cases, even adding another wing to a hospital may not solve the issue because it doesn’t address the root of the problem. We do have a gross citywide shortage of psychiatric beds, and psychiatric units have given the ED preference on admissions. As a result, someone might spend a few days on the medical ward while waiting for a psychiatric bed, but we have incorporated several strategies mentioned in the recent Health Affairs report (2012;31:1757-66) that have essentially eliminated boarding of medical and surgical patients.

One of our bottlenecks was a delay in the time taken to call the floor to get a bed cleared for an incoming patient from the ED. Now, when it is clear that a patient is going to be admitted from the ED, even if all the tests aren’t completed and the patient hasn’t been fully stabilized, the ED doc alerts staff to contact the nursing supervisor. This allows him or her to clear beds well before the patient would be transferred to the ward or ICU, even allowing time to call in a nurse from home or open up an overflow area.

We also encourage all ED doctors to write holding orders so that when the accepting physician or resident can’t see the patient right away, they aren’t held up in the ED; the orders are sent up to the floor with the patient.

Additionally, one strategy we follow is that we don’t have to room each ED patient. Sometimes a patient can be seen in triage, and then, if they are just waiting for an x-ray, for example, they don’t have to take up an ED bed; they can go to radiology and wait in the lounge. That’s not something I saw in the [Health Affairs] report. These "fast-track" or ambulatory care cases should be different from the acute ED cases and not necessarily occupy an ED bed. We have decreased diversion times for ambulances to a minimum, even though the ED is seeing more patients. Our divert times used to be hours to days, and now they are measured in minutes.

Another strategy I didn’t see mentioned in the report is the use of overflow units. We have created an area of the hospital that we can open up to accommodate overflow medicine and surgical patients during the busy times, and we staff it with nurses who are on from a float pool or on-call system. We also use a "bed czar," in the form of the nursing supervisor, who constantly tracks beds and bed turnover, electronically, in real time, and that has helped us avoid bottlenecks.

More Doctors, Shorter Shifts

As for what hospitalists can do to minimize overcrowding and improve patient care, staffing and rounding early on potential discharges are key. I staff our hospitalists so we have plenty of people rounding in the morning, so more patients can be seen earlier in the day. For example, instead of having four 12-hour shifts of hospitalists, one can staff five doctors, with three doing 8-hour shifts and two doing 12-hour shifts. It is the same amount of doctor-hours per day, but you are front-loading the morning, so patients can be seen and then tests can be ordered and discharges can be arranged. We have staffed our hospitalists adequately and motivated them to round early on patients who are discharging, making the bed available for early afternoon admissions.

I think it is very short-sighted to have hospitalists see 20-plus patients a day; there is no way they can round early and address issues in order to get patients’ care plans initiated early, unless they are only caring for simple postop patients.

Finally, a close relationship between hospitalists and discharge planners or social workers to begin planning for discharge from the patient’s first day in the hospital is very important. Early communication allows social workers/discharge planners to meet right away with certain families and patients, and this has dropped our time waiting for placement once the patient is stable. Our discharge planners have also worked hard to establish relationships and contracts with community organizations and nursing homes to accept "difficult" or nonpaying patients, which further frees up our wards. There is an up-front cost to the hospital, but I think if you analyze the potential cost and savings, it is a good idea, compared with the lost revenue to the hospital of taking up a medical bed.

A Sign of the Times

I do have a concern with the recommendation to board patients in medical ward hallways. First, it is poor patient care, and with the government’s "value-based purchasing," program, which is based partially on patient satisfaction, hospitals stand to lose reimbursement if they are boarding patients in hallways (and EDs). ... [But] boarding patients in the hallways would send a glaring reminder to administrators walking through the wards that there is a problem.

Gordon Johnson, M.D., is the director of the inpatient medical service at Legacy Mount Hood Medical Center in Gresham, Ore.. Dr. Johnson reported having no financial conflicts of interest.

At our institutions, we are down to minimal divert times and very little or no boarding time in the emergency department, with the exception of psychiatric patients.

Each hospital is unique and has different bottlenecks in different areas; in many cases, even adding another wing to a hospital may not solve the issue because it doesn’t address the root of the problem. We do have a gross citywide shortage of psychiatric beds, and psychiatric units have given the ED preference on admissions. As a result, someone might spend a few days on the medical ward while waiting for a psychiatric bed, but we have incorporated several strategies mentioned in the recent Health Affairs report (2012;31:1757-66) that have essentially eliminated boarding of medical and surgical patients.

One of our bottlenecks was a delay in the time taken to call the floor to get a bed cleared for an incoming patient from the ED. Now, when it is clear that a patient is going to be admitted from the ED, even if all the tests aren’t completed and the patient hasn’t been fully stabilized, the ED doc alerts staff to contact the nursing supervisor. This allows him or her to clear beds well before the patient would be transferred to the ward or ICU, even allowing time to call in a nurse from home or open up an overflow area.

We also encourage all ED doctors to write holding orders so that when the accepting physician or resident can’t see the patient right away, they aren’t held up in the ED; the orders are sent up to the floor with the patient.

Additionally, one strategy we follow is that we don’t have to room each ED patient. Sometimes a patient can be seen in triage, and then, if they are just waiting for an x-ray, for example, they don’t have to take up an ED bed; they can go to radiology and wait in the lounge. That’s not something I saw in the [Health Affairs] report. These "fast-track" or ambulatory care cases should be different from the acute ED cases and not necessarily occupy an ED bed. We have decreased diversion times for ambulances to a minimum, even though the ED is seeing more patients. Our divert times used to be hours to days, and now they are measured in minutes.

Another strategy I didn’t see mentioned in the report is the use of overflow units. We have created an area of the hospital that we can open up to accommodate overflow medicine and surgical patients during the busy times, and we staff it with nurses who are on from a float pool or on-call system. We also use a "bed czar," in the form of the nursing supervisor, who constantly tracks beds and bed turnover, electronically, in real time, and that has helped us avoid bottlenecks.

More Doctors, Shorter Shifts

As for what hospitalists can do to minimize overcrowding and improve patient care, staffing and rounding early on potential discharges are key. I staff our hospitalists so we have plenty of people rounding in the morning, so more patients can be seen earlier in the day. For example, instead of having four 12-hour shifts of hospitalists, one can staff five doctors, with three doing 8-hour shifts and two doing 12-hour shifts. It is the same amount of doctor-hours per day, but you are front-loading the morning, so patients can be seen and then tests can be ordered and discharges can be arranged. We have staffed our hospitalists adequately and motivated them to round early on patients who are discharging, making the bed available for early afternoon admissions.

I think it is very short-sighted to have hospitalists see 20-plus patients a day; there is no way they can round early and address issues in order to get patients’ care plans initiated early, unless they are only caring for simple postop patients.

Finally, a close relationship between hospitalists and discharge planners or social workers to begin planning for discharge from the patient’s first day in the hospital is very important. Early communication allows social workers/discharge planners to meet right away with certain families and patients, and this has dropped our time waiting for placement once the patient is stable. Our discharge planners have also worked hard to establish relationships and contracts with community organizations and nursing homes to accept "difficult" or nonpaying patients, which further frees up our wards. There is an up-front cost to the hospital, but I think if you analyze the potential cost and savings, it is a good idea, compared with the lost revenue to the hospital of taking up a medical bed.

A Sign of the Times

I do have a concern with the recommendation to board patients in medical ward hallways. First, it is poor patient care, and with the government’s "value-based purchasing," program, which is based partially on patient satisfaction, hospitals stand to lose reimbursement if they are boarding patients in hallways (and EDs). ... [But] boarding patients in the hallways would send a glaring reminder to administrators walking through the wards that there is a problem.

Gordon Johnson, M.D., is the director of the inpatient medical service at Legacy Mount Hood Medical Center in Gresham, Ore.. Dr. Johnson reported having no financial conflicts of interest.

At our institutions, we are down to minimal divert times and very little or no boarding time in the emergency department, with the exception of psychiatric patients.

Each hospital is unique and has different bottlenecks in different areas; in many cases, even adding another wing to a hospital may not solve the issue because it doesn’t address the root of the problem. We do have a gross citywide shortage of psychiatric beds, and psychiatric units have given the ED preference on admissions. As a result, someone might spend a few days on the medical ward while waiting for a psychiatric bed, but we have incorporated several strategies mentioned in the recent Health Affairs report (2012;31:1757-66) that have essentially eliminated boarding of medical and surgical patients.

One of our bottlenecks was a delay in the time taken to call the floor to get a bed cleared for an incoming patient from the ED. Now, when it is clear that a patient is going to be admitted from the ED, even if all the tests aren’t completed and the patient hasn’t been fully stabilized, the ED doc alerts staff to contact the nursing supervisor. This allows him or her to clear beds well before the patient would be transferred to the ward or ICU, even allowing time to call in a nurse from home or open up an overflow area.

We also encourage all ED doctors to write holding orders so that when the accepting physician or resident can’t see the patient right away, they aren’t held up in the ED; the orders are sent up to the floor with the patient.

Additionally, one strategy we follow is that we don’t have to room each ED patient. Sometimes a patient can be seen in triage, and then, if they are just waiting for an x-ray, for example, they don’t have to take up an ED bed; they can go to radiology and wait in the lounge. That’s not something I saw in the [Health Affairs] report. These "fast-track" or ambulatory care cases should be different from the acute ED cases and not necessarily occupy an ED bed. We have decreased diversion times for ambulances to a minimum, even though the ED is seeing more patients. Our divert times used to be hours to days, and now they are measured in minutes.

Another strategy I didn’t see mentioned in the report is the use of overflow units. We have created an area of the hospital that we can open up to accommodate overflow medicine and surgical patients during the busy times, and we staff it with nurses who are on from a float pool or on-call system. We also use a "bed czar," in the form of the nursing supervisor, who constantly tracks beds and bed turnover, electronically, in real time, and that has helped us avoid bottlenecks.

More Doctors, Shorter Shifts

As for what hospitalists can do to minimize overcrowding and improve patient care, staffing and rounding early on potential discharges are key. I staff our hospitalists so we have plenty of people rounding in the morning, so more patients can be seen earlier in the day. For example, instead of having four 12-hour shifts of hospitalists, one can staff five doctors, with three doing 8-hour shifts and two doing 12-hour shifts. It is the same amount of doctor-hours per day, but you are front-loading the morning, so patients can be seen and then tests can be ordered and discharges can be arranged. We have staffed our hospitalists adequately and motivated them to round early on patients who are discharging, making the bed available for early afternoon admissions.

I think it is very short-sighted to have hospitalists see 20-plus patients a day; there is no way they can round early and address issues in order to get patients’ care plans initiated early, unless they are only caring for simple postop patients.

Finally, a close relationship between hospitalists and discharge planners or social workers to begin planning for discharge from the patient’s first day in the hospital is very important. Early communication allows social workers/discharge planners to meet right away with certain families and patients, and this has dropped our time waiting for placement once the patient is stable. Our discharge planners have also worked hard to establish relationships and contracts with community organizations and nursing homes to accept "difficult" or nonpaying patients, which further frees up our wards. There is an up-front cost to the hospital, but I think if you analyze the potential cost and savings, it is a good idea, compared with the lost revenue to the hospital of taking up a medical bed.

A Sign of the Times

I do have a concern with the recommendation to board patients in medical ward hallways. First, it is poor patient care, and with the government’s "value-based purchasing," program, which is based partially on patient satisfaction, hospitals stand to lose reimbursement if they are boarding patients in hallways (and EDs). ... [But] boarding patients in the hallways would send a glaring reminder to administrators walking through the wards that there is a problem.

Gordon Johnson, M.D., is the director of the inpatient medical service at Legacy Mount Hood Medical Center in Gresham, Ore.. Dr. Johnson reported having no financial conflicts of interest.