Improving Patient Throughput in the Emergency Department

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Improving Patient Throughput
In the Emergency Department

Introduction
St. Vincent’s Medical Center, a 501 bed facility located in Jacksonville, Florida, provides general medical and surgical care to the North Florida Region. St. Vincent’s admits over 26,000 patients annually. The average occupancy rate is approximately 84% with the Emergency Department (ED) peeking at 100% for approximately 4-12 hours daily. The hospital is struggling with availability of bed space. This shortage of available beds creates a bottleneck in the ED on high census days. Bottlenecks are created in the ED when there is a shortage of inpatient beds to place admitted ED patients. Thus, patient flow, or throughput, is becoming more and more important. Like all healthcare facilities, the chief goal of the organization is to serve patients and the community. With this in mind, few people equate a hospital with being a service business that competes for customers and resources. With the healthcare industry becoming more and more competitive, the importance of service cannot be overstated. Improved patient flow would serve two purposes: provide better service and to attain financial goals. If the hospital cannot provide adequate service, then business will suffer. Moreover, financial reimbursement from Medicaid is now based in part on the “pay for performance” concept, giving patients more choices where to receive their medical care. Improved patient flow will increase revenue, reduce costs and waste, and improve service (Mayer & Jensen, 2009). Thus, the business case for improving patient flow is intriguing. The hospital relies on admissions from the emergency department. The ED is a strong contributor to the net operating income of the hospital. Each patient admitted into the hospital through the ED brings approximately $7,500 in revenue. Approximately 33% of all patients admitted to this hospital are admitted through the ED. Maintaining an efficient flow of patients through the ED is essential to the financial well-being of the hospital. Being able to serve more customers simply equates to more money. Many of these potentially paying customers turn away and leave the ED because the wait is too long. This wait is cause by a bottleneck in the ED because there are simply no inpatient beds in which to place the patient. Ten patients holding in the ED effectively reduces a 50 bed department into a 40 bed department, reducing the number of patients seen in a timely manner. This created an opportunity cost of lost income from patients who leave without being seen (LWBS). Using an approximate 4% LWBS rate, this could equate to $6,000,000 of lost revenue annually. Just reducing this LWBS rate by 1% would make a great impact. It is clear that a solution must be identified in order to improve the patient throughput of the hospital.

Step 1: Define the Problem
At times of high inpatient census, there is a shortage of inpatient beds. This shortage of inpatient beds prevents the timely movement of admitted ED patients to an inpatient unit. When there are no inpatient beds into which to place admitted ED patients, a bottleneck is created in the ED. The flow of the patients through the ED is constrained by the availability of inpatient beds. Many times, even though a patient is ready to be discharged, barriers arise which prevent a timely discharge. The barrier could be as simple as waiting for a ride home to arranging for home health care. Some patients discharged to skilled nursing facilities are delayed in the room waiting for ambulance transportation or an open bed at the destination. With the continued increase in ED patients due to the economy, this constraint could lead to major losses of potential revenue for the hospital. Historically, the solution to the throughput problem has been to attempt to discharge inpatients before 11 am. This initiative has been unsuccessful for the most part and does not appear to be feasible...
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