Want to Fix ED Boarding? Try ‘Surgical Smoothing,’ Expert Says

Want to fix the problem of patients “boarding” for days on end in the emergency department (ED) while they wait to be admitted to the inpatient unit? It starts with “surgical smoothing,” said Peter Viccellio, MD, professor and vice chairman of emergency medicine at the Renaissance School of Medicine at Stony Brook University in New York.

When he and his colleagues conducted a study to see how much inpatient admissions to New York hospitals fluctuated, they found that “almost all of the fluctuation was due to elective admissions, which I would also [call] schedulable admissions — admissions that you can control when they come in,” Viccellio said last week at a summit on ED boarding hosted by the Agency for Healthcare Research and Quality.

The study found that “if you compared it to the mean, the peak was 20% above at the beginning of the week to 30% below at the end of the week,” he explained. “So, if you look at just elective surgery, we’re not talking about going from 5 to 7 days a week. No, it’d be nice if we could go from 3 to 5 days a week, because most of the surgery is done in the first few days.”

At one institution where this “smoothing” was done, the surgeons went from having 776 surgical procedures canceled or rescheduled each year — that’s about two per day — to six for the entire year, Viccellio said. “[That’s] 776 versus 6 — I think that would be arguable that that’s a benefit.”

He emphasized that the “smoothing” — or spreading out — of the surgeries was “not to the number of cases a day — [instead], you’re smoothing to the number of inpatient beds needed, and you’re smoothing to the number of ICU [intensive care unit] beds needed. That’s the smoothing that you’re trying to do.”

Viccellio gave one other example of successful smoothing. The Children’s Hospital of Cincinnati decided to build a 100-inpatient-bed tower to solve its boarding problem. They were in the middle of doing the architectural drawings for the tower when they met with an expert who convinced them to first try surgical smoothing. “That smoothing resulted in canceling the building … and with the same surgeons and the same number of operating rooms, they were able to do $130 million more in business,” he said.

One other way to increase the number of inpatient beds available is by increasing the number of discharges completed earlier in the day or on weekends, Viccellio said. “At New York University, the CFO went to the CEO saying, ‘We have noticed that if [an ED] patient goes upstairs [to the inpatient ward] in the afternoon, their length of stay is a half a day longer. You’ve got to do something about this.'” The CEO then gave the hospitalists 6 months to increase the percentage of discharges done before noon to 30%. “There was a target … and a timeline as well,” Viccellio said, noting that the plan was successful in increasing morning discharges.

As for weekend discharges, at Montefiore Medical Center in New York City, where they had been boarding 30 patients a day on average, “the executive VP there decided to attack weekend discharges, [and he] enhanced weekend discharges to the tune of solving the boarding problem and actually closing a 30-bed unit for a while because they didn’t need the beds,” said Viccellio.

Using the right metrics is also important, Viccellio noted. He gave an example from one particular hospital ED: “Arrival to being seen by a healthcare practitioner is 25 minutes, CT scan from order to read is 267 minutes, and door to inpatient is 975 minutes,” he said. “So what should you work on?”

Hospitals often work on the first one — arrival to being seen by a healthcare practitioner — because that’s the metric that outside agencies have been most interested in, and specifically, they want to know how many patients left without being seen.

And the hospitals “fix” that problem by having the clinician briefly interact with that patient. “They can shake their hands; ‘I’ve seen you; I’ve captured you in my vision. [So now you] can’t [say you left] without being seen,'” Viccellio said. “‘Look, I’m at 100%; I’m perfect’ … and it hasn’t made a bit of difference to the larger picture.”

Another issue related to boarding are the inpatients who “need specialized placement, like in a nursing home,” Alison Haddock, MD, president of the American College of Emergency Physicians (ACEP), told MedPage Today in a phone interview. “The placement process can take several days and there’s no place for these new patients to go.”

That’s true for other types of patients as well, she continued. “Just like we can’t get our patients upstairs, they can’t get their patients out of the hospital if there just aren’t the community resources available for the patient. For example, if a patient needs IV antibiotics, and that could be arranged at home, that’s great. But then if the patient is homeless, you don’t have that option. So then the hospital, as the inpatient team, is not able to discharge that patient, even though they technically don’t need to be inpatients.”

One part of the solution to the boarding problem requires getting regulators involved, Haddock said. “ACEP is advocating for changing the conditions of participation in Medicare, calling for hospitals to have to measure the extent of boarding and have a plan in place so that if boarding is occurring, if you’re at a certain percentage of capacity, that you have a plan that you can trigger that will help resolve the problem to some degree.”

Having that requirement would, in turn, allow the Joint Commission to ask hospitals whether the plan has been implemented, and how well it’s working.

Boarding is also a problem for the hospital’s bottom line; a recent study in Annals of Emergency Medicine found that boarding nearly doubled hospitals’ daily cost of care for each patient, from an average of $993 to $1,856.

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