Ignoring the Front Door: U.S. Hospital Operations circa 2009

In 2006, the Institute of Medicine (IOM) published a report on the future of hospital-based emergency care in the U.S. health system.1 Among its many recommendations was a call to end the boarding of inpatients in emergency departments (EDs). Several steps were suggested to accomplish this goal, including the adoption of hospital-wide operations management principles, the use of informatics to support daily operations, changes in methods for scheduling elective surgeries, and implementation of both financial incentives and regulatory enforcement to improve patient flow. Perhaps chief among these recommendations was the call for hospital chief executive officers (CEOs) to become personally engaged in leading their institutions’ patient flow improvement efforts. The IOM’s call to end boarding took place in June 2006. In most U.S. hospitals, we are still waiting for an answer. During the past 3 years, there are no data to suggest that ED boarding has subsided, and several surveys indicate that the problem is getting worse (S.M. Schneider, personal communication, NY state survey, February 2007, 396 responses).2 In this issue of Academic Emergency Medicine, Lucas and colleagues3 report results from a five-hospital study of the relationship between hospital census variables and ED length of stay (LOS).3[Three additional papers on crowding and length of stay appear elsewhere in this issue—Ed.] They found a significant positive relationship between ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the daily percentage of ED patients admitted. In contrast, there was no relationship between the number of ED patients and ED LOS. Contrary to prior work,4 the authors did not find a significant relationship between ED LOS and either the volume of elective procedures (surgical or cardiac) or the total hospital patient census. A strength of the study was the fact that it involved multiple hospitals, which builds on prior single-institution work. A potential weakness is that Lucas and colleagues chose to use daily ED LOS. Although a common approach, this analytical method limits the ability to capture the dynamic nature of the relationship between hospital operations and ED LOS. For example, during peak hospital census periods on weekday afternoons, ED boarders likely will have their greatest impact on ED LOS. By using a single daily variable for hospital census parameters and median ED LOS, one loses the ability to understand real-time changes in operations. Future work should attempt to capture the complex relationship between hospital and ED operations using shorter analysis periods (e.g., 6- to 8-hour intervals). These analyses will require different analytical approaches, such as time series analysis methods, and much more sophisticated operational data systems in both hospitals and EDs. It is understandable why Lucas and colleagues did not have real-time census data available, as in most U.S. hospitals, the actual real-time hour-by-hour patient census is not known. Regrettably, in 2009 it is much more likely that a U.S. hotel will know its actual number of registered guests than a U.S. hospital will know the actual number of inpatients occupying its beds at any given point in time. Given the human stakes and costs involved with hospital-based care in 2009, this is not a reassuring supposition. Setting aside the limits of the study by Lucas et al., the broader point is clear: a growing body of evidence suggests that U.S. hospitals, from an operational perspective, are ignoring the needs of inpatients boarding in their EDs. Given the fact that EDs represent the community’s front door for hospital-based care, the public should expect a different reality in 2009. It is difficult for anyone who works outside of the emergency care system to appreciate the profound impact that boarding has on ED operations. When everyone else can say “no more,” EDs must care for any patient who walks through the front door. Although some EDs can divert ambulance patients when they are over capacity, this is a limited (and often unavailable) mechanism for controlling the demand for ED services. ED boarding is a convenient mechanism for hospitals to meet patient demand in other parts of the hospital. Unfortunately, it closes the back door for EDs when they, unlike virtually all other health care delivery venues, are unable to close their front door. The results are perfectly predictable: growing numbers of hospital “inpatients” filling the ED (and its hallways) as the waiting room overflows with patients. The key questions related to this situation are relatively straightforward: 1) why have hospitals not prioritized ED boarding as a key operational problem, and 2) assuming they wanted to eliminate boarding, how would they do it? The bottom line for U.S. hospitals is that form follows finance.5 In 2009, U.S. hospitals on average receive higher profit margins for elective surgical admissions than they do for emergent medical admissions from the ED.6 In the absence of strong regulatory barriers to prevent ED boarding, this means that surgical patients and elective admissions will be the first in line for a limited number of inpatient beds in most hospitals. This statement could be debated ad nauseam; however, my rebuttal would be a simple question: when was the last time your hospital canceled elective surgeries so the boarders in your ED could go to inpatient beds? This point could not have been made more clearly than it was by the University of Chicago Medical Center’s CEO in a recent article discussing the hospital’s controversial decision to reduce inpatient capacity for ED patients: Dr. Madara, the hospital’s chief executive, said in an interview last week that the hospital is seeking to admit more patients to its “programs of distinction” such as oncology and advanced surgery, and treat fewer in the ER, and that these moves will mean more privately insured patients at the hospital.7 Not withstanding the fact that tertiary referral centers offer unique services that are unavailable at other locations, one cannot help but wonder how many “programs of distinction” would develop around the country to accommodate emergent medical admissions if hospitals were provided financial incentives for reducing boarding in their EDs. It is difficult to imagine that the anesthesia literature would be filled with anything less than a cacophony of protests over “PACU boarding” if the financial incentives between surgical and ED admissions were suddenly reversed. It is easy to demonize hospital administrators for failing to address ED boarding. As satisfying as that argument feels during “locker room” discussions outside of the ED, a simple sobering fact demonstrates why admissions with more favorable margins are preferred in the current economic climate. A recent Trendwatch from the American Hospital Association indicated a drop in total hospital margins between the third quarter of 2007 and the third quarter of 2008 from 6.1% to –1.6%.8 If the economic survival of your organization was on the line, would admission delays for low (or negative) financial margin patients be your top priority? Financial and regulatory incentives to eliminate ED boarding are key steps for addressing the challenge. Fortunately, many of the operational changes needed to minimize ED boarding will result in positive financial returns for hospitals. For example, efforts to smooth elective surgical schedules can create greater functional operating room capacity and simultaneously reduce surges in demand for inpatient beds.9,10 Lucas and colleagues3 did not find a significant relationship between elective procedures and ED LOS; however, Rathlev and colleagues4 did report this finding. The surgical schedule likely has a variable impact on ED operations, and surgical schedule smoothing may be more helpful in some settings than others. A fundamental benefit of launching a hospital-wide patient flow improvement effort is an improvement in real-time operational awareness. The development of real-time operational dashboards helps hospitals adjust their staffing to patient workload and reduce capacity bottlenecks. This is particularly important for high-acuity areas such as ICUs. Of all the data on the risks of ED boarding, one of the most concerning findings was by Chalfin and colleagues,11 who reported higher ICU and in-hospital mortality in patients whose admission was delayed greater than 6 hours due to ED boarding. It is impossible to address ICU and cardiac telemetry capacity bottlenecks without a hospital-wide operational perspective. Although many hospitals are beginning to implement isolated patient flow improvement projects, relatively few CEOs have embraced and led the type of transformational change in hospital operations envisioned by the IOM.1 If the positive financial incentives of better real-time operations are not enough, regulatory options certainly exist. The United Kingdom’s National Health Service (NHS) implemented a 4-hour rule for total ED LOS in 2003. The 4-hour rule is simple: 98% of patients arriving at the ED are to be seen and admitted, discharged, or transferred within 4 hours from the time of triage. Although controversial, it is indisputable that the rule has fundamentally changed ED and hospital operations in the NHS.12 Recent reports indicate that similar rules are being contemplated in both Australia and Canada.13,14 In the United States, the National Quality Forum approved total ED LOS as a quality measure in 2008,15 and the Centers for Medicare and Medicaid Services has indicated that they may implement this as a hospital reporting measure in 2011. Ultimately it may require a combination of both financial and regulatory incentives to force U.S. hospitals to address ED boarding. In case there was any doubt, the study by Lucas and colleagues helps confirm that the ED’s fate is inextricably linked to hospital-wide operations. It is ironic that hospitals continue to ignore their front door, when they could help themselves and all of their patients by taking the operational steps needed to decrease and ultimately eliminate ED boarding. The IOM has called for a new era of hospital operations. Now it is time for senior hospital leaders to either accept the call or be forced to change. The front door is waiting for an answer.

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