Get On Up

Patients who linger in the Emergency Department may seem harmless – but, in reality, even a few minutes of added occupancy reduces availability for services by that much, to the point where excessive boarding may greatly diminish the ability to care for additional patients.  In many settings, such as County facilities or other space-limited departments, throughput is critical to maximizing the effectiveness of the resource.

This is a single-center descriptive study of a process improvement effort regarding the use of ED holding orders.  Rather than wait for the admitting team to fully evaluate a patient and place admission orders, the ED providers were given the authority to admit patients using a set of basic bridging orders prior to full assessment.  Their story is a success story – which is not at all surprising because their baseline state was that of nearly 7-hour ED length-of-stay for admitted patients.  Of that 7 hour baseline, over 3 hours was time elapsed between the ED physician making a decision to admit and the patient departing the ED.  After implementation of these holding orders, the ~200 minute ED loitering period was reduced to ~90 minutes – which, frankly, is still quite excessive.

It probably ought surprise no one giving the power to move patients to those most motivated to move them dramatically improves the alacrity of their departure.  These authors, however, appropriately note very little of the downstream effects were measured.  Their determination of attributable harms is reported as “purely anecdotal”, and only one instance of potential harm – a patient without the proper glucose monitoring orders on the floor – was observed.  This is probably not an entirely adequate assessment of this process change intervention, although I tend to agree true harms are likely to be vanishingly rare.

Simply put – there’s not much downside, and, in our increasingly space-strapped EDs, there’s a great deal of upside.  Clearly, unless your institution is as inefficient at baseline as the one featured in this article, the improvements will not be as profound.  But, for many hospital systems, these sorts of orders have been routine for quite some time – and it’s one more reasonable venue to intervene to improve ED LOS.

“Sustainable Mechanism to Reduce ED Length of Stay: The Use of Emergency Department Holding (ED Transition) Orders to Reduce ED Length of Stay.”
https://www.ncbi.nlm.nih.gov/pubmed/26999707