COMMENTARY

Off Gurneys, Into Beds -- How Can We Speed Up Admissions?

Alok S. Patel, MD

Disclosures

January 17, 2020

This transcript has been edited for clarity.

It's 2:00 AM. Things are finally calm when you suddenly get a page from the emergency department (ED). It's probably an admission.

You might be hoping it's the wrong service and it's not yours. Maybe they didn't do enough labs and imaging, and the patient's going to stay there till morning. You might be that hospitalist who's thinking about blocking that admission. Meanwhile, your ED colleague wants to try to do his job and get on with it.

ED admissions can go smoothly, but sometimes there are disagreements and delays—and then it's been hours and the patient still doesn't have a hospital bed. This isn't great for outcomes or for patient satisfaction. Let's stop the finger-pointing, start collaborating, and figure out how to speed up this entire process.

Every institution is different and people are trying all sorts of different things. Some are a little more common than others. Many hospitals have call centers, or outside bed requests are directly patched to the inpatient admission teams, skipping the ED altogether. Some EDs have actually increased staffing during peak times to speed up those potential admissions. This makes sense to me.

Some hospitals, such as the University of Virginia, use an admission and throughput coordinator to screen all bed requests, identify any mistakes, and make sure the right services are requested.

Penn State Hershey Medical Center tried something unique, whereby if the ED called the service and requested that a patient be admitted, and that service felt that another team was actually more appropriate, it was up to the service to call another department and get that patient admitted. There is an interesting tradeoff here because the median wait times went down, but the amount of requests going to the hospitalist team for admission went up.

There are some general ideas being thrown around, such as staffing EDs with hospitalists or family medicine docs to tackle admissions, or the idea of incentivizing hospitals in the same way that some ER docs have reimbursement tied to admission time.

Then there's the possibility of letting ED docs initiate admissions in severe clinical scenarios, including sepsis or surgical emergencies. Obviously, none of this would matter if a hospital were at full capacity. Boarding patients in the ED is a concept for another video, though.

All in all, delays in admission are a huge pain for everyone on a care team, including ED docs, nursing administration staff, hospitalists, and patients, who don't want to spend all night waiting for a hospital bed. Kaiser Health News reported a median ED wait time of 5.5 hours in California in 2017, with more and more patients simply leaving against medical advice. We need a fix.

Every place is different. I want to hear from you. Tell us about your experience with ED admission flow. What worked? What didn't? Share it with us.

Dr Alok S. Patel is a pediatric hospitalist, television producer, media contributor, and a digital health enthusiast. He splits his time between New York City and San Francisco as he is on faculty at both Columbia University/Morgan Stanley Children's Hospital and the University of California San Francisco, Benioff Children's Hospital. Alok hosts The Hospitalist Retort video blog on Medscape and is a medical producer at CNN.

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