Administration of Emergency Medicine
The Relationship between Inpatient Discharge Timing and Emergency Department Boarding

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Abstract

Background

Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling.

Study Objective

Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m.

Methods

A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies.

Results

A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4 h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0.

Conclusion

Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.

Introduction

Emergency department (ED) crowding has been the subject of significant public and academic attention 1, 2. ED boarding and crowding are detrimental to quality of care as well as patient safety and satisfaction goals 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. Reducing ED crowding and boarding would likely lead to improved patient satisfaction and potential cost-savings for the ED 13, 14, 15.

It has become increasingly apparent that activities outside the ED, such as elective surgical scheduling and inpatient bed management, impact ED crowding 16, 17. In hospitals that are capacity constrained due to a high inpatient bed occupancy, operations management skills are critical to optimizing patient flow and resource utilization (18). The hospital’s limited number of inpatient beds may be occupied by inpatients from several input sources, including the ED (18). When the hospital reaches high levels of occupancy, patients admitted through the ED are often the patients who “board” in the ED, awaiting an inpatient bed to become available (19).

Solutions to minimize boarding and crowding have been proposed, including altering the elective surgical schedule, moving ED boarding admitted patients to inpatient hallways, improving inpatient bed availability, and balancing inpatient discharges and admissions 20, 21, 22, 23, 24, 25, 26. Although it is clear that there is a relationship between activities in the inpatient hospital and boarding in the ED, it has not been demonstrated that the timing of inpatient discharges may impact ED boarding of admitted patients.

The goal of this investigation was to evaluate whether or not there is a relationship between the timing of inpatient discharge practices and ED boarding of admitted patients. We utilized two hospital operations datasets to develop a computer model of patient flow into and out of the inpatient hospital to examine the potential impact of three alternative inpatient discharge timing policies on total admitted patient boarding hours. The strategies included: a sensitivity analysis on incrementally shifting current inpatient discharge timing practices (the “discharge distribution curve”) earlier in the day, uniformly discharging 75% of inpatients before noon, and discharging all inpatients between 8:00 a.m. and 4:00 p.m.

Section snippets

Study Design

This was a cross-sectional time analysis of weekday admissions to inpatient beds in the hospital and weekday inpatient discharges during the month of September 2007. A computer model was used to identify relationships between inpatient bed demand from multiple sources and inpatient bed supply. The model then assessed the effects of incrementally shifting the discharge distribution curve to earlier in the day. The model assessed the effects of two proposed alternate inpatient discharge timing

Results

A total of 5277 patient records for the month of September 2007 were included. There were 501 records excluded for incomplete data, and therefore, 90.5% were available for analysis. The records with incomplete data were evenly distributed over both weekend days and weekdays, as well as over the time of day. There were 1927 weekday inpatient admissions available for analysis and 1622 weekday inpatient discharges. Included in the analysis were: 776 ED admissions, 432 elective surgical admissions,

Discussion

This analysis reveals the association and high impact of the timing of inpatient discharges on ED boarding of admitted patients secondary to lack of inpatient bed availability. The model examined the relationship between the supply of inpatient beds and the demand for this limited supply from three primary sources: ED admissions, elective surgical admissions, and transfers from the ICU to inpatient floor beds. Our results highlight a discrepancy between the timing of daily demand for inpatient

Conclusions

Effective solutions to ED crowding and boarding require a system-wide approach. Timing of inpatient discharge from the hospital has a meaningful effect on ED boarding and crowding. This model demonstrates this relationship and the potential to reduce or eliminate total ED boarding hours secondary to lack of inpatient bed availability by shifting inpatient discharge timing to earlier in the day, ahead of the daily surge in ED demand. This study highlights an area for further investigation of

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    Research for this work was completed in part while ESP and RKK were National Research Service Award postdoctoral fellows at the Institute for Healthcare Studies at Northwestern University under institutional awards from the Agency for Healthcare Research and Quality (ESP: T-32 HS 000078; RKK: F-32 HS 17876-01).

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