144 Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study

Abstract

Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. Despite years of quality and safety research, effective strategies to reduce ED crowding are not well elucidated. We identify potential hospital “best practices” to decrease ED crowding. Mixed methods comparative case study. We purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare and Medicaid Services case-mix-adjusted ED length-of-stay metrics for both 2012 and 2013, including length of stay and boarding times for admitted patients. We conducted semi-structured interviews with 4-6 people at each hospital involved with ED throughput and crowding process improvement, including hospital administration (eg, CEO, CMO, CNO), inpatient care (eg, internal medicine), and ED operations. We analyzed interviews using a grounded theory approach and identified best practices to improve ED crowding. We engaged 4 high performing and 4 low performing hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. We conducted 38 interviews across sites. Across all hospitals, ED crowding was recognized as a hospital-wide issue, yet the strategies for addressing ED crowding varied widely. Strategies that were common in high- and low-performing hospitals included: improvement of front end processes including physician in triage and nurse-initiated protocols; hiring consultants to utilize LEAN methods; and data-driven strategies shared amongst team members and other departments. Low-performing hospitals expressed barriers to care that included nursing shortages, lack of resources for change, and lack of support from hospital-level leadership. In contrast, high-performing hospitals reported that executive leadership was significantly engaged in efforts to reduce ED crowding. This engagement was characterized by use of data to model and predict patient flow to staff appropriately; reporting of metrics to hospital-wide leadership on a daily basis; and proactive strategies that are implemented at various levels of crowding. The leadership created multi-disciplinary teams composed ED staff, professionals from a variety of departments, and professional backgrounds in the quality improvement process. High-performing hospitals reported making multiple changes concurrently to reduce front end (ED), throughput, and back end (ie, inpatient discharge) processes. These efforts led to hospital-wide coordination to decrease radiology, lab, and bed turnover times. Interviewees were able to easily identify metrics to which they were held accountable; in addition, once metrics were met there was a continuous improvement process to evaluate, modify, and enhance current processes. High-performing hospitals commonly engaged in proactive, as opposed to reactive, strategies, including flexibility in utilization of their physical space in both the ED and inpatient settings. We identified several best practices, including concurrent changes in all steps of hospital-wide flow, strong executive leadership, continuous data feedback and improvement that were tied to high performance on ED crowding metrics. While further research might assess the causal link between these strategies and ED crowding, these practices represent actionable changes that other EDs may incorporate.