From the 2021 HVPAA National Conference
Ishmael Opare (Brookdale Hospital Medical Center), Fiorella Castillo, Supriya Bisht, Mohammed Alsabri, Kokila Jeyamurugan, Sarika Bai, Uday Tiwari, Shruti Kamat, Magalie Alfred, Dorian Alexander, Fernanda Kupferman, Kusum Viswanathan, Ratna Basak
Prolonged admission boarding time (ABT) has been recognized as a common phenomenon in hospitals worldwide with negative ramifications for patients, clinical staff, and health care institutions. Delayed admission boarding (AB) leads to emergency room congestion, higher rates of medical errors, low quality of care, increased cost of care, and staff frustration. Studies have shown potential savings of $1.5 million to $5.0 million per year by reducing the pediatric ABT by 1 hour in a tertiary teaching hospital in a major city in the US (Boston’s Children Hospital, 2017).
This quality improvement project aims to decrease the average pediatrics ABT at Brookdale Hospital from 158 min to 120 min in 6 months, which will represent a 24% reduction in pediatric ABT.
Plan-Do-Study-Act (PDSA) methodology was used after a needs assessment was conducted in July 2020. Barriers to timely AB were identified and mean Pediatric Emergency Department (PED) ABT was determined (Fig. 1). After discussion with stakeholders which included PED and inpatient nurses, residents, attendings, and auxiliary staff, a monthly PDSA cycle was started in December 2020. Cycle 1 focused on educating staff on the goals of the project with emphasis on the importance of early AB and the negative ramifications of delayed AB. These were discussed at the educational activities and during staff huddles. In Cycle 2, we focused on delays related to floor nurse unavailability during AB. Plans were made to have backup nursing staff available during floor nurse breaks and high patient census periods. Regulations on nursing staff breaks were also discussed. Cycle 3 focused on issues related to bed readiness. Inpatient beds were to be prepared within 1 hour of the patient’s discharge. Building Services were to be contacted within 15 mins of the patient’s departure (Fig. 1, 2) to ensure bed readiness for the next admitted patient (Fig. 2). Patient transportation was identified as the main cause of delay at the end of cycle 3 and was resolved by recruiting permanent transport staff in cycle 4.
The baseline ABT average was 2.6 hours and 36% of patients reached the pediatric floor within 2 hours the admission decision was made. The mean ABT decreased from 158 min to 114 min (28% reduction) by the end of Cycle 1. By the end of cycle 2, there was a slight increase in average ABT from 114 min to 120 min with patient bed readiness identified as the main cause of delay. After cycles 3 and 4, the ABT decreased further to 107 min (Fig. 3). Over these 4 cycles, ABT decreased by 32%.
Increasing staff awareness of the benefits of timely AB and negative effects of delayed AB, creating facility tailored interventions to address specific challenges, and involving all major stakeholders contributed to achieving the goal in this quality improvement project, which could decrease PED congestion, save costs, and improve patient outcomes.
Reducing ABT will improve the overall quality of care at relatively lower costs, increase access to care, and improve outcomes.