Reducing ED LOS for admitted Internal Medicine patients

From the 2023 HVPA National Conference

Rabie Kilan, Master Degree (JHAH), Muhammad Zia MRCS,FRCEM

Emergency Department (ED) crowding is one of the greatest challenges to delivering safe, high quality, urgent and emergency care. There is an association between ED crowding and Mortality, Increased length of stay, reduced quality of care, Poor patient experience, Staff burnout and difficulty in recruiting and retaining staff. According to a 2002 national U.S. survey, more than 90% of large hospitals report EDs operating “at” or “over” capacity.

When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised. Exit block (also known as access block) describes the situation where patients who have been assessed in the ED are unable to leave the department due to a lack of capacity in the downstream system. Exit block is the single most common cause of sustained ED crowding. In JHAH more than 70% of admitted patients stay more than 4 hours in ED. Data showed that 56% of these patients are admitted under Internal Medicine making more than with Average LOS of 284 minutes.

To reduce ED LOS time by 10% by December 2022 for Internal Medicine patients

A Multidisciplinary team was convened to work on quality improvement project using CUSP methodology. For better understanding a process mapping was conducted. followed by Root cause analysis. Finally the team developed action plan to address the findings. One of the major interventions was the early identification of patients who need medical admissions by Emergency physicians. DTA is an electronic record and notification of the event that a clinical decision to admit a patient has been made to medical team and alerts bed management.

20 random patients with DTA orders were compared to standard admission orders.DTA order was effective in reducing LOS for up to 14% in medical patients when used in Emergency Department in our sample size.

Data supports that DTA is effective in reducing LOS.More work is needed to increase utilization and expand to other services like cardiology and surgery. Assessment areas may be needed for further expansion and improve patient flow.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

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