Reduce Emergency Crowding by Active Bed Management:
A Case Study in the Emergency Department
By
Tom Hoogschagen S3518515
June 2019
University of Groningen Faculty of Economics and Business
MSc Supply Chain Management Wordcount: 10300
Supervised by: Dr. M.J. Land Prof. Dr. J.T. van der Vaart
Abstract
Introduction
Emergency departments (ED) are experiencing multiple problems related to crowding, which threaten patient safety (Trzeciak, 2003). Crowding occurs when the need for emergency services exceeds the available resources in the ED, i.e., in case of a mismatch in supply and demand (Hoot & Aronsky, 2008; Saghafian, Austin, & Traub, 2015). An important reason for crowding is that an admitted patient might have to wait several hours after diagnosis and/or treatment in the ED before an inpatient bed becomes available in the nursing department. This utilizes ED resources and blocks other patients from entering the ED (King & King, 2018; Trzeciak, 2003). Waiting for an inpatient bed is defined as patient boarding, and is seen as one of the primary causes of crowding in the ED (Howell et al., 2008; Moskop, Sklar, Schears, Geiderman, & Bookman, 2008). Accelerating the outflow of patients in the ED by a reduction in boarding time will increase patient safety, together with the level of care experienced by the patients (Jarvis, 2016). This paper examines how hospitals can improve the outflow of patients in the ED by analyzing the activities during the patient boarding process.
A study by Van Der Linden et al. (2013) showed that shortages of space and beds in the ED, delayed boarding times, a lack of staff, and shortages of inpatient beds are the leading causes of ED crowding in the Netherlands. It is argued that increasing capacity in the ED is an insufficient solution to crowding (Khare, Powell, Reinhardt, & Lucenti, 2009) as it will not solve the core problem of crowding (Mchugh, Dyke, Mcclelland, & Moss, 2011). Khare et al. (2009) argue that reducing the length of stay (LOS) in the ED by quickly moving admitted patients out of the ED is a better solution in order to alleviate crowding.
continuous interaction with a doctor during treatment before an inpatient bed is reserved (Howell et al., 2008). However, there is little knowledge of the activities involved in active bed management, and follow-up research is missing. This research seeks an in-depth understanding of active bed management, together with the problems that can accompany it. Given what is explained previously, the following research question has been composed: How can active bed
management be used to shorten patient boarding time in the emergency department?
In order to answer this research question, a single case study was conducted at the University Medical Center Utrecht (UMCU). In this research, the process of active bed management was observed, historical data were analyzed, and multiple stakeholders within active bed management were interviewed.
Previous research had briefly described the processes of active bed management. However, this research seeks to understand the mechanisms of active bed management in a hospital, both from the perspective of the ED and from that of the inpatient clinic. It identifies factors that result in a delayed boarding time within active bed management. In addition, this study analyzes the durations of the process steps what helps in understanding areas in need of improvement. A practical contribution of this research is that it provides hospitals with an in-depth understanding of the effects of active bed management. If hospitals are able to implement active bed management successfully, this can help them to reduce boarding time and alleviate crowding. By reducing crowding, hospitals will be able to focus on patient safety and increase their level of care.
Theoretical Background
This section discusses the logistics in the ED, followed by a discussion of the outflow issues in the ED. Next, the admission prediction and active bed management in hospitals and its expected results are evaluated.
Logistics in the Emergency Department
The ED is a department in hospitals, consisting out of a waiting room, triage room, treatment rooms and trauma rooms, where patients can arrive 24/7 to receive urgent care without an appointment (Duguay & Chetouane, 2007). An extensive literature review by Saghafian, Austin, & Traub (2015), from an operations research perspective, divided emergency logistics into patient flow into, within, and out of the ED. Patient flow into the ED relates to how patients arrive at the hospital, whether by self-referral, an emergency ambulance, or referral by a general practitioner (Lowthian et al., 2011). Patient flow within the ED consists out of several steps; the first step is triage, which means evaluating and prioritizing patients in need of urgent care by giving them an ultimate time target until they see a physician (Cronin, 2003; Saghafian et al., 2015). The second step within the ED focusses on the treatment and needed diagnostics test (Asplin et al., 2003). Patient flow out of the ED takes place when a physician finished treatment. When the patient leaves the ED he or she will either be admitted to the hospital or be discharged (Asplin et al., 2003; Saghafian et al., 2015). In this stage, it is essential that patients leave the ED rapidly to create space for new incoming patients (Saghafian et al., 2015).
Crowding in the Emergency Department
& Derlet, 2000). According to Van Der Linden et al. (2013), crowding results in a longer LOS, reduces the quality of care, has adverse effects on clinical assessments and degrades staff satisfaction.
Boarding of Patients
After treatment in the ED, the patient will either be discharged or be admitted to an inpatient clinic. A patient who is going to be admitted to the hospital enters the boarding process. Boarding problems are seen as the primary cause of crowding in the ED (Richards & Derlet, 2000). A detailed study by Gelissen (2016) on the components of waiting time in a Dutch ED showed that waiting before being admitted to the hospital was the most significant component. An increased boarding time results in a longer LOS and also increases the hospital mortality rates (Singer, Thode, Viccellio, & Pines, 2011). When a patient waits for an inpatient bed, he or she occupies a bed in the ED and blocks other new arriving patients from entering the ED (Saghafian et al., 2015). In a simulation study by Khare et al. (2009), it became clear that reducing the time needed to leave the ED after treatment will improve the performance of the ED.
Lack of available inpatient beds
A cause of ED outflow problems is the lack of available inpatient beds (Boyle, Beniuk, Higginson, & Atkinson, 2012; Richards & Derlet, 2000). In a study by Van Der Linden et al. (2013), among managers in Dutch hospitals, 64% of the managers agreed that a shortage of available beds is a cause of crowding. When no hospital beds are available, the patient must wait for a bed in the ED, increasing the boarding time and preventing other patients from entering the ED.
Lack of staff
Lack of collaboration
Good patient flow relies heavily on effective collaboration and information sharing between the ED and the inpatient clinics in the hospital (Abraham & Reddy, 2010). However, coordinating activities between different departments is challenging as each department has its own goals and way of operating (Tang et al., 2015). The ED focuses on achieving optimum patient outflow to deal with new arriving patients, while inpatient clinics do not focus that much on better patient flow as they do not deal with a continuous inflow of patients (Abraham & Reddy, 2010).
Solving boarding issues
Several attempts have already been made to resolve boarding issues. One of these efforts is making use of an acute medical unit where patients who need care for a short period can stay (Rabin et al., 2012). They are not hospitalized in an inpatient clinic but are kept under observation for a maximum of 48 hours (Di Somma et al., 2015; Saghafian et al., 2015). However, there is little evidence on the effectiveness of acute medical units (Galipeau et al., 2015). Another point mentioned is increasing the number of inpatient beds, but because this is also an expensive approach, it is not the preferred option (Saghafian et al., 2015). Another strategy used to reduce boarding is by smoothing the number of elective surgeries. This reduces the peak demand for inpatient beds and has proven to eliminate boarding (Rabin et al., 2012). A different attempt is made to reduce boarding time by reserving a bed based on an admission prediction during triage (Qiu et al., 2015). Finally, active bed management can help by placing a nurse in the ED who closely tracks inpatient bed capacity and inpatient demand (Howell et al., 2008; Rabin et al., 2012). This nurse evaluates triage decision and initiates a bed reservation when needed.
Predicting Hospital Admission
triage, reduced patient boarding time and indicated significant cost reduction. The predictions used in both studies are based on prediction models.
Figure 1 Reducing Patient Boarding (source: Peck et al., 2012)
There are also adverse effects to early bed reservation, such as a bed being reserved based on a prediction, but the prediction is inaccurate (Beardsell & Robinson, 2011). This situation means that a bed is ready for a patient who does not require a bed, which implies costs. It can also occur that, because of a reservation, another patient in need of a bed must wait for a bed (Beardsell & Robinson, 2011; Qiu et al., 2015). Therefore, it is somewhat controversial to use a single prediction for a bed reservation. Active bed management can support the admission processes by actively coordinate with emergency physicians during treatment whether admission is needed (Howell et al., 2008; Rabin et al., 2012).
Active Bed Management
LOS in the ED of a patient admitted to the hospital decreased by 98 minutes, from 458 minutes to 360 minutes.
Methodology
Research Design
This research study focuses on active bed management within a hospital and, with that, reducing the patient boarding time in the ED. Therefore, the flow of ED patients will be the observational unit of analysis to better understand the aspects involved in patient boarding. The emergency department embedded in the hospital supply chain is the explanatory unit of analysis; this helps in understanding the relational mechanism (Wilhelm, 2011). Where the observational unit refers to quantitative data collection and analysis and the explanatory relates to the patterns and relations between the multiple departments in the hospital.
The research design will focus on a single case, UMC Utrecht, and can be described as inductive exploration. The coordinating mechanism behind active bed coordination has not been researched in depth yet. Therefore an exploration study is appropriate for this research as this aims to understand the phenomenon and the related variables in depth (Karlsson, 2016). A single case study allows for a greater in-depth understanding of the problem. It also allows one to study the phenomenon in its natural setting and to generate a theory from observing practices (Karlsson, 2016). UMC Utrecht is suitable for this research as they recently appointed admission coordinators. They practice active bed management within the hospital and are located in the ED.
Data Collection and Analysis
This paragraph discusses the research stages performed to find an answer to the research question.
Analysis of Length of Stay
This research phase also analyzed patient LOS in ED before and after the implementation of active bed management. For this phase, data is collected from the hospital system and analyzed from the 1st of January until 31st of March in 2018 and 2019. To analyze the patient LOS a cumulative inflow/outflow diagram is created of this period. Moreover, a throughput diagram is created to get insights in the daily patterns in the ED.
Internal documents, such as annual reports and internal papers, which discusses relevant issues in the ED were also included in this analysis to triangulate this research. One of these documents was an internal analysis on the accuracy of the number of available beds displayed in the hospital system. The researcher was occasionally present at the daily meetings in the ED when the situation of the day was discussed. Notes that were deemed relevant by the researcher were included in the observational notes.
Analysis active bed management
For this research phase, the performance of active bed management was analyzed. A nurse who practices active bed management was located in the ED, one in the morning shift and two in the evening shift. They coordinate admission with the emergency physicians and nursing wards. First the roles within active bed management will be explained, followed by a description of the analysis.
Roles within Active Bed Management
Admission Coordinator - The admission coordinator is responsible for all emergency
admissions in the hospital. By gathering information on each ward, such as the staff and available beds, proper estimations can be made on where to locate patients. There is one admission coordinator on duty from 7:30 to 16:00 and two on duty from 15:00 to 23:30.
Nursing Ward Coordinator - Nursing wards receive the patients admitted from the ED. Each
nursing ward has a coordinator who arranges daily practices, such as admissions and discharges, and is the contact point for the admission coordinator. Each nursing ward focuses on their own specialty and forms part of a larger division of related specialisms.
Emergency Coordinator - The emergency coordinator is the nurse who manages the care
that the right people are present to provide care. The emergency coordinator also resolves daily problems and issues. Their relation to active bed management is that they want patients who have finished treatment to leave the ED as soon as possible.
Physician - Physicians may either be located in the ED or they may be on call. They provide
patient care and before active bed management was implemented they also arranged the localization of patients in the hospital.
Observations
To guarantee validity, observation field notes were made daily, as the researcher was physically present in the hospital for three days a week in the period from April 8, 2019 until May 24, 2019. This physical presence allowed the researcher to observe the nurse practicing active bed management on the following four days; day shift on Tuesday, March 9th and Wednesday, March 10th and an evening shift on Monday, April 29th and on Friday, May 10th. By following these shift the researcher was able to observe the practices of five different admission coordinators, where one admission coordinator was observed in a day and evening shift. With this observation the researcher was able to understand the daily practices of the admission coordinator. The researcher was also present at the bed consultation on these days. Aspects that were not clear were asked and explained by the admission coordinator. During the observation period the researcher recorded his observations in a notebook. The observations are important for understanding the three pillars of active bed management; proactive management of resources, evaluation and assignment of patients, and the role of the bed director.
Time stamps of boarding process
histograms, for example patient boarding time. This data provided insights into prolonged processes within active bed management and can help in finding areas for improvement.
Figure 2 Labels of measured time intervals
Semi-structured interviews
Three interviews were conducted with the admission coordinators, two with the emergency coordinators, and two with the nursing ward coordinators. Two interviews were conducted with a representative of different nursing wards in order to ensure reliability. In addition to validation, these interviews helped to provide a more in-depth understanding of the requirements and process steps of active bed management. The questions asked also explored how the people involved think active bed management works within the hospital. A semi-structured interview guide was used, and probing questions were asked when needed (Appendix 2). Each of these interviews lasted approximately 30 minutes. The interviews were recorded, transcribed, and coded. Figure 3 shows the coding tree.
Figure 3 Coding Tree
The proactive management of resources involves continuous assessments regarding bed availability in the hospital. The second order codes of proactive management focus on the processes and tools needed to create an overview of capacity. Bed consultations are meetings with multiple wards at which they discuss the daily situation and the number of available beds.
Time until admission request
Reservation process
Boarding time
Patient arrives at ED request by Admission physician
Bed reserved
at ward Patient finishes treatment Patient leaves ED
Active Bed Management
Proactive management of resources
Bed consultations Visiting nursing wards Hospital system (HIX)
Evaluation and assignment of admissions
Admission decisions Reserving beds
Clinically inappropriate ward Patient transport
Role of bed director
The admission coordinators also visit the nursing wards to gain insight into the work pressure and bed availability on each ward. The hospital system is also used to gain an overview of the available beds in the hospital.
Evaluation and assignment of admission is focused on aspects related to the admission process.
The first step in the process is the admission decision, which is released by the physician. The next step is to reserve a bed in the most appropriate ward. If this does not occur, patients may be located in a clinically inappropriate ward due to capacity constraints. Once the reservation has been made and the patient has finished treatment, they are ready to board the hospital. The third code is the role of bed director and focus on mobilization of resources. This can be achieved by a proper admission forecast, ensuring that the nursing wards have a rough estimate of the expected number of admissions. The timing of patient discharges in the nursing wards can also influence the available capacity. An ultimate measure for creating additional resources is achieved by cancelling elective surgeries for the following day.
Unstructured interviews
Results
This chapter first presents the initial results of the implementation of active bed management by comparing the ED LOS both with and without the admission coordinator. This is followed by a detailed description and analysis of the role of the admission coordinator within active bed management. The following section discusses the different perspectives on active bed management of the various stakeholders, and is followed by a section that addresses the reasons behind a delayed boarding.
Analysis of Length of Stay
Figure 4 Inflow/outflow diagram of the first quarter of 2018 and 2019
Figure 5 presents a throughput diagram of a day with an average LOS of 189 minutes and 63 patients. This day is chosen because the average LOS on this day relates to the average LOS of the first quarter and helps in understanding daily practices at the ED. This figure indicates that the outflow lines rise steeper from 15:00. A regular number of patients left the ED from that time onwards.
Figure 5 Throughput Diagram of March 13, 2019
0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10'1111-1212-1313-1414-1515-1616-1717-1818-1919-2020-2121-2222-2323-24 Av er ag e pa tie nt in flo w /o ut flo w Time
Inflow/Outflow Diagram ED
Inflow 2018 Inflow 2019 Outflow 2018 Outflow 2019
0 5 10 15 20 25 30 35 40 45 50 55 60 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 0:00 N umb er o f p ati en ts Time
Throughput Diagram March 13th
The following figure presents the inflow/outflow diagram for the first quarter of 2019, with the number of emergency nurses plotted on the right axis (Figure 6). It can be argued that the increase in personnel started too late in the day, given that the inflow was already high between 10:00 and 11:00. In addition, physicians usually have training and discuss the transfer and care of patients in the morning. This can also result in a longer patient LOS in the morning.
The average LOS per hour depends on the arrival hour of patients. During the day time, from 8:00 to 17:00, the average LOS was 225 minutes, while in the evening, from 17:00 to 23:59, the average LOS was 179 (Appendix 5).
Figure 6 ED inflow/outflow and number of ED nurses
In conclusion, it can be said that the presence of the admission coordinator does not create a significant reduction in LOS. The ED should focus particularly on the morning period, as that is the point where the most prolonged LOS occurs.
The Process of Active Bed Management
This section provides an in-depth understanding of the processes involved in the three fundamental pillars of active bed management during the day. Figure 7 provides an overview of the processes. 0 1 2 3 4 5 6 7 8 9 10 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10' 11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 Nu m be r o f E D nu rs es Nu m be r o f p at ie nt s Time
ED inflow/outflow and number of ED nurses
Figure 7 Processes of Active Bed Management
Proactive Management of Resources
Review of results of evening shift – The first task of the admission coordinator in the morning is to review the actual number of available beds at the end of the evening shift and the number of admissions during the night. This review helps to create an overview of the current number of available beds. However, patients can be discharged during the day and new elective patients can likewise be admitted to the nursing wards. Consequently, the actual number of available beds changes and a new inventory of the available beds needs to be determined. The process on how an overview of inventory is created will be described next.
Bed consultations – In order to create an overview of the actual number of beds, the admission coordinator attends the bed consultations of all the medical divisions within the hospital; these are the cancer center at 8:15, brain at 8:30, internal medicine at 9:30 and surgical specialty at 11:30. During these meetings, each specialty within the medical division shares the number of available beds, the number of patients ill-placed in a clinically inappropriate ward, any staffing issues, and the level of care involved. However, the number of discharges is not yet definite as the physician visit the patients later in the morning. The admission coordinator recognizes that meetings after the physicians’ visits will provide a better picture of the number of available beds, but also notes that “if there are any problems, they are signaled early during the day” – admission coordinator. Additional aspects can change during the day; “like nurses who call in
PATIENT FLOW
ACTIVE BED MANAGEMENT PROCESSES
PHYSICIAN ADMISSION COORDINATOR NURSING WARD
Patient arrives at ED
Triage and room placement Diagnostics evaluations and ED treatment Admission decision Finished treatment in ED Admitted to ward Bed consultations
Visiting nursing wards
Check for possible admission Inform on status and possible admission Actual admission request Place admission request at admission coordinator Reservation process Patient transported to ward Participate in bed consultations Inform admission coordinator on available beds, staff and level of
sick, a discharge that is canceled or an unexpected admission from the outpatient clinic” –
admission coordinator. The admission coordinator notes that the early bed consultations will provide a first impression of the available beds, but that a more accurate number of available beds is known around noon.
In addition to the individual meetings in the medical division, there are two meetings at the ED in which all the unit managers of the medical division discuss the situation (note: during this research phase this changed from two meetings at 10:00 and 15:00 to one meeting at noon). The preparation of the individual unit manager for this meeting differs according the admission coordinator: “Some managers check individually with all the nursing wards what gives a
correct image of the available beds and some only collect the information out of hospital system, HIX.” This can result in a situation in which the admission coordinator has an incorrect
overview of the hospital’s capacity. The admission coordinator collects all the information during all the bed consultations and records this on an overview paper. During the day, the numbers on this paper are adjusted according to the actual number of available beds. It can be argued that this information should be recorded on a tablet, allowing other employees of the hospital insights in the available capacity. However, this is not preferred by the admission coordinators as they cannot easily note information on a tablet.
Hospital system (HIX) – HIX refers to the internal hospital system in which all the wards record the number of patients on their ward and the number of available beds. The admission coordinators use HIX as a tool to assist them in addressing the available beds. “HIX should be
the main source of information. However, it is not accurate as the information is not up-to-date” – admission coordinator. Lack of staff means that many beds are not in use. Each ward
Visiting wards – Another aspect of creating an overview is to visit the nursing wards and to check the situation on the day with each ward supervisor. This is usually performed at the start of the late shift. Two admission coordinators divide the hospital between them and they each visit half of the wards, while the admission coordinator of the day shift stays at the ED and receives phone calls. This is a time intensive process, but it helps the admission coordinator to gain an overview of what is going in each ward and the level of care involved. This information enables the admission coordinator to make a better judgment on where to locate patients. It is also recognized that building relationships with the nursing wards helps to create goodwill. In addition, the admission coordinator can offer supportive services to the wards or mediate between wards with high and low levels of care.
The main points that arise from this section are that creating an overview of the number of beds is a time consuming process that should be supported by HIX. However, even with a fully updated HIX it is difficult to estimate the patient level of care that can be accepted on each ward. Proper consultation with the nursing wards is therefore needed, which is achieved by the admission coordinator.
Evaluation and Assignment of Admissions
Admission process – The admission process can either be reactive or proactive. In the reactive process, the admission coordinator waits for the admission request before taking action. The physician either places the admission request face-to-face or by phone. The time from a patient’s arrival at the ED until the admission request is labeled as the time until admission
request (Figure 2). This data is manually collected by the admission coordinators by recording
Figure 8 Time until admission request
In the proactive admission process, the admission coordinator reads the patient’s files, and makes an educated guess on whether the patient will be admitted. If a patient is likely to be admitted, the admission coordinator can consult an emergency nurse “as they can make quite
good guesses whether a patient will be admitted" – admission coordinator. This prediction
enables the search for an available bed to start early on. No actual reservation is made during this proactive process, the specific ward is only notified about a possible admission. The physician needs to agree to a reservation when the admission is certain.
The second step in the admission process is labeled the reservation process, and is measured based on the time of the admission request and the time at which a bed reservation is made. Figure 9 indicates that the reservation process does not last a long time. In 78% of the cases, a bed was found within 15 minutes. This short reservation process can be explained by the fact that the admission coordinator has an actual overview of the capacity and level of care on each specific ward. If the ward for the respective patient does not have any capacity, another clinically inappropriate ward must receive the patient. This decision depends on the level of care required by the patient and “which ward is the best second choice or on which ward the
patient has a known history” – admission coordinator.
0% 20% 40% 60% 80% 100% 120% 0 1 2 3 4 5 6 7 8 9 10 11 12 <0 00:30:00 01:00:00 01:30:00 02:00:00 02:30:00 03:00:00 03:30:00 04:00:00 More
Time until admission request
Figure 9 Reservation process
Patient boarding time - Figure 10 indicates the boarding time, which is the waiting time after a patient is medically ready to enter the hospital until he or she leaves the ED. Forty percent of patients enter the hospital within 20 minutes. However, this figure also indicates that in 50% of cases the patient waits longer than 30 minutes before leaving the ED. The main reason of a prolonged boarding time can be found in the fact that nursing wards are not ready to receive the patient yet, due to either cleaning of isolation rooms or waiting on a patient discharge.
Figure 10 Patient boarding time
Figure 11 indicates the boarding time as a percentage of the total LOS of individual patients in the ED. This percentage was less than 10% in only 29% of the total measurements during this period. This means that boarding time forms a significant proportion of the total LOS in the ED.
Figure 11 Boarding time as a percentage of the total LOS in the ED
Patient transport – It is the admission coordinator’s responsibility to deliver a patient’s transfer of care from the ED to a nursing ward. The admission coordinator will first collect information concerning medical policy from the physician and the emergency nurse before transporting the patient to the nursing ward. In order to create a comprehensive transfer of care, critical questions will be asked based on the information in the medical file. Creating a complete transfer of care “can be difficult as we had not treated the patient” – admission coordinator. Patient transport takes about 30 minutes, but “it is a nice way to visit the ward as you can get
new insights into the level of care on the ward” – admission coordinator.
For a proper evaluation and assignment of admission, an early notice by the physician to the admission coordinator is important, and this should preferably occur within two hours. This will give the admission coordinator and the nursing ward time to prepare for the admission. A bed reservation is made relatively quickly due to the overview created in the previous pillar of active bed management. Fifty percent of the patients still wait more than 30 minutes before they can board the hospital, which is a relatively long period considering the average LOS of 189 minutes. Patient transport is a time intensive process for the admission coordinator, and it could
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 5% 10% 15% 20% 25% 30% 35% 40% Meer
Boarding time as percentage of ED LOS
be outsourced to a third party. However, patient transport provides new insights in the level of care on each nursing ward, and outsourcing is not favored as it is considered patient unfriendly by the admission coordinators.
Role of the Bed Director
If the hospital is experiencing serious capacity issues, the admission coordinator can contact the capacity manager to escalate this problem. If such problems are noticed in the morning, the capacity manager will inform all the nursing ward managers and encourage them to cancel elective surgeries for the next day. When this problem is only recognized late in the afternoon, the capacity manager will inform all the nursing wards and encourage them to check whether there are patients still in the hospital that can be discharged. However, the cancellation of a patient’s surgery for the following day is unethical, as they are likely to have waited a long time for this surgery. Moreover, encouraging discharges late in the day may also negatively affect patient safety as the family will not be prepared for them to return home.
As previously noted, the time of discharge has a significant influence on patient boarding time in times of bed scarcity. Figure 12 shows the average daily discharges per time period. There is a significant drop in the number of discharges around lunch time. In order to cope with ED admission, it is preferred that all discharges should be dealt with around 13:00, three hours after the ED inflow starts to peak. The figure below shows that only 46.1% of all discharges are processed before 13:00.
Figure 12 Daily hospital discharges per time period
0 2 4 6 8 10 12 14 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10'1111-1212-1313-1414-1515-1616-1717-1818-1919-2020-2121-2222-2323-24 Nu m be r o f p at ie nt s Time
Average Daily Discharges per Hour
The preferred escalation for the bed director is to call up more staff. However, this cannot be achieved due to the scarcity of personnel. If the above approaches do not work, the capacity manager can decide in consultation with the emergency manager to close the ED. This option is not preferred and does not occur frequently. Moreover, 50.4% of the patients only visit the ED for treatment and will be discharged, and closing the ED will prevent these patients from being be treated in this hospital. In the first quarter of 2019 the ED restricted admission for a total of 23 hours.
Multiple Perspectives on Active Bed Management
The previous section discussed all the process steps in active bed management from the perspective of the admission coordinator. This section discusses the perspectives of various stakeholders on the process steps that are of most interest to these stakeholders.
Creating capacity – Sufficient capacity in the nursing wards is essential for a smooth output
from the ED. In order to develop adequate capacity, an accurate daily forecast is needed of expected admissions and discharges. However, a commonly found perspective on the predictability of admissions in the nursing wards is that it is difficult to create a prediction. “It
is not something you can predict, it is quite unpredictable when someone enters the hospital” –
nursing ward supervisor. By contrast, the physicians argued that the number of expected emergency patients is quite stable and predictable. Therefore, the nursing wards should place more emphasis on the creation of an accurate forecast in order to cope with the expected number of emergency admission. Once patients are admitted, the expected LOS becomes important in order to calculate the discharge day and create a capacity plan. “It is quite difficult to estimate
the length of stay; this also depends on the capacity of nursing homes” – nursing ward
supervisor. Sometimes patients who have been medically treated have to wait on a long waiting list for nursing homes before they can leave the hospital.
Creating an overview – A crucial step for the admission coordinator is to create an overview of
the actual number of beds available. This overview is created by bed consultations, HIX, and visiting wards. The nursing wards attempt to keep HIX up to date. However, there are always little nuances that cannot be properly addressed in HIX. For example, “We know that if this
patient revives this morning, he or she will likely be discharged, but that is not noted in HIX”
affect the number of available beds. This could mean that a nursing ward has one available bed, but only for a patient with a low level of care. According to the nursing wards supervisors, the admission coordinators are supportive in understanding the perceived level of care.
Creating this overview is significantly advantageous for all the parties involved. It reduces the amount of communication between the physicians and the nursing wards, which also enables the physicians to invest more time in their patients. The physicians previously called the nursing wards themselves, without having an accurate overview of the available beds and level of care on each ward. “If I need to perform the jobs of the admission coordinator, I cannot fully commit
to my job, taking care of patients” – physician. The emergency coordinator also recognizes that
an admission coordinator relieves the physicians’ duties. Appointing three daily admission coordinators who do the work that was previously done by the physicians themselves is an expensive solution. However, the physicians only did the reservation process previously, while the admission coordinators also visit wards to gain insights in the level of care and they transport patients to the wards.
Admission process – Once the patient has been medically examined and admission is certain,
Patient transport – When a reservation is made the patient must first finish treatment in the ED
before being transported to the nursing ward. The admission coordinator is responsible for patient transport. “It is nice that they bring patients, it saves us quite some time” – nursing ward supervisor. However, it is important for the admission coordinator to consult with the nursing ward on the patient’s arrival time. The transfer of care forms a significant part of patient transport, as “in most cases, the admission coordinator can deliver a sufficient transfer of care
with medical policy” – nursing ward supervisor. However, this is highly dependent on the
patient’s complexity and status. An external transport agency does not have medical knowledge and is unable to deliver a transfer of care. Therefore, neither the admission coordinator nor the nursing ward supervisors favor the introduction of a patient transport agency.
Follow up processes – Clinically inappropriate beds must be relocated to the correct ward when
there is sufficient space. This is principally the task of the nursing wards themselves, but they think “it can be beneficial if one person who has the overview of the available beds is
responsible for relocating patients to the correct ward” - nursing ward supervisor. This is not
presently the task of the admission coordinator, but they do mediate in this process when needed.
Causes of Delayed Boarding
The previous sections have discussed the main processes, together with some of the causes of longer boarding times. This section explicitly addresses three causes of delay within active bed management
Firstly, a late admission request by the physician can result in a longer boarding time. One
cause for this is unawareness; “As we are an education hospital, you have to deal with regular
staff replacements” – admission coordinator. Such replacements mean that the admission
The consequence of less preparation time for the nursing wards is a delayed boarding, as the nursing wards need time to prepare for an admission and sometimes have to wait before a discharged patient leaves. Preparation for admission can mean that the nurses need to read the patient’s files or prepare a room for the new patient, and the nurses may be busy on their own wards and may not have time to receive a new patient. The nursing wards consult with the admission coordinator about the appropriate admission time. Both preparing for admission and awaiting discharge mean that the boarding time of the patients is likely to increase. This result in a delayed boarding time as the patients have to wait in the ED before the nursing ward is ready to accept a new admission.
Secondly, the hospital has to deal with a considerable scarcity of beds. This scarcity means that
many patients have to be located in clinically inappropriate wards, which increases the time needed by the admission coordinator to find an appropriate ward. The nursing wards are hesitant to give away their last available bed to an emergency admission of another specialism, especially if they still expect admissions of their own specialism. This hinders the admission coordinator in finding a bed quickly, as a great deal of consultation is often required before the bed is finally released.
Thirdly, as previously noted, patient transport takes approximately 30 minutes. When multiple
Discussion and Conclusion
This section discusses the interpretation of the results and considers their implications for theory and practice. This is followed by a discussion of the limitations of this research and guidelines for further research. The section is concluded by a conclusion.
Interpretation of the Results
The proactive management of resources forms an essential part of active bed management, as it is important to assess the available capacity in each ward before the actual emergency admissions arrive. Visiting all the wards and participating in bed consultations is a time intensive process for the admission coordinator. By visiting the wards, the admission coordinators are able to create good relationships with the wards. This helps them to understand the situation on each ward, and enables them to create a proper overview of the available beds. It can be argued that all information regarding available beds must be up to date in the hospital system. However, as the admission coordinator argues, bed availability is not a binary variable and a proper evaluation of each ward is needed in order to assess the type of complexity that can be accepted for an available bed.
The evaluation and assignment of admission can be divided into the time it takes to inform about admission, the reservation process and patient boarding time. Previous studies have argued that a bed reservation based on a single prediction during triage can reduce boarding times (Peck et al., 2012; Qiu et al., 2015). The hospital researched does not use a prediction at the start, but depends on the admission coordinator’s interaction with the nurses or physicians during patient treatment. The physician or ED nurse can provide a first indication of the need of admission during triage or treatment. This first indication enables the admission coordinator to start searching for a bed. The final call on whether a bed can be reserved is made by the physician. This final call is received by the admission coordinator within two hours in 59% of the cases. An earlier reservation gives the nursing wards more time to prepare for an incoming admission what should also help with reducing patient boarding time.
information regarding the availability of beds. However, in some cases the physicians only contact the admission coordinator if they know there are no beds available in their department. This undermines the overview created by the admission coordinator. In addition, an admission coordinator assesses the level of care and can decide to locate low complexity patients in a clinically inappropriate ward. Placing patients in a clinically inappropriate ward is the result of scarcity of beds. It is argued that placing patients in clinically inappropriate wards negatively affects patient safety, as staff may lack knowledge of other specialisms (Goulding, Adamson, Watt, & Wright, 2012). The physicians and nursing ward supervisors recognize that the admission coordinator is good at estimating the level of care on each ward, but they agree that there needs to be consultation over inappropriate admission. They are not in favor of giving the admission coordinator authority on where to locate patients, as was argued in a previous study (Howell et al., 2008).
Patient boarding time should benefit from the implementation of active bed management, as this eliminates the waiting time for an inpatient bed. However, only 50% of all patients left the ED within 30 minutes. Reasons for delayed boarding go deeper than simply waiting for a bed. One of these reasons is the scarcity of available beds. This scarcity results in a late admission request by the physician, a longer reservation process and less time for the nursing wards to prepare for an incoming patient. In the latter case, the nursing department can give the admission coordinator a time on when the patient can be received, which can result in a prolonged boarding time.
With regard to mobilization of resources, it became clear that the nursing wards can put more effort in forecasting the daily number of emergency admissions. The nursing wards explained that emergency admissions are difficult to forecast, while the physicians say that emergency admissions are quite predictable. The escalating role of the capacity manager was not as present as in Howell et al., (2008), where extra staff could be called in and patients moved to other facilities. The capacity manager in this study was only able to encourage the cancellations of elective patients in the morning or encourage patient discharges in the afternoon.
invest in creating a system that shows the number of available beds more accurately, including the level of patient care on each nursing ward. Consequently, the nursing wards should receive training on how they can create the most up-to-date HIX. Giving the physicians access to such accurate information should enable them to make bed reservations relatively quickly. Moreover, patient transport can be outsourced to a third party or to students within the hospital. As transport will be outsourced, it is important for the physicians or ED nurses to deliver a comprehensive transfer of care to the nursing wards, either by means of conversations or remarks in HIX. Such a scenario would enable the seven admission coordinators, who are skilled nurses, to be deployed on the nursing wards, thus creating extra capacity on the nursing wards.
Implications for Theory
Previous research indicated that the implementation of active bed management caused the average LOS of admitted patients to drop significantly, by 98 minutes (Howell et al., 2008) and 88 minutes respectively (Murphy et al., 2014), although the latter only focused on the LOS of all the patients. This study indicated that the patient LOS only decreased by nine minutes. However, the present study had fewer patients and the initial LOS was significantly lower than that in the other studies.
This study’s contribution to the theory includes an in-depth understanding of the process involved in each pillar of active bed management. Previous studies only briefly explained the roles within active bed management. By contrast, this study provides an in-depth discussion of the daily practices, and explains the issues and problems that can arise in each pillar and how they should be dealt with. Another contribution of this study is that it analyzes the duration of patient boarding. Moreover, it considers the causes of delayed boarding time within active bed management, such as scarcity of capacity, late requests by physicians, and nursing wards being unprepared for admissions due to late discharges.
Implications for Practice
for incoming admissions. This study can also serve as direction towards indicating the perceived level of care of each nursing ward in HIX. This should allow a better overview of the hospitals capacity as beds are not seen as a binary variable.
This study may also be useful to other hospitals by enabling them to understand the processes involved, and will therefore help them in implementing active bed management.
Limitations and Further research
This study has several limitations. Firstly, while it seeks to understand whether active bed management reduces patient boarding, it is unable to compare boarding times before and after implementations. The total LOS of patient was slightly reduced, but this could also be attributed to other factors, such as a change in the complexity of the patients or improved processing times during treatment. Secondly, the sample of the collected data that provided information about admissions, the reservation process, and boarding times was relatively small. In addition, this data was collected manually by the admission coordinator, which may raise doubts concerning its accuracy. Thirdly, as the case hospital is an academic hospital the results of this study may be different to hospitals with less complex patients.
For further research, it would be interesting to analyze in depth how hospitals can forecast the number of daily admissions in the nursing wards, as this is not yet properly understood. A proper forecast based on historical data will enable future capacity problems to be recognized early on. Another aspect of interest is to research how hospitals can create an overview of capacity, taking into account the perceived level of care on each ward.
Conclusion
The main question asked in this research was: How can active bed management be used to shorten patient boarding time in the emergency department? The first aspect of active bed management is the proactive management of resources, which helps to provide an understanding of the hospital’s available capacity. Achieving an accurate overview is a time intensive process, and it is here that the admission coordinator creates the most added value. However, it can be argued that this overview should rather be generated by means of HIX and not by multiple bed consultations and ward visits by three skilled nurses each day.
This overview is required in order to minimize the time needed for the admission coordinator to find an available bed. The admission coordinator either starts the search for a bed when informed by the physician, or when they have proactively read the medical files and asked probing questions to the ED nurses and physicians. The search for a bed is a relatively quick process as 79% of all requests are completed within 15 minutes. This quick reservation process calls into question the need for admission coordinators. While physicians had previously complained that they spent too much time finding appropriate beds, that was in a situation where they did not have a proper capacity overview available. A reason for delay in the evaluation
and assignment of admission is that the physicians share information on admissions at a
relatively late stage once treatment is finished. This gives the admission coordinator less time to find a bed and prepare for transport, and also gives the nursing ward less time to prepare for an incoming patient. If this information is shared earlier, patient boarding time will probably decrease as both parties will be able to prepare for an admission.
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Appendix 1 Recording of Process Steps
Datum: Patiënt Nummer/ Naam Geïnformeerd over (mogelijke) opname Bedgevonden Patiënt beschikbaar voor opname
Appendix 2 Interview Guide
Admission coordinator
Achtergrond
Hoe ben je op deze functie gekomen, was je al OPCO voordat het hele huis erbij was betrokken? Inventariseren
Welke stappen onderneem je om een actueel beeld te krijgen van de beddenstand in het huis? Klopt dit beeld ook?
Hoe verschilt de ochtend en avond dienst in het inventariseren van bedden?
Zijn alle vergaderingen nodig en juist geroosterd volgens jou? (09:30, 10:00, 11:30, 15:00) Wat zijn de voordelen van fysiek inventariseren door het huis?
Wat zijn de nadelen van fysiek inventariseren door het huis?
Maak je gebruik van HIX om de beddenstand te inventariseren? Waarom niet/wel? Waar ligt het aan dat HIX geen correct beeld geeft?
Zou een 95% kloppend HIX de functie makkelijker maken? Opnamebeslissingen
Wanneer bepaal je actie te ondernemen voor een patiënt die moet worden opgenomen? (meelezen, geïnformeerd door chirurg..)
Wordt je tijdig geïnformeerd over opnamebeslissingen? Als je te laat wordt geïnformeerd, wat is dan de rede hiervan?
Denk je dat iedereen bekend is met de OPCOs? En ook als gewenst omgaat met de OPCOs? Is het specialisme waar de patiënt moet worden opgenomen vanaf het begin duidelijk? Bed reserveren
Reserveer je altijd eerst bij de afdeling, ook als uit de inventarisatieronde blijkt dat er geen capaciteit is?
Welke stappen onderneem je als blijkt dat de betreffende afdeling geen capaciteit meer heeft? Als je weet dat afdeling XX al een aantal leenbedden heeft, sla je deze dan over?
Is het lastig om een buiten bed te plaatsen bij een afdeling? Coördineer je ook terugplaatsing van leenbedden?
Patiënt vervoer
Is er afgesproken of patiënt gebracht of gehaald wordt naar de afdeling? Wat is jouw persoonlijke voorkeur, en waarom?
Vertraagd vervoer de opname van andere patiënten? Overige vragen
Wat is, volgens jou, de grootste reden dat patiënten lang op de SEH verblijven en waarom? Wat zou je zelf graag verbeterd zien worden?
Heb je contact met andere ziekenhuizen in de buurt?
Wat zou er moeten gebeuren als er geen capaciteit is in het huis vanwege geplande opname?
Supervisor of Nursing Ward
Wat is jouw functie op deze afdeling? Spoedopnames
Ben je bekend met het aantal verwachte spoedopnames per dag? Hoe houden jullie rekening met spoedopnames?
Hebben jullie plek voor alle spoedopnames die verwacht worden? Waar ligt het aan als jullie geen plek hebben?
Ben je bekend met de OPCOs?
Ben je tevreden met de het opereren van de OPCOs? Wat gaat er goed?
Wat kan er beter?
Wat zijn voor jullie de voordelen van een OPCO ipv arts die bed regelt?
Hoe gaat de communicatie met de opco? Is er teveel/precies goed/te weinig communicatie? Gebeurt het wel is dat jullie actie ondernemen wat achteraf niet nodig is? Hindert dit je eigen taak?
Heb je liever dat de OPCO de patiënt brengt of dat jullie halen? Waarom? Wat vind je van de overdracht die de OPCO doorgeeft?
Leen/buitenbed
Is er een specifieke afdelingen waar vaker dan gemiddeld buitenbedden van jullie liggen? Is er een specifieke afdelingen waar vaker dan gemiddeld leenbedden van bij jullie liggen? Werk je met hix om een beeld te krijgen van het aantal leen/buitenbedden?
Zijn jullie actief bezig in het terugplaatsen van leenbedden? Zijn jullie actief bezig in het terughalen van buitenbedden?
Zou de OPCO een taak moeten hebben in het terugplaatsen van leen-buitenbedden? Zou dit voordeling zijn voor jullie afdeling en of tijd schelen?
Electieve opnames
Komt het voor dat jullie electieve opnames afzeggen? (zeer zelden, zelden, regelmatig, vaak, zeer vaak)
Zouden jullie vaker electieve opnames moeten afzeggen om spoedplekken te creëren? Hoe bekend is de ligduur bij electieve opnames?
Wanneer besluit je actie te ondernemen om langliggers te verplaatsen?
Emergency Coordinator
Wat houdt jouw functie op de afdeling in? Spoedopnames
Wat is de grootste reden dat patiënten lang op de SEH verblijven? Welk type patient heeft de langste ligduur op de SEH en waarom? Wat is de voornaamste oorzaak van sluitingen op de SEH?
Heeft de komst van de OPCO het wachten op een bed versneld?
Zijn er aspecten die je anders wilt zien in het functioneren van de OPCO? Heb je het idee dat de arts juist gebruikt maakt van de OPCO?
Ben je bekend met het onderzoek van Jasper Venema over opname voorspellingen?
Heeft een voorspelling bij triage een voordeel over een arts overleg met opco na ongeveer 2 uur dat de patiënt aanwezig is op de SEH?
Overige vragen
Als een afdeling over 2 uur plek heeft, gaat de voorkeur dan uit naar eerdere doorstroming naar ander specialisme of langer op SEH verblijven?
