Patient Flow Enewsletter
Volume 1, Issue 4
Tuesday, March 2, 2004

Innovations
Reducing ED Boarder Hours and Volume by Engaging Non-ED Staff

 

Resources in this article: ED Dashboard data definitions Screenshots of the ED Dashboard

Like many health systems and hospitals across the country, Inova Health System - a four-hospital, not-for-profit health care system located outside of Washington, DC, in Northern Virginia - has for years been striving to better manage boarders, or patients awaiting hospital admission. Though Inova is recognized for specialties in cardiac, pediatric and women's health care, it's by no means immune to the over-crowding challenges faced by emergency departments nationwide.

Dr. Thom Mayer, past chairman of the Emergency Department at Inova Fairfax Hospital/Inova Fairfax Hospital for Children, the system's largest and only tertiary facility, and other members of the hospital's ED staff are always looking for innovative and creative ideas to better control patient flow and crowding. However, last year's award of an Urgent Matters demonstration grant provided by The Robert Wood Johnson Foundation, provided for a system-wide team to address the challenge head-on.

"We can't fail to mention all of the work that's been done leading up to this," said Mayer. "If we had not been working to address this problem for years, we'd never be in as good of a position as we are today. In the past, however, as soon as we'd see a little progress, we would also see an increase in ED volume. It was clear that we needed a sustained effort to stay ahead of the curve."

The Inova Fairfax team approach was a novel one - host a two-day, off-site retreat involving representatives of every facet of the organization, even those who may not see ED boarders as their problem to solve. Physicians, registered nurses, registration staff, lab technicians, information systems staff and even volunteers participated.

See re-design team.

"We needed everyone to see boarders from a new perspective," said Candice Saunders, chief operating officer. "We needed to change the culture, shift the paradigm. Boarders lingering in ED hallways aren't ED patients. They're the hospital's patients. Therefore, we need to work together to create an environment that achieves the highest possible level of patient care, comfort and satisfaction, which means moving patients from the ED to beds as quickly as possible."

This multi-disciplinary group focused on what they referred to as the 80-20 rule - the 20 percent of the potential changes they could make that would affect or improve 80 percent of the problem. One of the retreat's key outcomes was a goal - admittedly an ambitious one - to reduce both boarder hours and boarder volume by 50 percent within one year.

See redesign goals and recommendations.

The team has implemented a number of changes to help meet this goal - placing inpatient boarders in inpatient hallways, installing new software that allows housekeeping to turnover empty beds more quickly and changing physician practices, so that they do rounds in the morning, freeing up beds earlier in the day.

See patient flow initiatives.

Structural changes in the coming year will put Inova Fairfax in an even stronger position to meet the 50 percent goal. The new Inova Heart and Vascular Institute, slated to open this fall, will allow for more efficient streamlining of cardiac patients who come into the ED. It will also free up space - allowing, among others, the hospital's intensive care and pediatric units to expand, meaning more beds for boarders to be admitted to more quickly.

Yet even prior to these changes, significant strides have already been made in reducing boarder hours, particularly among those patients considered "long-term" boarders. The number of patients boarding for more than eight hours has decreased 72 percent, while patients boarding for more than 24 hours has decreased by 50 percent.

See impact charts.

Reducing boarder volume, however, is shaping up to be a greater challenge.

"We were absolutely right in setting out to reduce boarder volume by 50 percent," Melody Knapp, senior director, Cardiac, Critical Care and Respiratory Services. "And if we typically operated at 80 or 90 percent capacity, I think we could have met the goal within a one-year period. Monday through Friday, however, there's no room at the inn. We run at 100-plus percent capacity, which means it will probably take us 18 months to meet this second goal."

Interestingly, the team views the extended time period needed as an opportunity, not an obstacle. "Since last summer, we've made great strides - many based on learnings from other Urgent Matters grantees in hospitals across the U.S.," said Ellen Crowe, director, Grant Facilitation. "When the project's funding ends, the work doesn't. We're going to continue networking with other grantees and continue to improve quality of care for our patients."

Click here to download a Powerpoint presentation on the Inova Re-design Work Shop case study.

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Tom Mayer, M.D.
Former Chairman, Emergency Department
Inova Fairfax Hospital
Fairfax, VA