Patient Flow Enewsletter
Volume 1, Issue 2
Tuesday, January 10, 2004

Innovations
Making Room in the ED by Starting with . . . Elective Surgery?

It's a common problem for many hospitals. Patients arrive in the ED who need to be admitted, but there are no available beds elsewhere in the hospital. Therefore they remain in the ED longer than they should, forcing the hospital to divert other incoming ED patients because of lack of capacity.

To combat this, Boston Medical Center is more thoughtfully scheduling the time and pace of elective surgeries, as well as planning more time-sensitive patient discharges.

"When I learned in the course of a medical meeting presentation that the recognized guru of hospital flow, Dr. Eugene Litvak, was on the faculty at my own university, I nearly fell out of my seat," said John Chessare, MD, Boston Medical Center's chief medical officer and senior vice president of medical affairs, who immediately pursued an Urgent Matters demonstration grant to bring Dr. Litvak on board as a consultant.

Boston Medical Center is a 547-bed facility, serving as the primary teaching affiliate for Boston University's School of Medicine. The Medical Center is likely best known as the largest and busiest 24-hour Level 1 trauma center in New England. Approximately 50 percent of its patients are either uninsured or have Medicaid, and four out of 10 ED arrivals have no primary care physician.

Many thus think of the facility only as a 'safety net' hospital, but surprisingly, its role as one of the primary providers of cardiothoracic and other specialty surgery in the region is the focal point of the Urgent Matters project.

The project is testing whether careful scheduling of elective surgery - initially cardiothoracic and vascular surgery - can "smooth" a facility's patient flow and ultimately reduce ambulance diversions.

The theory behind Dr. Litvak's is simple, yet revolutionary. When there are no empty beds in a hospital, ED patients who have been admitted remain in the ED. And when no ED beds remain, ambulance diversion begins. Rather than accepting that such ambulance diversions are unavoidable, Dr. Litvak is helping the team at Boston Medical Center examine the causes of the ED's overcrowding.

Dr. Litvak's theory of "smoothing variability" suggests that a hospital needs to control, or smooth, the variables affecting beds that its management and surgeons can - and the most prominent of these is the scheduling of elective surgeries.

Prior to the project's initiation, Boston Medical Center's vascular surgery staff performed, on average, three to five surgeries per week - in patients that needed intermediate care - often all on the same day.

"Rather than having these peaks that would force us to cancel vascular surgeries because we were out of beds, we put a cap on the number of such surgeries performed per day," said Dr. Chessare.

This is just one of the many changes that Boston Medical Center is implementing to reduce ED crowding. Others include a more efficient turnover of empty beds via a redesigned housekeeping system and an approach to discharging more patients in the morning - rather than late in the afternoon or early evening, when the ED arrivals are simultaneously starting to pick up.

"I believe the best way to serve people without health care choices is to become the hospital of choice," explained Dr. Chessare. "We know that we'll still have work to do when the Urgent Matters grant expires, but we look at the grant as a phenomenal gift, the resource that got us moving in the right direction."

Click here for a presentation on the initial results after the first month of Elective Surgery Smoothing at BMC.

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John Chessare, MD, MPH
Chief Medical Officer and Senior Vice President of Medical Affairs
Boston Medical Center
Boston, MA