September 18, 2017

Pediatric emergency medicine physicians Therese Canares and Oluwakemi Badaki-Makun were becoming increasingly frustrated with the length of time it took to get patients who needed inpatient care admitted to the hospital. Then they asked nurses in the emergency department (ED) what they saw as possible causes in the delay.

“What kept coming back were delayed acceptance pages,” says Canares.

Acceptance pages, Canares explains, are what senior residents on an inpatient service send to ED attendings like Canares after they submit an admission order. Nevertheless, before they send that page, the residents—following tradition and the practice they learned from their senior residents—trek down to the ED to examine the patient, review the medical record and verify the need for admission. As it turns out, as Canares, Badaki-Makun and the residents discovered in the quality improvement project they initiated, the window of time for that step between the admission order and the patient’s arrival on the inpatient floor—known as the boarding time—was very unpredictable.

“When the resident says it is okay to move the patient from the ED to the floor is highly variable and often the number one delaying factor,” says pediatric resident Keith Kleinman. “If I’m really busy when I get paged to do an admission in the ED, I might have to wait another 20 minutes before I get to go see that kid.”

“In the time it takes to walk to the ED, a resident can receive 10 or more other pages,” says pediatric resident Ted Kouo, who volunteered for the project because of his low tolerance for inefficiencies in care.

Searching for a solution, the team theorized that minimizing the need for an exam and evaluation by the inpatient residents, which duplicated the work of the ED attending and staff, was key to improving patient flow to a hospital bed. A patient presenting with serious respiratory needs or experiencing painful crises of sickle cell disease, for example, would benefit from that second set of eyes, but not necessarily a child with a skin infection that is not going to get significantly worse in the next few hours.

“I’m not saying it’s unnecessary every time—some patients do benefit from an evaluation in the ED by a second set of eyes,” says Kouo. “But for a very stable patient, it’s not necessary.”

“If they’re clinically well appearing in the ED,” adds Kleinman, “they can be evaluated once they’re on the inpatient floor.”

However, creating efficiency in patient flow from the ED to inpatient services meant changing a long-standing and ingrained cultural behavior of residents. How could the team effect such a change?

A number of actions were taken, including additional education on the signs and symptoms of patients in the ED residents should be most concerned about. Also, at morning reports and inpatient meetings, residents were reminded by senior residents that they could, after exercising their clinical judgment, bypass a visit to the ED and direct admit the patient. Similar messaging was blasted out via email and posted on placards placed on residents’ computers at their inpatient workstations. To speed admission even more, residents were urged to use a ping app rather than email to send their acceptance page. The results?

The daily mean boarding time in the ED decreased by 36 minutes, from 170 minutes to 134 minutes. Also, the total length of stay in the ED, from the time the patient enters the ED to the time he/she leaves for the floor, decreased from 370 minutes to 310 minutes.

“We found we were able to significantly decrease the ED length of stay, specifically the time from admission order being placed to time of leaving the ED,” says Kleinman.

The main takeaway?

“The message has evolved—you can send your acceptance page before you meet the patient,” says Canares. “For institutions with a strong body of residents, we’ve proven there’s a way to improve patient care by effecting change in resident behavior.”