Active bed management by hospitalists and emergency department throughput

Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, Scott Wright
Annals of Internal Medicine 2008 December 2, 149 (11): 804-11

BACKGROUND: When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success.

OBJECTIVE: To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times.

DESIGN: Pre-post study that compared institutional data from November 2006 to February 2007 (intervention period) with data from November 2005 to February 2006 (control period).

SETTING: Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

PATIENTS: All adult patients registered in the emergency department during the study periods.

INTERVENTION: Active bed management is a hospitalist-led, multifaceted intervention that consists of proactive management of hospital and departmental resources, including twice-daily bed management rounds in the intensive care unit and regular visits to the emergency department to assess congestion and flow; assignment of all admissions to the department of medicine and facilitating transfer from the emergency department to the appropriate care setting; and support from the "bed director," who can mobilize additional resources in real time to augment hospital capacity to address emergency department throughput problems.

MEASUREMENTS: Emergency department throughput times and ambulance diversion hours.

RESULTS: The emergency department census was 8.8% higher during the intervention period than in the control period (17 573 patients vs. 16 148 patients). Throughput for patients who were admitted decreased by 98 minutes (SD, 10) (from 458 minutes in the control period to 360 minutes during the intervention period). Throughput for patients who were not admitted did not change (274 minutes vs. 269 minutes). The percentage of hours that the emergency department was on "yellow alert" (ambulance diversion because of emergency department crowding) decreased 6%, and the percentage of hours on "red alert" (ambulance diversion due to lack of intensive care unit beds in the hospital) decreased 27%. Staffing, length of stay, case-mix index, intensive care unit transfer rates, and mortality rates were stable across the 2 periods.

LIMITATIONS: Pre-post designs are less effective than randomized, controlled trials on the study design hierarchy, and unidentified external forces may have influenced the results. The study was done at a single hospital, and the findings may not be generalizable to other institutions.

CONCLUSION: Emergency department throughput and diversion status improved with the implementation of an active bed management process coordinated by hospitalists.

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