Assistant Professor of Pediatrics Cincinnati Children's Hospital Medical Center Cincinnati, Ohio, United States
Background: Optimizing emergency department (ED) to inpatient flow improves system access by decreasing ED waiting room times and improves patient/caregiver experience by facilitating timely clinical care. At our institution, the baseline average time from admit disposition selected to a patient leaving the ED was 2.5 hours. Objective: To decrease the average time from ED admit disposition set to out-of-department for patients being admitted from the main campus ED to our primary hospital medicine inpatient unit by 25% (149 minutes to 112 minutes) by December 31, 2023 Design/Methods: This quality improvement project took place at a free-standing children’s hospital. The multidisciplinary team created a process map for the admission process and worked with process stakeholders to identify common delays. Our initial process map revealed a complex system that relied heavily on individuals to move the workflow forward. Additionally, stakeholders frequently reported delays related to accessing the appropriate bed type and supplies on the inpatient unit, identifying an accepting inpatient service team, and ED to inpatient provider handoff. Using these data and the model for improvement we determined key drivers and designed, tested, and implemented interventions to improve ED to inpatient flow (Figure 1). Effective interventions to address common process delays included: automating admission process steps including creating a bed request order to eliminate a manual step to assign patients to beds, working with patient flow coordinators to expedite unit and team assignment, partnering with the environmental services team to alter the bed cleaning approach and improve age-appropriate bed availability on the inpatient unit, addressing common “myths” about patient disposition from the ED (i.e., certain labs need to be collected prior to admission), and streamlining the process of ED to inpatient provider handoff. Results: The average time from ED admit disposition set to out-of-department decreased from 149 minutes to 134 minutes (Figure 2) for patients being admitted to our primary hospital medicine unit. As a balancing measure we monitored emergency transfers to the intensive care unit within 12 hours of admission and did not have any during our study period.
Conclusion(s): While we have successfully decreased our main outcome by 10%, further improvement efforts will focus on automation to limit the impact of human factors throughout the admission process and enhancing real-time identification and mitigation of barriers and delays.
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