Many hospitals in the country operate at capacity, and many patients are boarded in the emergency department. Although there are many ED-based flow initiatives, virtually none of these address the most significant impediment to flow: boarding of admitted patients in the emergency department due to lack of inpatient beds. Only a few interventions really have any lasting and significant impact on boarding and capacity.
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ACEP Now: Vol 35 – No 12 – December 2016This is one of a series of interviews that highlight dramatically effective interventions to reduce boarding and crowding. Early-morning discharges can have a strong impact on capacity, virtually eliminate boarding, and also decrease the length of stay. I recently sat down with Katherine Hochman, MD, to discuss NYU Langone Medical Center’s efforts to increase capacity by discharging patients earlier in the day.
Participants
- Peter Viccellio, MD, FACEP, is vice chairman of the department of emergency medicine and associate chief medical officer for the Health Sciences Center at Stony Brook University in New York.
- Katherine Hochman, MD, is assistant professor and associate chair for quality of care in department of medicine at NYU Langone Medical Center in New York City.
PV: Welcome and thank you for joining me to discuss another issue related to hospital overcrowding and flow. As you know, this is a major issue for emergency medicine, hospitals, and patient safety. Previous literature has suggested that early discharge could really have a dramatic impact on hospital capacity and on hospital flow. You have been a leader in some major initiatives at NYU in order to improve early discharge.
KH: Thanks very much for having me. The major metric that changed how we viewed early discharge was the fact that patients who came up to the floor after 1 p.m. stayed an average of 0.6 days longer even after you adjusted for all the different diagnoses compared with those patients who physically arrived on the floor before 1 p.m. This was a major eye-opener for us; the metric that really changed it all was that 0.6 increase in length of stay.
PV: There are five or six articles that looked at length of stay as a function of boarding, and the punchline was that there was roughly a day increase in stay if you boarded patients in the emergency department. When we initiated the full-capacity protocol, we reversed that. We were always curious as to why. If you admit and board a patient in the emergency department, they are going to get their antibiotics and their CT scans, but they’re not going to get care management, social work, and other inpatient services. If you don’t get them up in the morning, they lose that day.
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One Response to “Early Hospital Discharge Can Improve Capacity, Patient Flow”
December 1, 2022
Mark BThis is ridiculous. The inpatient/hospitalist team controls discharges, and they are trying to get patients out. I am a cardiologist but worked as a hospitalist during and for months past COVID. Everybody wants to discharge. Administration is looking at everyone of your patients and saying about your patient who had two rapid responses overnight “Well these haven’t had one this morning, can they be discharged.” The patients want to leave. They can have two chest tubes in and as your rounding on them they say”can’t you pull these out and I can go home”. Hospitalists make more on discharges than progress notes, so they are trying to discharge their service. But the hospitalists are generally short term employees and so are the dumping ground for the whole hospital. Let hospitalists actually do their job and not be the answer for everything the hospital doesn’t want to deal with. The ER contributes to this issue. If a patient is a true ICU patient and the ICU initially denies, sending them to the floor is not the answer. Spending three hours straight with one patient, you are not going to be able to discharge your other 19 patients. You don’t call to admit a severe nose bleed, then the hospitalist gets down their and the patient is on anticoagulants, has a SBP of 255, and a severe headache. So you are in the ER getting down the BP and ordering a head CT to make sure their is no bleed. The patients need to be reasonably stable. But the hospitalists are quoting. I would estimate over 75% of my shifts we were down at least one hospitalist, which means you are carrying too many patients to just discharge. And the hospitalists are getting worked dumped on them that should not be theirs from all directions. I will never do the job again and most of the hospitalists I worked with are looking for different careers. As their is a hospitalist shortage and I have just gotten two calls in the last hour about opening because their is a shortage, plan on boarding to get worse. We need to discharge more. Thanks for the rocket science.