We know that many hospitals in the country operate at capacity, and many patients are boarded in the emergency department. The literature is replete with the adverse consequences, including morbidity and increased mortality. It seems that it’s the way our system runs that creates this problem. We’re a nine-to-five, Monday-through-Friday system, trying to address a seven-day-a-week problem.

There are a few major initiatives to address this, including smoothing of elective admissions, which seems to have a profound effect on improving capacity. Early-morning discharges also have a strong impact on capacity, can virtually eliminate boarding, and also decrease the length of stay. The untouched area in the hospital industry has been weekends. Looking at the Statewide Planning and Research Cooperative System (SPARCS) data compiled by the New York State Department of Health reveals that discharges on a Saturday have an average length of stay of 3.9 days, but patients discharged on a Monday stay an average of 7.3 days.

I recently had a conversation with Peter Semczuk, DDS, MPH, and David Esses, MD, both with the Department of Emergency Medicine at Montefiore Medical Center, about how they solved their problems with ED boarding, particularly on weekends. The following is an edited transcript of our conversation.

Moderator

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.

Participants

Peter Semczuk, DDS, MPH, is senior vice president and executive director of Montefiore’s Moses Campus in Bronx, New York. He is well-known for his work in emergency services, having overseen the expansion of Montefiore’s Department of Emergency Medicine to the second busiest in the nation.

David Esses, MD, FACEP, is a professor of clinical emergency medicine and vice chair and medical director at the Department of Emergency Medicine at Montefiore Medical Center, Moses Division, in Bronx, New York.

PV: David, would you describe what the emergency department was like before these interventions and then describe the interventions and what has changed at Montefiore?

DE: I’ll paint the picture of January and February of last year. We had an average of 29 patients waiting for beds at 8 o’clock in the morning. We would have more than a ward full of patients just waiting for beds every single day—that includes Saturdays and Sundays. About eight years ago, we hired a team of hospitalists to help take care of the patients who were waiting for beds.

PS: Our work actually began in March 2015. We have a very large academic medical center with 96,000 discharges a year and a little over 300,000 ED patients. We were in the busiest quarter of the year and were falling behind our admission and discharge targets in the first two months. We were contemplating all kinds of actions, and chose to take on ED crowding.

It was really unbelievable in the middle of March, the winter flu season. The emergency department was packed, and yet all of these admitted patients were being boarded because we were not looking at ED crowding as a system-wide issue. One of the less popular but most important changes we made was that we insisted that each of our key directors join me and come in on the weekends. We worked consecutively for about six months, every Saturday and Sunday, so that we could get a much better understanding of some of the rate-limiting steps to safely discharge patients. It was painfully apparent that things that should have been happening on Saturday and Sunday simply were not.

An example was that you couldn’t get an echocardiograph done on a Saturday or a Sunday. It turned out it was only a matter of talking to the leadership in cardiology and saying, “Guys, we have to find a way to do echos seven days a week, especially if it’s going to help our clinical teams reach disposition decisions.” Today, we have access to echos seven days a week.

We also realigned the schedules of our physical therapists because we didn’t have rehabilitation services on Saturdays and Sundays, a major barrier to discharges. We asked them to schedule over a seven-day period instead of a five-day period. We did the same thing with social services. We identified the five biggest nursing homes that we do business with and clearly communicated to them that if they valued the Montefiore business, they needed to figure out a way to have intake coordinators available to us on weekends. It’s amazing. Once you put that kind of pressure and leverage on them, everything changes.

PV: How hard was it to get people to come in on weekends?

PS: I think initially there was a tremendous amount of resistance at the leadership level to coming in on Saturdays and Sundays. It was a matter of working seven days a week for six months to really better understand some of the struggles that our clinical teams were having on weekends. The skeptics started to see the change by going downstairs and seeing the impact that it was having. Now on Monday morning, our biggest day of the week, there are only two or three patients waiting for beds.

PV: What advice would you give to other places that struggle with boarding? 

PS: I think it begins with leadership. They need to come in on the weekends in particular. When you think about it, you have quite a bit of capacity to do things for patients on two out of seven days, and most institutions just don’t use them. The work we’ve done here, without question, has been transformative for everyone.

PV: We have a 600-bed institution and experience a lot of boarding. If we absorbed the exact same volumes moved out over seven days a week, which we’re not planning on doing, we would actually need only 498 beds instead of 600 to take care of that volume, and we wouldn’t have capacity issues. It speaks to how much money we spend as a result of running a hospital system 65 percent of the time while the 35 percent that represents Friday afternoon to Monday morning is just lost.

PS: Also, we drove down our inpatient length of stay dramatically. Over the course of last year, not only were we able to significantly exceed our targets for admissions and discharges, we actually closed 30 inpatient beds. At the early part of last year, we were at about 6.5 days for average length of stay. We finished at about 5.5. And this is at a place that runs at near 100 percent occupancy all the time.

PV: If I understand my hospital economics, a wild guess is that that change in length of stay would be worth about $150 million annually to your hospital.

That was one of the most eye-opening things for the directors when we started coming in on the weekends and we started going floor by floor. You’d see patients here for 120 or 125 days. —Peter Semczuk, DDS, MPH

DE: You started the hallway placement program as a safe option for stable patients, which is a big deal. It plays a huge role over here in getting patients out of the emergency department when there are no beds.

PV: Do you have problems with discharge where it takes a long time to get the orders in and it takes a long time for the nurse to go through it and get them out?

DE: Yes.

PV: I think when you start the discharges in the hallway, the tail would wag the dog. Suddenly, discharge papers would be available.

PS: One of the hidden gems is to take a look at your long-stay patients. That was one of the most eye-opening things for the directors when we started coming in on the weekends and we started going floor by floor. You’d see patients here for 120 or 125 days.

The point is this: Think about creating just one additional bed when someone is in that bed for 100 days. You asked earlier what my recommendation would be to a CEO. Start looking at these long-stay cases; we define long-stay as anyone here more than 20 days.

In some instances, it has a lot to do with our partner nursing homes being more willing to take patients from us who were here for a long period of time. In other instances, there were placement issues that were somewhat beyond our control. There were many examples of, “We could always do this next Thursday.” That’s different now. It’s, “Why can’t you do that today or tomorrow?”

PV: Have you done anything in terms of smoothing of elective schedules?

PS: We’ve got a couple of our pediatric subspecialties telling us that they’re very busy Monday through Friday, and they want to start Saturday hours. That’s also happening with some of the adult disciplines. We used to start our operating rooms late on Monday. Monday was grand rounds for anesthesia and surgery; we wouldn’t start until 10 o’clock. We shifted grand rounds to Friday, which was the slowest day of the week from the operating perspective.