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.

This is one of a series of interviews that highlight dramatically effective interventions to reduce boarding and crowding. Eugene Litvak, PhD, is a world-renowned expert in hospital flow who made the remarkable discovery that our problem with capacity is driven in large part by elective scheduling, not by ED admissions. We sat down to discuss his experiences tackling the issue of hospital crowding.

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.

 

Eugene Litvak, PhD, is president and CEO of the Institute for Healthcare Optimization and an adjunct professor in operations management at the Harvard School of Public Health in Boston.

PV: This is one of a series discussing hospital and ED crowding and its impact on patient safety, finance, and staffing. How did you get into the whole arena of hospital capacity and flow?

EL: I came to this country in 1988 from the former Soviet Union. I already had dozens of publications in the United States, and many of my colleagues recommended that I should go anywhere but health care because in this industry, efficiency is not a goal; there is no interest to increase efficiency. That was a red flag for me. I started doing some limited consulting at hospitals and started trying to learn the environment at the hospital, working with the frontline people, ie, nurses, physicians, etc. At that point, I met Dr. Michael Long, an anesthesiologist. At that point, the question that we were trying to address was, what happens with hospitals overcrowding? We found that at the same time hospitals are getting more and more overcrowded, the hospitals’ census and bed occupancy experienced large fluctuations. My initial belief was that everything stemmed from the emergency department. There are two main portals to any hospital. Emergency departments are responsible for over 50 percent of all admissions, and there are elective admissions, mostly surgical, typically responsible for up to 30–35 percent of admissions, the remaining admissions being medical referrals, transfers, etc.