As emergency departments have struggled with inefficient admission processes, a new domain called the ED-inpatient interface (EDii) has been identified. In the December 2017 issue of Emergency Medicine Australasia, Staib et al discussed and characterized the importance of this interface.¹

Meanwhile, in emergency departments across the country, the term “contested admissions” has been used to depict the problem of getting patients with an increasing number of comorbid conditions admitted. The contested admission refers to any discussions, testing, or consultations that delay the admission process—in other words, any answer but “yes” to the admission call.

The contested admission contributes to ED boarding, and a robust body of literature describes the ill effects produced by boarding (see the sidebar, “The Badness of Boarding”). So how are facilities are reducing admission inefficiencies in general and contested admissions delays?

Three Areas of Inefficiency

Hospitals intensely focused on admission efficiency have discovered there are three areas in which inefficiencies can occur. First, bed assignment has been a source of delay, particularly in the current era of inpatient geography (ie, services with strict unit assignments) and in facilities that employ capping (ie, strict numbers of admissions allowed by services). However, many facilities have streamlined these processes with tele-tracking products and performance improvement initiatives. The admit-decision-to-departure Centers for Medicare and Medicaid Services metric currently measures the time from the admission order or bed request to departure.

Hospital services such as housekeeping and transport services can also contribute to delay. Many facilities staff environmental services (EVS) heavily on the day shift, but hospital discharges often peak in the late afternoon or early evening. This demand-capacity mismatch ensures terminal room cleaning takes more time than the 30-minute industry standard. In addition, housekeeping and transporters often lack a systematic deployment scheme, and time is wasted walking between medical center towers. Improved deployment strategies can improve both housekeeping room turnaround and transport times.

The area that currently accounts for the longest delays, however, is the time from the call to the admitting team until the admission is accepted. Emergency departments often get pushback from various services and requests for further testing and consultations. This contested admissions phenomenon at the EDii gives the impression services are trying to avoid patient admissions.

To obtain an idea of the problem’s magnitude, an informal and unpublished survey of academic emergency medicine chairs was completed. Half of the academic programs that responded to the survey were working on the problem, according to Bruce Adams, MD, chairman of emergency medicine at the University of Texas Health Science Center at San Antonio. Another unpublished study conducted at Virginia Commonwealth University showed 39 percent of admissions were contested, which added three hours to patients’ ED length of stay.