Overview

This report profiles five safety-net hospitals—Boston Medical Center, Denver Health, Memorial Regional Hospital, Memorial Hospital West, and Virginia Commonwealth University Health System—that made improvements to curb emergency department (ED) crowding, reduce long waits, and lower the number of hours spent on ambulance diversion. Hospitals used a combination of interventions, including: reconfiguring the ED to maximize efficiency; devising a pre-diversion system to alert staff of ED crowding; installing an electronic tracking system; designating staff members to be responsible for tracking patients; and developing meaningful performance metrics. To be successful, such interventions need to take place within a broader improvement strategy that entails: recognition that ED crowding is a hospital-wide issue; leadership provided by the CEO and other senior staff; vigilance in pursuing change, reviewing outcomes, and working to improve; transparency; and a commitment to quality for safety-net populations.

Executive Summary

Nationwide, hospital emergency departments (EDs) are in crisis. The demand for ED services has increased steadily while capacity has shrunk, due largely to hospital closures. Many EDs are overcrowded, causing long waits for care and high rates of ambulance diversion. ED crowding may be even more acute at safety-net hospitals because of their historic mission and legal mandate to care for vulnerable and underserved individuals.

All hospitals, including safety-net hospitals, can implement operational management and process improvements to curb ED crowding, reduce long waits, and lower diversion rates. This report profiles five safety-net hospitals that have done so. The hospitals—Boston Medical Center in Boston, Mass.; Denver Health in Denver, Colo.; Memorial Regional Hospital in Hollywood, Fla.; Memorial Hospital West in Pembroke Pines, Fla.; and Virginia Commonwealth University Health System in Richmond, Va.—were selected based on their long-standing commitment to providing quality care for poor and vulnerable patients as well as their current performance on nationally recognized measures of care. These hospitals are maintaining their critical position in the community as the gateway point to care for underserved populations, while reaching and often exceeding state and national benchmarks for quality care.

We collected information from site visits and follow-up interviews to identify strategies to:

• raise ED efficiency; 
•  reduce the number of hours on diversion (when an ED closes its doors to patients arriving by ambulance because of overcrowded conditions); 
•  improve ED throughput (the actual operations of the ED); and 
•  improve ED output (the ability to move patients from the ED to other services or types of care in the hospital or community).

Key Findings: Successful Throughput and Output Initiatives
The study hospitals used a combination of interventions to promote the smooth and timely flow of patients through the ED and other departments, known as "patient flow." They have seen improvements in a number of measures, including greater patient satisfaction, better patient care, reduced waiting times, decreased costs/increased revenues, and less time spent on ambulance diversion. We identified five strategies to improve quality and efficiency in the ED. Some do not require significant investment and therefore could be undertaken by many hospitals, including those that are challenged financially.

1. Reconfigure the ED to maximize efficiency. The study sites have undertaken a range of physical improvements in the ED, from a simple reorganization of ED triage and treatment rooms to a whole-scale redesign and rebuild. Even small redesigns such as identically equipping ED exam rooms or color-coding ED treatment room trays can produce efficiencies.
2. Devise a pre-diversion system to alert staff of ED crowding. Several of the study sites devised systems to signal that the ED is nearing diversion status. The alert triggers a communication strategy throughout the hospital that inpatient beds are needed for patients in the ED, in order to make room for incoming ED patients.
3. Install an electronic tracking system. Study sites that have installed electronic tracking systems have found them to be an invaluable tool for managing patient flow. A tracking system enables a manager to easily identify rooms that are empty, those that need to be cleaned, and those that house a patient ready for discharge.
4. Identify individual(s) responsible for tracking patients. Some sites have created a "bed czar," or bed facilitator position, to oversee patient flow throughout the hospital. This individual is empowered to communicate with the ED, medical departments, and hospital floors to smooth and expedite patient transitions between departments and through discharge.
5. Develop meaningful metrics. The hospitals emphasized the importance of developing metrics to measure, analyze, and improve performance. This strategy is crucial to establishing baseline performance and setting improvement goals. Hospitals can begin this work with a small set of measures, limited to specific departments or conditions, and expand as they gain experience and expertise.