Mixed effect of increasing outflow of medical patients from an emergency department

Background and aim: Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25-30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments.

Methods: We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED.

Results: Implementation of the first stage led to an increased morning discharge rate from a baseline of 2-4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8-12 per department), providing significant relief for the ED. However, the additional workload for the IM departments' medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42-44, included constant hallway housing, and often midday peaks of 48-50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning.

Conclusion: We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.