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Problem
At the Syracuse Veteran Affairs Medical Center, Syracuse, New York, we were faced with inefficiencies in patient flow from emergency department (ED) to the floor as evidenced by the metrics consistently not meeting the goals. The data revealed that 24.6% of all patients were staying in ED for over 6 hours. Among this patient group, 59.1% were admitted to the hospital and 69% admitted to medicine service. Several reasons for delays were discovered, with the major reason being unavailability of inpatient beds, responsible for 38.3% of the delays.
The entire process of patient flow was analyzed, and this revealed inefficiencies in the discharge process. Both patient admissions and discharges consistently peaked at the same period of the day (12 to 5 pm), when 46% of daily admissions and 74.7% of daily discharges occurred. This put a significant strain on the system and the staff.
We recognized that fluctuation in the number of admissions was a factor of natural variation that we would not be able to affect. On the other hand, variation of discharges throughout the day was a result of artificial variation, where we may be able to make an impact. Based on feedback from nursing staff, patients were usually occupying an acute bed for several hours after completion of discharge while waiting for a meal or transportation to arrive.
Background
Emergency department flow is not just about the metrics of not meeting goals. From the patient perspective, prolonged ED stay has been associated with increased hospital mortality and length of stay.[1]
Several approaches to improve efficiency of the discharge process have been described in the literature including various versions of a discharge lounge, which, if designed appropriately, can be a valuable tool to increase efficiency of the discharge process. The suggested key components of a successful discharge lounge were communication with stakeholders and their buy-in, appropriate location allowing convenient patient pick-up and diligent selection of appropriate patients.[2]
We took into account our own unsuccessful experience from the previous pilot of a discharge lounge. Several reasons that contributed to the past failure were identified:
- Lack of upfront and continuous education of the front-line staff and, as a result, lack of their understanding of the process
- Location in a small isolated...