MASSACHUSETTS NURSE NEWSLETTER :: February 2008

Emergency Department overcrowding, diversions and boarding
Q: Can they be controlled?
A: Yes … theoretically
By Mary Crotty

Huge safety problems for nurses and patients arise from the related issues of emergency department (ED) overcrowding, ED diversion and patient boarding on inpatient units. There has been an assumption for all too long that these problems are inevitable. Hospitals have argued that they cannot predict demand —for any given shift or day. As a result, the industry has long claimed they cannot be held accountable for staffing appropriately, since ‘patterns cannot be predicted' and they ‘cannot afford to staff to "peak" volume around the clock.' Nurses in turn point out that avoidable errors, morbidity and mortality are most likely to occur during the staffing ‘lows' – which is not acceptable. One obvious potential solution is to determine how to control the peaks and lows, and by doing so, smooth out the resulting demand for beds and services so that available resources more closely match the need.

Experts in what is termed "managing demand" (the concept comes from the world of manufacturing) in Boston are showing that theoretically at least, demand for hospital services can be smoothed out and managed significantly. Local leaders in this field of research, operating out of Boston University's Management of Variability in Health Care Delivery program, funded by the Massachusetts Department of Public Health and other private sources, have labeled the strategies emerging from their research as "patient flow" technology. Their ultimate goal is to help hospitals learn how to smooth or manage demand, minimize the ‘demand peaks' for ED beds, for tests, for ICU beds, and to thereby make care safer by matching resources (staff, beds, test times, OR availability, etc.) with the demand for those resources. As Professor Eugene Litvak, co-founder and director of the BU program points out, "Hospital census is not handed down from on high by God. It is a variable that can be controlled."

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), possibly recognizing the link between the emergency department crisis and strategies known to control demand, issued a new standard that went into effect on Jan 1, 2005 that directs hospitals to manage patient flow in order to address ED overcrowding and consequent problems. Unfortunately, it's not yet apparent that the techniques and strategies that could be used by hospitals are being tested or put into use. However, it does appear that they have significant potential.

Briefly: there are two different types of variation in demand. One is "natural"—largely outside the control of health care managers. For example, patients differ in the type and severity of disease; similar patients respond differently to treatment; patients arrive for treatment randomly over time; different providers treat similar patients in different ways, etc. However, even these sources of "natural" variability can be managed through various "operations management" tools and techniques adapted from other industries.

There are also "artificial" sources of variability that can be reduced and even completely eliminated. Much of this arises from poor management processes. The Boston University Management of Variability Program (MVP) has developed, implemented, and evaluated methods to (1) reduce this type of artificial management variability, and (2) better manage "natural" variability at a number of hospitals across the country.

Examples of strategies that researchers think can be successful when implemented appropriately and managed over time include smoothing of vascular and cardiac surgery schedules by changing block time distribution, eliminating block scheduling from one OR suite, designating an other OR suite for emergent cases and others for orthopedic cases, and going to an "open" scheduling system for other OR suites. Many of the strategies center around control of elective procedures. Unfortunately, elective procedures frequently generate significant profit for institutions and surgeons in particular, and as a result, hospital administrators are reluctant to require physicians to alter their admitting and OR scheduling practices. If we are to seriously control variable admissions and address this crisis, it may well be that regulators (i.e. Department of Public Health) will need to be forceful with hospitals, in view of their responsibility for public safety.

For more information, go to www.bu.edu/mvp/ or contact Brad Prenney or Dr. Eugene Litvak via www.bu.edu/mvp/people/index.html.

Due to the interest in this subject, an outgrowth of the research has been the development of a private company called PatientFlow Technology. Case studies and more information is available online at http://www.patientflowtech.com/.

You may also contact Mary Crotty, RN, MBA, JD, MNA associate director of nursing, at mcrotty@mnarn.org or 781.830.5743.