Sustainable Mechanism to Reduce ED Length of Stay: The Use of Emergency Department Holding (ED Transition) Orders to Reduce ED Length of Stay

Abstract

Objective

To evaluate the effect of an emergency clinician initiated “ED Admission Holding Order Set” on emergency department treatment times and length of stay. We further describe the impact of a performance improvement strategy with sequential PDSA cycles used to influence the primary outcome measures, ED length of stay (EDLOS) and Disposition Decision to Patient Gone (DDTPG) time, for admitted patients.

Methods

We developed and implemented an expedited, emergency physician facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA-cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a “non-value added” activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior.

Results

The use of an emergency physician initiated admission holding order protocol resulted in sustainable reductions in ED length of stay (ED LOS) when comparing the 2 years prior to the intervention, with median lengths of stays of 410 minutes (min) (IQR 295, 543) and 395min (IQR 283, 527), to the 2 calendar years following the intervention, with the median lengths of stay of 313 min (IQR 221, 431) and 316 min (IQR 224, 438), respectively. This overall reduction in EDLOS of nearly 90 min was found to be primarily the result of a decrease in the time from the emergency physician's admitting disposition decision to patient gone times (DDTPG) with median times of 219 min (IQR 150, 306) and 200 min (IQR 136, 286) for the 2 years prior to the intervention compared to 89 min (IQR 58, 138) and 92 min (IQR 60, 147) for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision (DTDD) of admission times during this same study period with annual medians of 176 min (IQR 112, 261) and 178 min (IQR 129, 316), respectively, for the 2 years prior to 207 min (IQR 129, 316) and 202 min (IQR 127, 305) following the intervention.

Conclusions

We conclude that the use of emergency physician initiated holding orders can lead to marked reductions in ED length of stay for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change

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