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Quality Improvement Promising Practices from the Field

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Bursting at the Seams: Improving Patient Flow to Help America's Emergency Departments

    • June 4, 2008

Across America, hospital emergency departments (EDs) are in crisis. For many communities, the local hospital ED has become the linchpin of their health care safety net. With a legal obligation to see patients at all times and with more people than ever seeking their services, EDs nationwide are bursting at the seams.

From 1992 to 2002, the number of annual ED visits increased 23 percent in the United States, while the number of operating EDs decreased by about 15 percent, due to hospitals either closing their EDs or going out of business.1 Many EDs are overwhelmed by the number of patients needing their services, with 62 percent of the nation's EDs reporting they that are “at” or “over” operating capacity.2 Almost daily, newspaper headlines across the country relay stories about patients waiting for hours in the ED before being seen and tales of ambulances being diverted from one hospital to the next because of overcrowding. While much of the blame for this situation has been placed on broader social issues—such as increasing numbers of uninsured Americans and increasing reliance on the ED by those who are uninsured—3many hospitals have done little to address the patient flow obstacles that lead to overcrowded EDs.

The Urgent Matters program, a national initiative of the Robert Wood Johnson Foundation, worked intensively to try to find solutions to this problem that could be applicable nationwide.As part of the program, 10 hospitals were selected to participate in a year-long Learning Network to develop a series of practical management tools to address issues related to ED overcrowding. As the initiative evolved, hospitals participating in the Learning Network developed a variety of strategies designed to improve patient flow and reduce ED crowding, and in the process created their own best practices. While each of the Learning Network hospitals decided which strategies to implement within their own organization, a number of common overarching themes for success quickly became apparent.

Critical Success Factors:

  • Recognizing that ED crowding is a hospital-wide problem, not an ED problem
  • Building multidisciplinary, hospital-wide teams to oversee and implement change
  • Determining the presence of a “champion”
  • Guaranteeing management's support
  • Using formal improvement methods
  • Committing to rigorous metrics
  • Making transparency an organizational value
  • Finding the right balance between collaboration and competition

The program used an input/throughput/output (I/T/O) model as a framework for understanding why patient flow breaks down. Creating a hospital-wide team to participate in decisions and changes to patient flow was a critical factor for success.

Core MetricsThe program identified 17 key performance indicators (KPIs) designed to evaluate each hospital's patient flow performance. Information systems varied greatly among the Learning Network hospitals. Many hospitals had to implement manual systems to capture the required data, although collecting the necessary data was sometimes eased by using data sampling strategies.

Web-Based Project Management SystemLearning Network hospitals accessed the Urgent Matters toolkit of available materials via the program's Web site and also posted action plans, monthly project reports and “Celebrating Success” stories. The Web-based management system both spurred collaboration among hospitals while fostering healthy competition.

Sample Strategies and Innovations




Patient Flow Coordination and Facilitation

  • Implement a “bed czar” or patient flow manager by designating a specific position responsible for ensuring the timely transfer of ED patients to assigned inpatient beds
  • Dedicate a nurse with admissions/discharge/transfer duties who is specifically responsible for facilitating pending discharges to accelerate available beds for admits
  • Develop accelerated triage and registration processes to triage more efficiently based on the patient's acuity and reduce patient waiting times by re-ordering or combining triage and registration processes

Early Discharge

  • Initiate preliminary discharge by designating patients for early discharge the next day
  • Redesign rounding and discharge processes to focus on patients ready for discharge
  • Create a discharge room/lounge for inpatientswho have been discharged and are awaiting transportation, medications or education
  • Establish a discharge coordinator position to coordinate procuring information that is required to discharge the patient
  • Implement monetary incentives (bonuses) and nonmonetary incentives (movie tickets or cafeteria vouchers) for physicians and nurses to promote efficient and early discharge of patients who are ready to go home

Boarding and Inpatient Bed Assignment

  • Replace the traditional “push system” with a “pull system” in which the inpatient floors play an active role in pulling ED patients into available beds

Diversion Management and Reduction

  • Establish new protocols and monitoring systems to determine when the hospital is approaching maximum operating capacity and its threshold for diversion
  • Develop a hospital-wide diversion response protocol to focus existing resources on facilitating all appropriate patient discharges in a more timely manner
  • Create a community-wide diversion plan in collaboration with local hospitals and the community's emergency medical services unit to establish a common protocol for hospitals going on and off diversion or bypass


Tracking ChangeTracking dozens of changes that are being implemented at one time in a single hospital can be a huge challenge. Yet, to properly identify achievements or successes as outcomes of a specific change, each change must be closely tracked and monitored. To streamline the process, a number of Learning Network hospitals developed a rapid cycle testing (RCT) tracking worksheet to record all of the changes made, allowing them to maintain momentum while providing a redesign audit trail.

RCT Tracking Worksheet



RCT #8

RCT #11




RCT Initiative

Met with Pharmacy to develop par level and add Td to current EC PYXIS. Td was removed some time back because of a national shortage. Shortage has improved, but Td is expensive and often wasted. Td protocol added to standing orders for EC.

For this RCT, a registration specialist will be designated to register all Pediatric and PA triage patients. During the RCT, nursing staff in triage will be asked to put triaged patients' charts in a bin designated for Pediatric and PA triage patients. This will ensure that these patient charts will not be included with other EC charts during the RCT. The designated specialist will be continuously monitoring the bin. Registration will be done continuously without delay due to other charts.

Resp Party






Source: University Hospital in San Antonio



  1. McCaig LF, Burt CW. “National Ambulatory Hospital Medicare Care Survey: 2002, Emergency Department Summary.” Web Page, No. 340, March 18, 2004. Available at . Accessed April 2004.
  2. “Emergency Department Overload: A Growing Crisis.” The Lewin Group analysis of AHA ED and hospital capacity survey. April 2002.
  3. Cunningham P, May J. “Insured Americans Drive Surge in Emergency Department Visits.” October 2003. Available at . Accessed August 2004.

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