[en] Introduction
Improving patient flow from emergency department (ED) to in-hospital bed admission has become an everyday challenge. Implementation of an ED bed manager (BM) who monitors hospital beds availability daily has been advocated to reduce boarding time for admitted patient. However, little is known on the actual burden and pitfalls of ED bed coordination. Indeed, overcrowded hospitals often lead to inappropriate transfer from ED to less adapted hospital unit or unit with lower level of care. We design the present study to evaluate the occurrence of such step-down units transfer.
Methods
This prospective study was conducted in a tertiary care academic hospital accounting for 622 licensed beds and an ED census of 45000/year. In 2014, a BM was implemented as a result of a quality improvement program. Focus was made solely on facilitating and improving patient movements form ED to the hospital wards. The investigators extracted data from a 20-days random observation period in February and March 2015, or a total of 231 patients administered by the BM.
Results
During this period, mean ED census was 131 (±12) patients /day, of which mean hospital admission rate was 20,6 %. BM administered 12 (±3) of these patients daily. Most of these patients were transferred to an appropriate unit (47.6 %) or a short stay unit (32.1%), while 17.7 % were referred to under adapted units and 2.6 % to step down units. Patients’ average length of stay (LOS) was 32 hours. LOS for patients immediately admitted in the ED short stay unit (n=74) was 26.5 (±22) hours, while it took 35.8 (±26) hours to reach an appropriate unit (n=110) and 35.6 (±27.4) to reach a less-appropriate unit (n=41). Interestingly, patients transferred to a non-appropriate unit (n=6) stayed 29.5 (±15.7) hours in the ED. Communications means used by the BM was face-to-face talk almost half of the cases (n=93) and phone calls for the other half (n=115).
Discussion and conclusion
These results emphasize the complexity of ED flow coordination. Whether or not such coordination is effective on ED overcrowding or patients’ LOS, this preliminary study identifies the frequent use of short stay and under-adapted units instead of optimal bed location. Besides, further research should clarify the impact of these hospitalisations’ pathways on the quality of care.
Finally, these observations indicate the urgent need for early determination of patients who could actually be safely transferred to such units.
