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Quantifying the operational impact of boarding inpatients on emergency department radiology services

Published:April 07, 2018DOI:https://doi.org/10.1016/j.ajem.2018.04.013
      Emergency Department (ED) crowding continues to be a pervasive national problem, with myriad and intransigent negative effects on care efficiency, quality, and cost [
      • Institute of Medicine
      • Committee on the Future of Emergency Care in the United States Health System
      Hospital-based emergency care: at the breaking point.
      ,
      • Bernstein S.L.
      • Aronsky D.
      • Duseja R.
      • et al.
      The effect of emergency department crowding on clinically oriented outcomes.
      ,
      • Miro O.
      • Antonio M.T.
      • Jimenez S.
      • et al.
      Decreased health care quality associated with emergency department overcrowding.
      ,
      • Diercks D.B.
      • Roe M.T.
      • Chen A.Y.
      • et al.
      Prolonged emergency department stays of non-ST-segment elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events.
      ,
      • Fee C.
      • Weber E.J.
      • Maak C.A.
      • et al.
      Effect of emergency department crowding on time to antibiotics inpatients admitted with community-acquired pneumonia.
      ,
      • Pines J.M.
      • Hollander J.E.
      • Localio A.R.
      • et al.
      The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction.
      ,
      • Cowan R.M.
      • Trzeciak S.
      Clinical review: emergency department overcrowding and the potential impact on the critically ill.
      ,
      • Hoot N.R.
      • Aronsky D.
      Systematic review of emergency department crowding: causes, effects, and solutions.
      ,
      • Kohn Linda T.
      • Corrigan Janet
      • Donaldson Molla S.
      To err is human: building a safer health system.
      , ,
      • AHA Hospital Statistics
      ]. Furthermore, this demand-capacity mismatch is often due to hospital capacity constraints, manifested as prolonged patient ED length-of-stay (LOS) while awaiting inpatient admission [
      • Harris A.
      • Sharma A.
      Access block and overcrowding in emergency departments: an empirical analysis.
      ,
      • Asplin B.R.
      • Magid D.J.
      • Rhodes K.V.
      • et al.
      A conceptual model of emergency department crowding.
      ]. Termed “ED inpatient boarding”, patients often spend many hours awaiting an inpatient bed, and frequently undergo additional testing and treatment during that time [
      • Asaro P.V.
      • Lewis L.M.
      • Boxerman S.B.
      The impact of input and output factors on emergency department throughput.
      ]. As an important example, radiology testing is a frequently utilized process, highly subject to capacity constraint, and with significant effects on ED patient throughput [
      • Kocher K.E.
      • Meurer W.J.
      • Desmond J.S.
      • et al.
      Effect of testing and treatment on emergency department length of stay using a national database.
      ,
      • Centers for Disease Control and Prevention
      Quick Stats: Annual Percentage of Emergency Department Visits With Selected Imaging Tests Ordered or Provided — National Hospital Ambulatory Medical Care Survey, United States, 2001–2010.
      ,
      • Paul J.A.
      • Lin L.
      Models for improving patient throughput and waiting at hospital emergency departments.
      ,
      • Storrow A.B.
      • Zhou C.
      • Gaddis G.
      • et al.
      Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model.
      ,
      • White B.A.
      • Baron J.
      • Dighe A.
      • Camargo C.A.
      • Brown D.F.
      Applying lean methodologies reduces ED laboratory turnaround times.
      ,
      • Langley G.J.
      • Moen R.
      • Nolan K.M.
      • Nolan T.W.
      • Norman C.L.
      • Provost L.P.
      The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
      ]. Given a large subset of admitted inpatients receive ED imaging, we sought to quantify radiology utilization in boarding inpatients in our ED.

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