Objectives: Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED.Methods: This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured.Results: After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001).Conclusions: A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.ACADEMIC EMERGENCY MEDICINE 2014; 21:266-273

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We thank you for your questions and complimentary comments about the work we did to improve admission wait times at our hospital.The intervention was guided by: 1) agreement among everyone with the goal to move admitted patients from the emergency department (ED) to the inpatient unit within 1 hour, 2) top leadership engagement in the effort, and 3) distribution of daily/weekly/monthly status reports that were fully transparent to all parties. Early in the intervention, when a delay occurred, the chief operations officer or ED chief/manager directly contacted the department that was responsible for the delay, 24/7. A call made directly by the top leader was a powerful influence on that department, letting them know that someone was watching the flow of patients from the ED into the hospital. Further, electronically tracked flow data and real-time delays were readily identified by everyone in the ED and the hospital, with subtle peer pressure to encourage quicker turnarounds. Finally, a friendly competition was in play between the ED and the hospital staff: who could meet and exceed their respective 30-minute goals in the admission wait time process? The hospital's goal was to make the appropriate bed and accepting nurse available within 30 minutes. The ED's goal was to transfer the admitted patient to the ward within 30 minutes of receiving the bed assignment. These items (setting an agreed-upon goal, friendly competition, transparent view of real-time flow data, and direct monitoring of the process by top leadership) were the key ingredients to success. Hospital and ED staff were provided daily and weekly e-mail updates, along with a monthly newsletter that trumpeted the successful results of meeting the 1-hour admit wait time goal. Kudos were sprinkled liberally for specific excellent cases, serving as motivation for others. Consequently, we never developed or required "enforceable sanctions." Top leadership used their good will to encourage both hospital and ED staff to do what was best for their patients. The daily, weekly, and monthly data, circulated to everyone transparently, served as the official scorecard.While we would love to provide a table that outlined particular bottlenecks, as leaders of the process, we did not specifically look to identify them. We felt that each department knew its own barriers (we suspect that with slight variations, these same departments in hospitals all across the country already know them also). It was not a matter of having top leadership list the bottlenecks and work to hammer each department to improve. Instead, we found that if leadership set the overarching goal of admission within one hour of the bed request (after the decision to admit was made) and then followed up in real-time when delays were observed to get each specific department to remove the obstacles right then and there, then individual staff in each department would figure out their own successful options for resolution. In fact, we saw them do just that, routinely and regularly. Rather than listing bott...