The Economics of an Admissions Holding Unit

Abstract

IntroductionWith increasing attention to the actual cost of delivering care, return-on-investment calculations take on new significance. Boarded patients in the emergency department (ED) are harmful to clinical care and have significant financial opportunity costs. We hypothesize that investment in an admissions holding unit for admitted ED patients not only captures opportunity cost but also significantly lowers direct cost of care.MethodsThis was a three-phase study at a busy urban teaching center with significant walkout rate. We first determined the true cost of maintaining a staffed ED bed for one patient-hour and compared it to alternative settings. The opportunity cost for patients leaving without being seen was then conservatively estimated. Lastly, a convenience sample of admitted patients boarding in the ED was observed continuously from one hour after decision-to-admit until physical departure from the ED to capture a record of every interaction with a nurse or physician.ResultsPersonnel costs per patient bed-hour were $58.20 for the ED, $24.80 for an inpatient floor, $19.20 for the inpatient observation unit, and $10.40 for an admissions holding area. An eight-bed holding unit operating at practical capacity would free 57.4 hours of bed space in the ED and allow treatment of 20 additional patients. This could yield increased revenues of $27,796 per day and capture opportunity cost of $6.09 million over 219 days, in return for extra staffing costs of $218,650. Analysis of resources used for boarded patients was determined by continuous observation of a convenience sample of ED-boarded patients, which found near-zero interactions with both nursing and physicians during the boarding interval.ConclusionResource expense per ED bed-hour is more than twice that in non-critical care inpatient units. Despite the high cost of available resources, boarded non-critical patients receive virtually no nursing or physician attention. An admissions holding unit is remarkably effective in avoiding the mismatch of the low-needs patients in high-cost care venues. Return on investment is enormous, but this assumes existing clinical space for this unit.

The impact of hospital boarding on the emergency department waiting room

“…3 Boarding leads to increased patient morbidity and mortality for both intensive care and non-intensive care units, longer lengths of stay, and higher costs for the hospital. [4][5][6][7][8][9][10] Insufficient availability of inpatient beds can also lead to loss of ED revenue estimated at millions of dollars. 5,6 In addition to worse patient outcomes, patient satisfaction levels were reported to be lower when patients were boarded in the ED rather than being transferred to inpatient floors.…”

“…[4][5][6][7][8][9][10] Insufficient availability of inpatient beds can also lead to loss of ED revenue estimated at millions of dollars. 5,6 In addition to worse patient outcomes, patient satisfaction levels were reported to be lower when patients were boarded in the ED rather than being transferred to inpatient floors. [11][12][13] ED patient treatment can be divided into 3 stages: waiting room time, treatment time, and boarding time.…”

Traumatic Health Effects Due to a Storm: An Observational Case-Study on Patients Received at the County Emergency Clinical Hospital From Timisoara

“…A small number of the patients (5) left the hospital without being consulted (3) or without a doctor`s recommendation (2) and one patient was declared deceased. Studies regarding financial costs (Schreyer & Martin, 2017) of emergency department activities and the improvement of emergency services through telemedicine (Abo-Zahhad et al, 2014) indicate that researchers are very concerned with improving the efficacy of emergency responders. A limit of the performed study is that it is an observational one.…”

Assessment of Time-Series Machine Learning Methods for Forecasting Hospital Discharge Volume

“…The biomedical literature includes many efforts to predict discharges at the level of hospital unit or clinical domain. 4,5,6 Although these efforts are invaluable tools for discovery, the resource demand is such that they cannot typically be integrated into routine operations as a monitoring tool or scaled across all units; thus, there is a need for highly scalable forecasting approaches that are suitable for broad application and operational implementation.…”