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Keywords:

  • crowding;
  • financial management, hospitals;
  • outcome and process assessment (health care)

Abstract

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

ACADEMIC EMERGENCY MEDICINE 2010; 17:840–847 © 2010 by the Society for Academic Emergency Medicine

Abstract

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

Emergency department (ED) crowding is a problem that affects the majority of U.S. hospitals.1 However, in most hospitals, ED crowding is not a constant phenomenon, but a cyclic one. At certain times of the day and week, there are insufficient space and human resources to care for new ED patients.2 In a 2009 study of Pennsylvania EDs, 83% of medical directors agreed that ED crowding was a problem in their hospitals, but most reported that their EDs were crowded less than 25% of the time and that fewer than 25% of patients who were admitted were delayed for more than 4 hours.3 ED crowding has also been associated with compromised patient care and safety. Crowding is associated with delays in antibiotic therapy in pneumonia,4 delays in care for acute myocardial infarction5 and many urgent and emergent conditions,6–9 higher rates of complications for patients admitted with chest pain,10 and increased mortality in the critically ill.11,12 Two Australian studies demonstrated increased mortality at hospital day 7 (hazard ratio 1.3)11 and hospital day 10 (relative risk 1.34).12 Therefore, the mortality risks of the crowding may not be directly felt by the emergency physician, but more by their inpatient colleagues. While these data have not been replicated in other countries, the delays in care demonstrated by crowding suggest that the same mortality risks exist elsewhere.

ED crowding is caused by an inability to move patients efficiently through the process of care to another setting, whether it is home, to an inpatient floor, or another hospital. Inefficiencies within the ED that cause delays in care are one cause for crowding. Some EDs are not properly staffed or sized to accommodate significant surges in the typical patient volumes. However, the most cited cause of crowding is the boarding of admitted patients in the ED when there is insufficient inpatient bed capacity for ED admissions.13–19 As a result, ED boarders occupy ED beds, consume ED resources, and reduce the capacity for new patients. The greatest volume of boarding occurs when ED admissions and non-ED admissions compete for the same inpatient bed resources (typically early in the Monday-Friday workweek).20–22 But high hospital occupancy itself is not the only cause for boarding. Other operational issues cause prolonged boarding times, such as the lack of flexibility between service areas (e.g., open hospital beds are available but not on the appropriate floor or reserved for elective patients), inefficiency in care transfer (e.g., delays in physician or nursing report), a desire by inpatient services for patients to remain in the ED for additional services (e.g., consultation, laboratory testing, or radiography), and other nonclinical administrative inefficiencies (e.g., delays in room turnover). To address this, organizations like the Institution for Healthcare Improvement (http://www.ihi.org/ihi) have proposed solutions and diagnostic strategies to improve hospital flow in addition to improvement in ED processes.23

It has been proposed that ED crowding and the hospital practice of boarding benefit the hospital financially due to the imbalance between revenues from ED patients and non-ED patients. Support for this proposal comes from the 2006 Institute of Medicine report on hospital-based emergency care: “No major change in health care can take place without strong financial incentives, and today hospitals have almost no incentives to address the myriad problems associated with inefficient patient flow or ED crowding. Indeed ... hospitals have a number of financial incentives to continue the practices that lead to these problems,”24 and studies have addressed the economic incentives and disincentives for boarding, ED crowding, and ambulance diversion.

The purpose of this paper is to summarize and synthesize the current literature on ED crowding and financial outcomes for hospitals and to present several solutions to both reduce ED crowding and improve the financial health of hospitals. This work is prepared on behalf of the Society for Academic Emergency Medicine ED Crowding Interest Group.

A conceptual model for hospital admissions and lost demand

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Patients are admitted to hospitals in three ways: through the ED, as direct admissions (which includes directly from clinics and scheduled procedures), or by transfer from other health care facilities. The latter two can be described together as non-ED admissions (Figure 1). In general, ED admissions generate a relatively stable demand for inpatient beds. Trended over time, the number of daily inpatient admissions from the ED is predictable. However, demand by service type can vary, especially in large hospitals with more complex services (e.g., there may be variability in the numbers of oncology admissions from the ED). By comparison, non-ED admissions demonstrate wider differences in the daily inpatient bed demands, including intensive care unit beds.25 Elective admissions typically mirror the Monday–Friday workweek with high numbers of admissions occurring during the week and relatively few on weekends.

image

Figure 1.  Conceptual model of hospital demand with several sources of admissions.

Download figure to PowerPoint

Long waits (either for ED admissions or non-ED admissions) occur when there is insufficient bed capacity to meet demands. In operations-management terms, the concept of more demand than supply is known as capacity-constraint. When the ED and hospital is at over- or near-capacity, long waits lead to ED patients leaving without being seen (LWBS) or leaving before completing treatment (LBCT). Additionally, some hospitals use ED wait times as criteria for ambulance diversion when patients being transported by ambulance are directed to other hospitals. LWBS, LBCT, and ambulance diversion together can be described as lost ED demand (Figure 1). A 2005 study estimated that the annual lost ED demand due to LWBS and ambulance diversion in one suburban teaching hospital exceeded $3 million.26 Similarly, long waits for non-ED admissions may also result in either lost demand (if a patient chooses another hospital or forgoes service use) or deferred demand (if a patient chooses to wait until his/her case can be scheduled at a later date).

Hospital occupancy and revenues

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Capacity constraint has become the norm in U.S. hospitals. This has been caused by the combination of hospital closures coupled with rising demand for services.27,28 From 1995 to 2005, annual ED visits in the U.S. increased by 20% (from 96.5 to 115.3 million), and the ED utilization rate increased by 7% (from 36.9 to 39.6 ED visits per 100 persons). Despite this increase in ED visits, the number of hospital EDs decreased by 381, the number of U.S. hospitals decreased by 535, and the number of hospital beds decreased by 134,000 during the same decade.29

The imbalance between the hospital bed supply and demand among surviving hospitals may be economically advantageous for several reasons.30 Because hospitals operate with mostly fixed costs, the strategy that maximizes revenue is to maintain a full hospital. Assuming a favorable payer mix, an empty, staffed hospital bed is a missed revenue opportunity, much in the same way that an empty airline seat or an unused hotel room is lost revenue. However, if the hospital has a public model with a greater uninsured population, then the converse is true in that filled beds may be a financial liability. The strategy in the airline and hotel industry is to overbook because the industry calculates that the cost of an empty seat or room exceeds the cost of the service recovery from a displaced passenger or guest. Therefore, the fundamental economic principle in all these industries (including hospitals) is that maintaining high occupancy levels through surplus demand ensures the greatest use of fixed resources and facilities.24 A 2009 study found a positive association between ambulance diversion and hospital revenues.31 Periods of higher levels of ambulance diversion (a surrogate for full capacity) were associated with higher revenues for the hospital, even at centers where ED admissions were seen as more profitable than non-ED admissions.31 Paradoxically, when hospital occupancy rates are greater than 85%, it has been shown that the waiting time increases exponentially, which ultimately leads to lost demand as patients leave or are directed elsewhere.32 The business question then becomes which demand (ED or non-ED) is more expendable to maintain a high occupancy level?

The profitability of ed and non-ed inpatient admissions

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Studies have investigated whether ED inpatient admissions are more profitable than non-ED inpatient admissions.33,34 A 2009 study reported that ED admissions result in higher contribution margins (revenues minus direct costs) than non-ED admissions in a single hospital.33 However, a study in 2008 found that admissions for Medicare beneficiaries admitted through the ED were very unprofitable, while non-ED admissions were barely profitable.34 Whether ED admissions are more profitable than non-ED admissions likely depends on local economics with regard to case mix, payer mix, and other externalities. For overall revenue, case mix is a critical matter because procedural care garners high payments, and ED patients are less likely to have procedures than elective patients. In hospitals with high-volume elective procedures, non-ED admissions may be viewed as more profitable. Insurance prescreening of elective admissions ensures better reimbursement than for unanticipated and frequently underinsured ED admissions. In addition, local payment issues may also influence this calculation. There is one study that demonstrated higher profitability for ED patients in Massachusetts, which at the time of publication had a large uncompensated care pool of funds available for ED patients that may have been partly responsible for the findings.33,35 Another example is in Pennsylvania, where workman’s compensation insurance pays hospitals 100% of the charges for severely injured trauma patients. This may make trauma diversion from ED crowding result in largely negative swings in revenues.

However, there are several fundamental problems with a one-to-one comparison of the profitability for ED versus non-ED admissions. The first assumption, likely false, is that a non-ED admission will compete with and displace an ED admission on a one-for-one basis. It is based on the premise that ED boarding is caused only by the lack of bed availability, which is not the case in many hospitals. Hospital operational inefficiencies related to team assignment, differing opinions on when ED care has finished, and administrative delays may also contribute to boarding. A second problem with comparing ED to non-ED admission profitability is that there are cyclical supply and demand factors. Hospital occupancy varies considerably on a daily, weekly, and monthly basis, so that an ED admission is frequently not competing with a non-ED admission. Even under the assumption that ED boarding is dependent only upon hospital occupancy, ED admissions during low occupancy times fill available capacity and allow hospitals to maintain high occupancy. Displacing and delaying non-ED admissions during high occupancy may be an effective strategy at specific times. The third issue in calculating the profitability for individual admissions is the matter of idiosyncrasies of hospital cost accounting, which can vary based on local accounting practice.

The ED as a gateway to the hospital

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Over time, the ED has served as an increasing source of hospital admissions, going from 33% in 1993 to almost 44% in 2006. In 2006, 49% of all admissions for patients 18 and older were from the ED. During this year, 36% of admissions of 18- to 44-year-olds came from the ED, followed by 53% of 45- to 64-year-olds, 55% of 65- to 84-year-olds, and 67% of the 85 and older age group.36 Therefore, an alternative approach is to take a more holistic view of ED and hospital crowding. Rather than studying boarding in isolation, if the ultimate goal is to maximize revenue, then any lost demand (whether it is from an ED or non-ED source) is ultimately undesirable. The immediate missed opportunities to capture revenue from ED admissions may be compounded if patients diverted to other institutions ultimately do not return to the diverting hospital for care in the future. In addition, voluntary inpatient physicians may decide to admit patients elsewhere if admissions through the ED prove cumbersome. Under this more holistic view, ED boarding may not be just the result of disordered incentives that entice hospitals to overload the ED. Rather, systematic inefficiencies and incentives within hospitals lead to boarding, ED crowding, and the negative outcomes that result. Thus, boarding may negatively affect a hospital’s bottom line through lost revenue as patients (both ED and non-ED) elect to go elsewhere or are directed elsewhere by ambulance diversion. By taking this alternative approach, we can start to consider what issues within hospitals cause boarding and how understanding the real causes can inform decisions to reduce boarding, increase ED efficiency, and maximize hospital revenue.

Disordered incentives and hospital cultures that promote nonflow

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Hospitals are highly complex organizations with multiple stakeholders where often operational decision-makers are clinicians acting on their own authority or within a structured or semistructured set of complex hospital policies. Clinical work is by its nature high stress and unpredictable because it involves making complex, often subjective decisions with incomplete information. Therefore, despite best intentions to structure efficient operations, many minute-to-minute throughput decisions are made at the bedside. And outside of the ED, many clinicians often do not have personal incentives to maintain high flow across the hospital.

While some clinicians have incentives based on productivity, many clinicians and other health care professionals are compensated largely through fixed salaries. When paid a fixed salary, the financial incentive is to minimize new work because each additional work unit results ultimately in a lower per unit pay. However, few clinicians have direct incentives to increase their own personal incremental utilization at the point of care and consider flow through the entire system in bedside decision-making. This manifests as administrative inefficiency, resulting in ED admission delays independent of overall hospital capacity. In many hospitals, the same logic carries over to throughput for hospital admissions, critical procedures, testing, and hospital discharge. The overall effect of this disincentive is reduced flow through the entire system, and the behaviors that ensue, such as bed-blocking and delay tactics. ED and hospital crowding from disordered incentives results in lower revenue as demand is lost through the ED as the whole process of care can be slowed by a culture of inefficiency.

Another structural incentive that results in poor throughput is the organization of hospitals into units that sometimes only consider their own flow. Nonflow in the ED caused by ED boarding may be viewed as an ED problem, as opposed to a hospitalwide problem. However, nonflow in the ED may be caused at that moment by a backup in radiology, which is rarely known in real time to the radiologists who are interpreting ED studies. A similar phenomenon may occur with the laboratory or a floor charge nurse who may not consider their personal decisions based on the flow throughout the organization. Similarly, the ED may not realize there are long waiting times for non-ED admissions or that elective cases may need to be canceled if ED flow does not improve. Finally, these rigid boundaries between service lines can lead to an adversarial “us v. them” culture that can lead each individual service to act in its own best interest and result in lower flow and quality of care for patients in other locations.

Solutions for fixing ED crowding, aligning incentives, and maximizing revenue

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References

Because hospitals are mostly fixed-cost organizations, when it comes to balancing the expected profits from ED versus non-ED patients, four questions emerge that suggest several potential solutions. Overall hospital revenues are the relevant outcome because from the perspective of the entire hospital, allocating costs to one particular admission type becomes less meaningful when considering the hospital as a whole.

Question 1: Should Hospitals Seeking to Maximize Revenue Close Their EDs?

In many settings, this is not a consideration due to regulatory standards and requirements for hospitals to have an ED. The answer is probably not. As mentioned before, this is also dependent on the payer mix seen in the ED. With a high uninsured population at a public hospital, closing the ED would have a significant positive effect on the financial bottom line, but may contradict the service mission of the institution. In contrast, a private hospital with a favorable ED payer mix may find the ED as a profitable contributor to hospital operations. Some capacity-constrained hospitals may be theoretically viable without an ED, and certain institutions, such as subspecialty hospitals, choose not to have an ED. But the financial, reputational, and operational impact of closing an ED in a general purpose hospital may not serve the institution’s best interests overall, regardless of perceived economic benefit. Even if net ED revenues are not positive, longer-term financial benefits from the loyalty of patients, voluntary physicians, and the community at large due to services available in the ED may be great. Also, because of the cyclical nature of non-ED admissions and the relative constancy of ED admissions, ED admissions permit capacity-constrained hospitals to maintain higher occupancy levels as the ED admission fills the gaps left by non-ED admissions. Some nonconstrained hospitals depend on ED admissions to fill their capacity, and many others find that ED admissions are more profitable than their alternative admissions.33 In fact, California hospitals with nontrauma EDs realize a loss on each outpatient ED visit, but a gain on each ED patient who is admitted as an inpatient. When the outpatient and inpatient effects are combined, hospitals with EDs derive an economic benefit from maintaining their EDs, and hospitals will even expand ED capacity if the expanded capacity leads to an increase in hospital admissions.37

Question 2: For Hospitals That Choose to Maintain ED Services, Which Bed Utilization and Prioritization Schemes Lead to the Highest Hospital Revenues?

The current model in many hospitals is to schedule elective admissions to hospital capacity (i.e., overbook like the airline industry), allow unscheduled ED admissions to fill the gaps in specific service locations that have beds, and permit overflow as ED boarding. In a capacity-constrained hospital, this minimizes lost demand or deferred demand for elective cases while ED boarding results in lost ED demand and diversion. It allows the ED to be the buffer for hospital overflow because of the priority placed on non-ED patients. Aside from the clear association between this management practice and worse health outcomes,4,5,7,9,10 hospitals with high LWBS, LBCT, and ambulance diversion rates have considerable lost revenue from the inefficiency of this bed prioritization scheme.26 This scheme also tends to have an inherent inefficiency: some periods of increased boarding (and the resulting lost revenues) occur when inpatient beds are empty, reserved in case surgical patients need them and only released later if they do not.

There are several alternative options for bed assignment and prioritization schemes that may reduce crowding and increase revenue. Two of these are advanced bed allocation for ED admissions and increasing service-location flexibility. Because of the relatively stable demand for ED admissions, but the variable demand by admission type, advanced bed allocation would require an increase in the flexibility of inpatient floors or intensive care units to handle variable types of ED admissions, operationally known as pooling. Then, allowing flexibility between service locations may reduce the boarding associated with a lack of occupancy on a particular unit and allow hospitals to maintain high occupancy in all staffed locations and ultimately capture more ED demand. A second related concept is to allow not only flexible capacity by service location, but also flexible capacity of overall bed volume. Because of the variable nature of the demand for inpatient beds, the ability to open and close inpatient beds, such as through the use of a transition unit or alterative service locations (e.g., inpatient floor hallway beds) may reduce boarding and result in higher rates of capturing lost ED demand.38 The main barrier to implementation of this scheme would likely be the needed flexibility in staffing.

Question 3: For Hospitals That Choose to Maintain ED Services, Which Hospital Operations Management Interventions Lead to Reduced Variability and Improved Institutional Flow?

In the ED, there have been several strategies proposed to increase ED operational efficiency. These include immediate rooming of patients, bedside registration, advanced triage protocols, use of physicians/practitioners at triage, a dedicated “fast-track” service line, tracking systems and whiteboards, observation units, wireless communication devices, kiosk self check-in, ED dashboards, and personal health record technology (“smart cards”).39 While the revenue implications of these strategies are not known, implementing front-end operational strategies that permit higher throughput with the same physical space can reduce lost ED demand due to inefficient ED operations and may increase overall revenue. Downstream from the ED in the hospital, similar operational initiatives may be implemented to streamline the admission process and reduce administrative barriers to bed placement. A 2007 paper in the operations literature demonstrated that transferring admitted patients between hospital floors might be an effective strategy to alleviate boarding and increase the utilization of existing hospital capacity.40 Implementing systems to improve communication among departments (e.g., ED and radiology) might improve communication issues where individual departments are unaware of their roles in patient flow through the hospital.

Another effective strategy has been the concept of reducing the variability in elective admissions, which in the setting of elective surgery is termed surgical schedule smoothing or operating room (OR) schedule smoothing. Surgical smoothing has been shown to reduce ED crowding and increase OR utilization rates and likely will increase overall hospital revenues.40,41 However, the barrier to smoothing of elective admissions has been one of political power within hospitals. Because surgical services have great power due to the ability of surgical specialties to generate demand, the implementation of surgical schedule smoothing has failed in several hospitals. Individual surgical services have balked at requests to alter OR scheduling because there is little incentive to improve ED and overall hospital operations. However, in several centers where smoothing has been implemented, surgical services have enjoyed reductions in surgery cancellations and more predictable OR hours.42 As more such evidence accumulates, surgical services might become more agreeable to smoothing OR schedules. However, hospitals will recognize a need to smooth the OR schedule only if they perceive the loss of revenue from ED crowding to be greater than the potential loss of revenue from disgruntled surgical specialists who are free to affiliate elsewhere. Where to begin in terms of operational improvement depends on what are considered the greatest constraints for a particular institution, which only can be determined after review of all operational processes. Using the theory of constraints logic,43 once it is determined what is the greatest bottleneck to efficient patient flow, this area should be addressed first.

In hospitals where incentives are not aligned to overcome the organizational culture or where there is not otherwise enough motivation to change the practice of ED boarding, external payment or policy regulation may be necessary for efficient ED care. This is of particular significance to those hospitals that maintain nonprofit status and receive tax subsidies from the local, state, and federal governments. These hospitals are required to demonstrate community benefit. The most visible role of an ED is the treatment of seriously ill and injured patients.44 If an ED is crowded, boarding patients, or diverting ambulances to other hospitals, it is not effectively serving the community. This may be taken into account when considering “community benefit standards.” Although most nonprofit hospital systems do provide community benefits that are at least equal to their tax subsidies, there is little standardization in the hospital industry with regard to quantification and reporting of those benefits. This has led to a lack of credibility and ability to clearly demonstrate the benefit provided.45,46 The threat of losing even a local tax subsidy may be enough to drive change in the largest health systems.

Question 4: How Can Hospitals Change Incentives to Promote Flow and Reduce Lost Demand and Revenue From Inefficiency?

Moving from problems to solutions will require better aligning incentives across the hospital for improved flow through the entire system. Instead of the current state of permitting loss of ED demand in favor of non-ED admissions, efforts should be focused on improving throughput at all levels. Removing the bottlenecks and reducing inefficient processes will likely lead to improved patient care, higher staff satisfaction, and a safer health care system. It may also improve the financial position of hospitals. To do this, there need to be clinician-level incentives to provide high-quality, efficient care not just for patients located in one department (such as the ED), but to consider the flow of patients throughout the entire continuum of care. These incentives can be applied to both ED and non-ED clinicians. To maintain both high flow and high quality, this will require all clinicians being rewarded for the success of not only their individual units, but the organization as a whole.

One of the most challenging aspects of affecting change within an institution is changing the established culture and set of values. Instead of seeing each unit or inpatient versus the ED as distinct entities, the interoperability of the patients throughout the institution needs to be appreciated by all involved in patient care. Instead of looking at each area as an independent entity, like a silo, each unit should see itself as one step of many for the patient in the continuum of care. A patient-centered model needs to be the emphasis of the delivery of care, not location.

As reimbursement trends continue to squeeze profit margins, hospitals will need to find ways to use their existing capacity more effectively. This will mean operating at higher occupancy on a consistent basis, with the focus of managers to reduce delays and capture all demand (ED and non-ED) while delivering the highest quality care. Transition units, full-capacity protocols, and admission lounges serve as operational models to help alleviate crowding and long waiting times.

With alignment of incentives for reimbursement, hospitals should find it equally attractive to provide care in both emergent and scheduled settings. But as long as reimbursement favors prescreened scheduled care, emergency care may continue to have a secondary role in the priorities of patient flow within hospitals. However, with the aging of the population, it is likely that the ED will play an increasing role in U.S. health care, both with increasing comorbidities contributing to postprocedural complications and with more emergent disease presentations. As the health care reform debate continues, this must be taken into consideration to assure that our patients have access to the care they need and deserve.

ED crowding is clearly a widespread situation that negatively affects ED patient care. From the perspective of hospitals, there are clear benefits and costs associated with delays in ED throughput and resultant ED crowding. The profitability of ED inpatient admissions and the financial benefits of improved ED throughput need to be carefully evaluated at the level of each institution. We propose a holistic and integrated approach for hospitals that incorporates financial solutions that both benefit hospitals and improve ED efficiency and care.

References

  1. Top of page
  2. Abstract
  3. A conceptual model for hospital admissions and lost demand
  4. Hospital occupancy and revenues
  5. The profitability of ed and non-ed inpatient admissions
  6. The ED as a gateway to the hospital
  7. Disordered incentives and hospital cultures that promote nonflow
  8. Solutions for fixing ED crowding, aligning incentives, and maximizing revenue
  9. References