Thinking Outside of the ED Box: Growing Capacity Through Inpatient Integration

Theo Koury, MD, President of Vituity

Theo Koury , MD

President of Vituity

Published June 11, 2019

three doctors and nurses wearing stethoscopes standing elbow to elbow in a hospital hallway

Our nation's emergency departments (EDs) have never been busier, and demand for care continues to grow. However, increasing patient volume has not been supported by an increase in emergency department capacity. Successful hospitals have optimized their ED capacity by thinking outside of the ED box and integrating processes across hospital departments.

Moving patients through the ED more quickly can serve the same purpose as adding beds, or expanding the physical footprint: more capacity for patients to be seen. One of the biggest delays in care in the ED happens before a patient is admitted. Sometimes called “boarding,” admitted patients wait in the ED until an inpatient bed becomes available. Admitted patients board in the ED for a nationwide average of 92 minutes before being transferred to an inpatient unit or another facility.i

Boarding times are especially high for psychiatric patients, ranging from 6 to 34 hours across the country.ii The opioid crisis, which has caused patients to seek behavioral healthcare in record numbers, has greatly exacerbated the boarding issue.

To end ED boarding, hospitals must shift toward integrated, team-based processes. A collaborative approach to expediting admissions from the ED has many benefits, including:

  • Improved overall length of stay
  • Faster emergency department (ED) throughput and reduced crowding
  • Expanded inpatient and ED capacity without facility upgrades
  • Safer patient handoffs and decreased risk of adverse events
  • Decreased loss of patients without being seen in ED
  • Greater patient and provider satisfaction

So when it comes to ending boarding and improving disposition for admitted patients, where can hospital leaders start? Three foundational areas to address are culture, actionable data analytics, and process innovation:

1. Culture

Integration flows naturally when teams across the hospital share the same mission and values. In order to expedite ED admissions, emergency medicine, hospital medicine, and other key services must take joint ownership of patient outcomes. In other words, they must see all patients as "theirs," even when those patients are located in another department.

Successful integration often depends on the department's ability to recruit strong medical directors who can serve as "CEOs" of their respective services. Strong leaders are in the best position to work across practice lines to integrate proven, collaborative solutions.

Strong leaders are also poised to attract and recruit likeminded providers who share their mission and collaborative spirit. These providers work hard to build bridges across service lines, even when it would be faster and easier to "do it our way."

2. Actionable data analytics

Another way to encourage emergency physicians and hospitalists to work together is to make them jointly accountable for certain metrics. Relevant examples include:

  • ED throughput
  • ED length of stay for admitted patients
  • Overall length of stay
  • Satisfaction of patients admitted from the ED

To move the needle on any of these measures, each department will need access to high-quality data. When investing in your health system, prioritize the collection, management, and analysis of data. A strong data infrastructure will often pay for itself in the form of operational efficiency and process optimization.

3. Process innovation

Working together, acute care teams can design, test, and propagate shared processes that improve communication and performance across departments. Some proven examples include:

  • Expedited Patient Admission Program (HM, EM) — Teams flag the patients who are most likely to be admitted and provide them with a streamlined workup.
  • Hip Fracture Pathway (EM, HM, anesthesiology) – ED patients are admitted and scheduled for surgical and post-surgical care before reaching an inpatient floor.
  • Team Care (EM, HM) – The sending emergency physician, receiving hospitalist, ED nurse, and ED technician gather at the patient's bedside during the handoff to answer questions and paint a full picture of the patient's condition.


In Summary

ED capacity and throughput challenges should be viewed not as departmental issues but as calls to action for the entire hospital or health system. Reducing boarding time and improving disposition of admitted patients is a significant opportunity to improve patient experience and increase capacity of the ED.

In order to end boarding, hospitals must break down silos and encourage their service lines to co-design new care pathways. This journey to meaningful integration requires time, effort, and culture change. However, it almost always pays off in the form of improved efficiency and patient and provider satisfaction.


i Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1–6. doi:10.5811/westjem.2013.6.17848
ii ER Wait Watcher. Propublica. Last updated March 2019 with 2017–2018 data.

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