Revenue Cycle Management Journal Source: The Academy of Healthcare Revenue
Emergency Department Overcrowding and Queuing Theory
As we explored in The Academy’s March 30th e-Brief, overcrowding in hospital emergency departments is a national problem that can have a significant negative impact both on hospitals’ finances and on patient care. Many healthcare experts and some lawmakers have proposed strategies for reducing ED overcrowding and the closely-related problems of ED boarding and ambulance diversions. Addressing the shortage of inpatient beds—which is one of the main reasons for ED boarding, overcrowding, and ambulance diversions—is the focus of one widely-hailed strategy known as queuing theory.
Many factors contribute to the problem of ED overcrowding, including rising demand for emergency services, a declining number of emergency departments and available hospital beds, and increased inappropriate use of ED services for non-emergent conditions. As the graph below shows, national healthcare spending is projected to increase by almost 100 percent by 2014. This surge in utilization coupled with a decrease in capacity will almost certainly lead to more patients being boarded in the ED—and further loss of hospital revenue—unless healthcare providers take significant action to optimize throughput.
One significant area of concern for hospitals is The Access to Emergency Medical Services Act of 2007, a bipartisan bill introduced in both the U.S. House and Senate in February. Both the House and Senate versions of the bill call for the creation of a national bipartisan commission on access to emergency medical services, which will examine factors affecting and possibly impeding the delivery of care in U.S. emergency departments. Both bills also call for additional resources allocated to support care delivery in EDs nationwide.
The Senate version of the bill calls for a working group to be formed within CMS to develop boarding and diversion standards, as well as guidelines and incentives for implementation of those standards. The House version requires hospitals to report statistics to the Department of Health and Human Services showing how many patients are boarded and for how long. The legislation would increase payments to providers for EMTALA-related services, which would help to offset the financial burden of the frequently uncompensated care provided by hospitals’ EDs. These payment increases would be designed to help alleviate the additional staffing and equipment required of emergency departments. The boarding and ambulance diversion data reporting portion of the House bill also calls for the information reported by hospitals to be made public.1 It is likely that the reporting requirement will also be tied to hospitals’ receipt of full Medicare and Medicaid payment updates.
With research showing no let-up in patient volume and possible legislation mandating boarding and diversion reporting, it is clear that hospitals must take action to alleviate the causes of ED overcrowding. ED boarding is one of the central issues hospitals must address. The practice of boarding patients in the ED is not only a primary cause of overcrowding and ambulance diversions; it is also a patient safety and quality of care concern, because boarded patients (who may often be on beds in busy hallways for hours or even days) require additional equipment and staff members’ time and attention, further reducing the already limited resources that are needed to treat incoming ED patients with serious medical conditions.
One area of scientific research that has been hailed by some healthcare leaders is queuing theory. The Institute of Medicine recommended the use of queuing theory in a 2006 report, saying, “Tools developed from engineering and operations research have been successfully applied to a variety of businesses, from banking and airlines to manufacturing companies…one such tool is queuing theory, which by smoothing the peaks and valleys of patient admissions has the potential to eliminate bottlenecks, reduce crowding, improve patient care, and reduce cost.2
Queuing theory is, in short, the mathematical study of waiting lines. Queuing theory has been used by telecommunications, internet, airline, and other industries to more efficiently allocate fixed resources to random demand, including the stresses of periods of peak demand.3 This is ideal for emergency departments, although the nature of emergency department queuing is somewhat unique. Unlike other industries—in which the optimal outcome is zero time waiting, and instantaneous service for the customer—it is undesirable in hospitals to push length of stay to zero, as patients need to be monitored and cared for during their recovery. Other differences in hospitals’ queuing patterns are that patients who are waiting typically create additional work for clinicians, because these patients must be monitored and served as they wait. Their conditions may even deteriorate as they are waiting, necessitating additional work when a clinician treats them. Thus, as hospitals’ queues become larger, the workload increases and the capacity to efficiently serve patients deteriorates. Third, healthcare providers operate within a complex web of local, state, and federal laws; for instance EMTALA, which requires that EDs treat all patients regardless of their ability to pay, changes the economic environment seen in queuing solutions often found in the private sector, such as peak-period pricing.4
Although queuing theory algorithms can be dauntingly complex, some basic principles of queuing theory can be applied to hospitals’ emergency departments’ patient flow. Some of these applications of “queuing intuition” include.5
Match capacity to demand. If the organization has capable information systems in place and high standards for data tracking and analysis, applying queuing theory algorithms using computer programs can be a very useful tool in allocating staff correctly. One study that applied queuing theory to ED staffing at an urban hospital showed that despite an increase in patient arrival volume of 6.3 percent, re-allocating provider hours in accordance with queuing theory calculations enabled the hospital to lower its LWBS rate by 22.9 percent.6
Frontload, when possible. Empower clinical staff members at the front end to begin needed testing and treatments to eliminate bottlenecks downstream.
Create parallel processes. One example of this is the use of bedside registration, enabling patients to complete necessary administrative work between tests or procedures. Another example is to send patients to receive X-rays before their formal evaluation with the physician so that X-ray processing can occur while the physician is examining and evaluating the patient.
Reduce the number of process steps and bring steps closer together. Reducing hand-offs and automating as many clinical and revenue cycle steps as possible helps to optimize patient throughput, as does bringing services physically closer together, such as having labs located in or adjacent to the ED.
“Pull” rather than “push” your patients. Typically, emergency departments “push” patients who need to be admitted as inpatients—that is, an ED clinician will call in a request to the appropriate department. Instead, consider implementing a “pull” system. In this system, when appropriate hospital departments have a bed available, staff members in that department call the ED to alert them of bed availability.
By implementing queuing theory and other strategies to reduce ED overcrowding, hospitals can significantly increase their revenue, since reducing ambulance diversions and LWBS rates immediately infuses revenue. Additionally, reducing boarding in the ED improves patient care and reduces stress levels in ED staff and patients. With Congress likely to pass legislation requiring that hospitals report boarding statistics—and with that information likely to be made public—it is in hospitals’ best interests to take immediate and aggressive steps to reduce ED boarding and improve patient throughput.
1.“Access to Emergency Medical Services Act,” American College of Emergency Physicians, 2007.
2.Gail Warden, et. al., “The Future of Emergency Care in the United States Health System,” Institute of Medicine Issue Brief, June 2006.
3.Eugene Litvak et. al., “Emergency Department Diversion: Causes and Solutions,” Academic Emergency Medicine, 2001.
4.Randolph Hall, “Patient Flow: The New Queuing Theory for Healthcare,” OR/MS Today, June 2006.
5Ellen Lamel, “Queue Tips,” Emergency Physicians Monthly, February 2007. 6.Linda Green, et. al., “Using Queuing Theory to Increase the Effectiveness of Emergency Department Provider Staffing,” Academic Emergency Medicine, January 2006.
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