How to Improve Inpatient Discharge Process

Nurse Talking To Senior Couple In Hospital Room

Last week, I covered the many benefits of having a solid inpatient discharge process. It can benefit your hospital across departments, raise patient satisfaction and safety, and help your bottom line. So, what are some steps hospital leaders should take to improve their inpatient discharge process?

1. Examine Your Current Process

If you want to improve patient experience and sustain a culture of patient safety within your hospital, call for an examination of inpatient and emergency department discharge procedures.  Bring stakeholders — from both the ED and inpatient unit — to the table to ensure good communication. Open a dialogue about what’s working and what isn’t.

2. Set Up Clear, Consistent Communication

Communication — whether among staff, patients, family members or other caregivers, or outside health providers — is by far the most important component of discharge. Ensuring that communication is clear is paramount.

Here are a few benefits that result from patients receiving consistent instructions and information from staff regarding their diagnosis, treatment, medications, and follow-up care:

  • patients report a more favorable experience. satisfaction scores increase

  • readmissions and return visits to the emergency department drop — upwards of 30 percent, according to a study funded by the Agency for Healthcare Research and Quality   

3. Create a Staff Checklist and Patient Discharge Packet for Clear Communication

Two key components of the inpatient discharge process are a checklist for staff and discharge packet for patients. Remember, the discharge process begins as soon as the patient is admitted, not the day patients go home. Early utilization is key to a successful discharge.

While many resources are available for hospital leaders to use to create a discharge checklist and revamp their discharge process, AHRQ’s IDEAL Discharge Planning Overview, Process, and Checklist is a great place to start. Staff checklists should cover everything from the initial nursing assessment steps to action items designated for the day of discharge.

Creating discharge packets can help ensure that patients know how to care for themselves after leaving your hospital. Packets should include a few things and staff should go over these with patients:

  • medication information

  • self-care instructions, including how to recognize complications like infection or reactions to medication

  • resources for referrals and follow-up

  • information regarding whom the patient should contact if any problems, complications, or questions arise after discharge. Depending on the circumstances, this could be a primary care physician, specialist, counselor, or other healthcare professional.

Simply put, discharge packets can help patients have better outcomes and avoid readmission.

In everything you do, effective communication with patients and families should be your focus. Hospitals that follow AHRQ’s recommendations shouldn’t be surprised when patient outcomes are improved, readmissions drop, and patient satisfaction scores increase. (AHRQ also provides this valuable tool for hospitals interested in “re-engineering” their discharge process.)  

If you’re a hospital leader looking to retool your inpatient discharge procedures and you’d like some personalized feedback, feel free to drop me a line. I’d love to schedule a complimentary phone consultation to discuss with you what steps you can take to improve this critical component of the patient experience.


Agency for Healthcare Research and Quality: IDEAL Discharge Planning Overview, Process, and Checklist

Agency for Healthcare Research and Quality: Preventing Avoidable Readmission

How an Integrated Inpatient Discharge Process Improves Patient Experience

mature female patient on wheelchair listens to doctor perscripti

Getting patients prepared to leave your hospital is crucial to patient safety and experience. A good discharge process requires proper planning and coordination. While I’ve written extensively about the importance of the emergency department discharge process, inpatient discharge is just as critical and deserves equal attention from hospital leaders. Patients of all kinds and hospitals will reap the rewards of a discharge process done well.

Rewards of Revamping Your Inpatient Discharge Process

What exactly are those rewards?

1. It improves inpatient functional capacity. When patients check out in timely manner, more beds become available for new patients. That can lead to an increase in admissions and inpatient revenue.

2. It has a positive impact on EDs. The inpatient discharge process not only affects those patients receiving inpatient care but also impacts patients in the emergency department. Moving those patients along who need an inpatient bed can increase the emergency department’s functional capacity.

It can reduce the number of emergency department admissions being held in the ED awaiting an available inpatient bed. This improvement can result in higher patient satisfaction scores, and that can positively affect revenue.

When an integrated and multidisciplinary inpatient discharge process — one that takes into account the inpatient ward and ED’s needs — is in place and optimized, patients admitted to the hospital from the ED will experience a faster transition to inpatient care.

3. It improves the quality of care patients receive across your hospital departments. Those needing inpatient care can get it sooner. ED staff can devote their time to patients requiring active emergency treatment. It also helps maintain a culture centered around patient safety. Patients are being cared for by the right professionals in the right setting.

4. It can help reduce avoidable hospital days. When you look at discharge processes for inpatients and ED patients in an integrated way, you can find delays that happen across the continuum of care.

Delays can come from a number of areas:

  • physicians
  • case management or discharge planners
  • patients and family
  • hospital staff
  • outside transportation services
  • healthcare settings such as skilled nursing facilities

That’s why improving both the inpatient and emergency department discharge processes is a highly effective tactic to reduce unnecessary days of inpatient care. By successfully decreasing avoidable hospital days, they increase the likelihood of significant cost savings.

Next week, I’ll go over how you can improve your inpatient discharge process so you can reap all of these benefits. In the meantime, if you’d like a complimentary phone consultation to discuss your inpatient discharge process, drop me a line.



Agency for Healthcare Research and Quality: IDEAL Discharge Planning Overview, Process, and Checklist

Agency for Healthcare Research and Quality: Preventing Avoidable Readmissions

How EDs Can Limit Chronic Visits by the Homeless

Homeless Woman

This week I’m revisiting a blog post that takes a deep look at one of the biggest contributing factors to overcrowding in the emergency department — chronic visits by the homeless. Coordinating care with outside services, such as housing organizations, and other healthcare providers, can help meet the needs of homeless patients better, and thus reduce their use of the ED.

A few weeks ago, I wrote about how homelessness is one of two top causes of ED overcrowding. Today, let’s take a deeper dive into what experts think may help.

A recent study published last year in Psychiatric Services, a journal of the American Psychiatric Association, followed a cohort of more than 700 homeless individuals over a three-month period, tracking their use of the ED. Over the course of the study, 30 percent of participants visited the ED one or two times, which researchers deemed moderate use. Meanwhile, 12 percent visited three or more times, estimated as “high use.”

Researchers determined the reasons behind chronic ED use by the homeless were complicated.

Surprisingly, researchers concluded that housing status didn’t play a large role in chronic ED use. Homelessness wasn’t a cause in itself. Also, outside services did little to stem visits. However, the situation isn't totally hopeless. They found a possible solution lies in the cooperation of vested interests.

They contend that more coordination between outside services, housing organizations and healthcare providers “may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.”

“Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services,” researchers wrote. “Thus ED use was related to high need and acuity and was not ameliorated by use of other services.”

So what does better coordination look like? Two recent news stories highlight how EDs and hospitals can better coordinate care with outside organizations to decrease ED use by homeless individuals. While these initiatives appear to be working, it’s still too early to gauge whether they’ll be sustainable in the long-term. But what they do show is how cooperation between outside organizations and healthcare providers can lead to better outcomes for homeless patients.

Finding respite in old motels

“It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.”

This story out of Buena Park, CA is a wonderful example of how coordinated care for homeless patients can better serve these individuals and positively impact a hospital’s bottom line.

The Illumination Foundation, a homeless services non-profit, has converted an old motel into a place of refuge for recently discharged patients. A triage center has been set up in the lobby and the rooms have been transformed into recovery facilities, with funding assistance provided by area hospitals and health insurers. Patients stay between two to three weeks and are able to obtain the social services necessary to help move them into more permanent housing. A nurse is even on staff.

And the program, still in its early stages, appears to be cost-effective—to the tune of $2,000 less per day than a hospital stay, which saves hospitals and insurers money. Patients, too, are experiencing positive results.    

“Housing first style” housing

“The hospital is paying to get them out of the emergency room and into housing.”

In Chicago, the University of Illinois Hospital has partnered with the Center for Housing Health to provide homeless patients an apartment and a case manager in order to curb chronic ED use. And it seems to be working.

Case managers help coordinate care by scheduling follow-up appointments, which lessen the odds of a return visit to the ED; and the apartments — which cost the hospital a third of what a hospital stay would — lessen the burden of homelessness on the patient and the healthcare system. And that’s not all. So far, with 15 patients in the pilot program, the initiative has helped lower healthcare costs for these patients by 75 percent, while having a positive impact on their health.

What these two programs highlight is how high-quality care doesn’t have to come at the expense of a hospital’s bottom line. What’s evident, is that investments in long-term solutions for the homeless and coordination of care pay off. Hospitals are able to increase the quality of care for all its patients — not just its chronic users who suffer from homelessness or mental and substance abuse issues — and cut costs.   

Is your hospital or ED working with an outside organization, or has a cutting-edge initiative it’s employing to counter the chronic use of the ED by the homeless? I’d love to hear about it. Feel free to comment below or drop me a line.



Psychiatry Services: “Factors Affecting Emergency Department Use by a Chronically Homeless Population”
Kaiser Health News: “Old Motels Get New Life Helping Homeless Heal”
Texas Public Radio: “A Hospital Offers Frequent ER Patients An Out — Free Housing”

Why Discharge is the Most Important Component of the Patient Flow Process

Doctor showing patient test results

The emergency department discharge is the most critical aspect of the patient flow process, but often, it’s the most challenging. As this article in the Annals of Emergency Medicine points out, three important tasks have to be properly executed for a successful discharge:

“At patient discharge, the emergency provider must effectively complete 3 tasks: communicate the crucial information, verify comprehension, and tailor teaching to areas of confusion or misunderstanding to ensure patient safety in the home environment.”

The complexity of the discharge process lies in the fact that it has to be standardized for efficiency, but also flexible to address varied health literacy levels and cultural backgrounds.

“Too often, however, discharge communication becomes an afterthought, limited only to a brief exchange of forms and prescriptions, leaving patients with uncertainty about the care plan and at risk of errors in medication use,” the authors state. “Patients and families with limited health literacy or language fluency are likely to be at particular risk of departing from the ED with insufficient comprehension.”

So, what do proper discharge practices mean for patient safety and quality of care in the ED?

First, an effective discharge process is key to significantly reducing emergency department readmissions. Often, patients have a difficult time understanding instructions related to medication and dosage, proper home care, and what the follow-up process entails. All of these areas represent potential “knowledge gaps” for patients and could result in a return visit to the ED if discharge instructions aren’t effectively communicated. And I can’t stress enough the importance of relaying proper instructions regarding medications. Recent reports suggest nearly 35 percent of ED visits among people 65 and older were due to adverse drug events.

Focusing on the discharge process is also a relatively simple and low-cost strategy to improve quality of care, patient safety, and reduce crowding — your biggest investment will be time. If you don’t have a strong discharge checklist in place, I recommend starting there. Next, evaluate the communication strategies and language utilized by staff. Do they offer enough flexibility to efficiently communicate key instructions about care and follow-up to patients from diverse backgrounds? If not, determine which patient groups are most at-risk for readmission, such as the elderly or homeless. Consider tailoring checklists for each group if possible, and communicate with staff the importance of taking the time to ensure comprehension of discharge instructions.

It’s also crucial to remember that family members and caregivers play a tremendous role in the well-being of patients upon discharge. Empower these individuals with the knowledge necessary for their loved one’s improved health, ensuring they understand all discharge instructions and are comfortable with any duties they may have to perform at home.

The discharge process is a prime opportunity to improve the health literacy of patients as well as outcomes, safety, and quality. It’s important to routinely evaluate communication strategies used during the discharge process and any interaction between patient/caregiver and staff. If you’re a hospital or ED leader looking to retool your discharge procedures, feel free to drop me a line to schedule a complimentary phone consultation to discuss what steps you can take to improve this important component of the patient flow process.


Annals of Emergency Medicine: “Effective Discharge Communication in the Emergency Department”

Academic Emergency Medicine: “Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest?”

The Agency for Healthcare Quality and Research: Preventing Avoidable Readmissions

Do Return ED Visits Signal Lower Quality of Care?

This week, I’m revisiting a blog post from the summer that discusses whether or not return visits to the ED are an appropriate metric to consider when measuring quality of care. While one may think that return visits to the ED are a good indicator of hospital performance, a recent study from the Journal of the American Medical Association offers evidence to the contrary. 

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

  • An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
  • An ICU admission rate of nearly 6 percent less (23.3 percent vs 29 percent).
  • The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced. 

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below, or feel free to drop me a line.


The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”

How to Improve Care for Geriatric Patients in the Emergency Department

Doctor Talking To Senior Female Patient In Wheelchair

As the population ages and life expectancies increase, there’s now, more than ever, a need within emergency departments for care tailored specifically for geriatric patients. The U.S. Department of Health and Human Services’ Administration on Aging (AoA) notes more than 46 million people in the country are age 65 or older — over 14 percent of the entire U.S. population. That number is expected to rise to 22 percent by 2040 and double to 98 million people 65 and older by 2060.  

The health and well-being of this segment of the population will continue to be a concern for the healthcare industry as a whole, with emergency departments continuing to serve as an important point of access to care.

Currently, only 44 percent of men and women 65 and older characterize their level of health as excellent or very good, and most seniors have at least one chronic condition, if not more. According to the AoA, arthritis and heart disease were most common, with 49 percent and 30 percent of older Americans experiencing these conditions, respectively. Even more telling, nearly 7 million people age 65 and older spent at least one night in the hospital in 2014.

In collaboration with The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for EDs to follow to improve care for geriatric patients. If you’re an ED or hospital leader wanting to effectively refine the quality of care geriatric patients presenting to your ED receive, consider implementing these strategies as outlined by ACEP:

Staffing and Education

Emergency departments with high volumes of geriatric patients may want to consider employing dedicated staff and leadership trained in geriatric care. Depending on hospital resources, these positions could be filled with physicians and nurses with specialized training as well as ancillary service providers, such as occupational and physical therapists.

Education is another way to train your current team in understanding the needs of your elderly patients. Hospital leaders may want to consider developing  training programs to increase awareness among staff about how to provide the highest quality of care to geriatric patients or encourage staff to take part in continuing education or outside programs focused on geriatric care.

Follow-up Care

Effective communication is often key when it comes to patients — no matter their age — successfully receiving follow-up care after an ED visit. ACEP notes, “Older ED patients identify misinformation as a primary course of dissatisfaction with their emergency care, a problem confounded and magnified by ongoing under-recognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up.”

When EDs ensure discharge instructions are relayed to patients and caregivers –– along with pertinent information about treatment and continuity of care –– geriatric care will improve significantly, and satisfaction will increase. ACEP recommends delivering the following facts, figures, and information to patients at discharge:

·      Presenting complaints

·      Test results and interpretation

·      ED therapy and clinical response

·      Consultation notes (in person or via telephone) in ED

·      Working discharge diagnosis

·      ED physician note, or copy of dictation

·      New prescriptions and alterations with long-term medications

·      Follow-up plan

·      Clinical information will be presented in a format in a way best suited for older adults

·      Large font discharge instructions

·      Health Insurance Portability and Accountability Act (HIPAA) compliant copied discharge instructions should be provided to family and care providers.


The type of equipment and supplies utilized by EDs have a great effect on the quality of care a geriatric patient receives. Consider making exam chairs more comfortable and accessible for older patients and using soft, moisture-proof upholstery. Special equipment such as warm blankets, non-slip mats, and walkers are also valued and appreciated by geriatric patients and their caregivers. Small touches such as painting the wall with light, non-glare paint, soft overhead lighting, and allowing natural light to fill rooms also go a long way to improve the well-being of elderly patients.

The benefits of improving the quality of care geriatric patients receive in your ED are great. EDs with care plans tailored for senior citizens can expect an increase in patient satisfaction scores, staff morale, and increased patient safety. I discussed just a few strategies hospital and ED leaders should take based on ACEP’s guidelines. If you’re interested in learning more about what your ED can do to serve geriatric patients better, feel free to schedule a complimentary phone consultation with me to discuss in detail additional steps you and your team may want to take.


U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Aging Statistics

U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Profile of Older Americans: 2015

American College of Emergency Physicians: Geriatric Emergency Department Guidelines

2 Factors Contributing to ED Overcrowding

This week I’m revisiting a blog post that discusses one of the most pressing issues facing emergency departments today — overcrowding. I discuss two of the biggest factors contributing to ED overcrowding — homelessness and boarding — and steps EDs can take to tackle the problem head on. These steps are especially important to consider as the holiday season and winter approach, which result in increased patient visits to the emergency department.

Overcrowding is the most pressing issue facing emergency departments today. When an ED is at — or over — capacity, quality of care, patient safety, and staff morale all begin to suffer.

EDs experience overcrowding for many reasons. While this blog focuses on two of the biggest culprits, it’s important to understand that a variety of factors, both internally within the ED and externally in the community, contribute to this growing problem.

Here are two of the most common issues contributing to overcrowding in the ED and a few suggestions to help EDs tackle the problem head on.

1. Homelessness

A 2002 study conducted by the American Public Health Administration found that more than 40 percent of the homeless respondents it surveyed had visited an ED at least once over the course of a year (Nearly eight percent visited on three or more separate occasions). Fast forward 10 years and not much has changed. This study from 2013found that single homeless women visited the ED 13 times more often than women in the general population. For single homeless men, the rate was nine times higher than the general population.

While homeless individuals make up a small fraction of the overall population in the U.S., the frequency of ED use by the homeless takes a toll when it comes to crowding.

What can EDs do? First, they must ensure that they have a strong patient flow process in place. Optimized patient flow is the first step to eliminating overcrowding, regardless of the cause.

Second, it’s important to build relationships with organizations within the community that can offer assistance to homeless patients once they’re discharged. Make sure you have a list of shelters, mental health and substance abuse professionals, food pantries, and other related organizations at the ready. Often, the most effective treatment is to empower patients with information on where they can seek assistance.   

2. Substance Abuse, Mental Health, and Psychiatric Boarding

Much like homelessness, patients battling mental health and substance abuse issues find themselves in the ED more often than the general population. In 2007, one in eight ED visits were made by adults with a mental health or substance abuse problem. The role of the ED is to perform emergency medicine, not provide long-term treatment for those patients suffering from these chronic problems. But in reality, EDs are on the frontline when it comes to treating the effects.

To help patients with mental health or substance abuse problems — and reduce the number of repeated visits to the ED — EDs should serve as a guide to outside resources and organizations that can offer long-term assistance. Just as with homeless patients — many who may suffer from mental health and substance abuse-related medical issues — the ED best serves as an intermediary.

The boarding, or holding for treatment, of psychiatric patients is another challenge contributing to the crowding of EDs. According to Dr. Scott Zeller, vice president and head of Emergency Psychiatry at CEP America in Emeryville, California, ED staff spend twice as much time trying to find in-patient beds for psychiatric patients as they do helping other patients. 

Dr. Zeller says, “Often these patients are kept with a sitter, or in ‘holding rooms’ or hallways on a gurney, some languishing for hours in physical restraints, often with no concurrent active treatment.”

As a solution, he recommends regional dedicated emergency psychiatric facilities that are EMTALA compliant. Patients could go to these centers on their own to seek care, be taken by ambulance when mental health is a concern or transferred there from hospitals that don’t offer psychiatric care once medically stabilized. They could be treated right away rather than spend hours waiting in an ED bed. 

Zeller’s suggestion is that the problem should be treated at the source — when patients first present –– rather than at the destination — once admitted to the hospital after hours of waiting and boarded in an ED. He sites that a great majority of psychiatric emergencies can be stabilized in less than 24 hours. In his model study, patient boarding times decreased significantly — by more than eight hours, an 80 percent improvement. 

These two factors that contribute to ED overcrowding have distinct characteristics that call for customized solutions. There’s not a single, universal course of action EDs can take to address overcrowding. Only by stepping back and taking into account all the factors at play can EDs begin to tailor a specific plan of action.

If your ED is facing issues related to overcrowding, Donovan+Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing, and patient flow as well as any external issues facing your community. Then we’ll help you implement the best solutions to alleviate crowding. Contact us today at or 651-260-9918. For more information on the services we offer, visit our website.


American Public Health Association: “Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study”

Science Daily: “Homeless people more frequent users of ED, other health services”

Medscape Medical News: “Mental Disorders, Substance Abuse Linked to Increased Emergency Department Visits”

Zeller, Scott: “Psychiatric Patient Boarding Problems in the Emergency Department”



How to Assess Patient Safety Within the Emergency Department

Portrait Of Group Of Workers In Medical Professions

Establishing and maintaining a culture of patient safety within the emergency department is critical to the patient experience. However, assessing levels of safety and the overall culture of patient safety within the ED can prove difficult.

Hospital and ED leaders must understand that the role patient safety plays within the context of clinical operations is crucial to strengthening ED performance. And reaching out to staff, whether through regular meetings, surveys or group huddles, is one of the most effective ways to gauge how well patient safety initiatives are working and being received by staff and patients.

To assess the culture of patient safety, the Agency for Healthcare Research and Quality provides a handy tool that can be utilized by hospital and ED leaders. This short survey — AHRQ recommends allowing 10 to 15 minutes to complete — elicits responses to patient safety-related prompts, which ultimately provide compelling data to determine just how important of a role patient safety plays in your ED.

From “Strongly Disagree” to “Strongly Agree” staff can comment on how well they support one another in their unit and whether colleagues treat peers with respect. But some of the most telling prompts are related to how emergency departments respond to mistakes and errors. For example:

Mistakes have led to positive changes here.

When an event is reported, it feels like the person is being written up, not the problem.

After we make changes to improve patient safety, we evaluate their effectiveness.

While surveys, whether specifically tailored for your emergency department or adapted from AHRQ, are the most effective and efficient ways to assess the culture of patient safety within your ED, it’s important to utilize other measurement strategies to make an accurate assessment.

Observation is one of the simplest ways to determine the role patient safety plays within the ED. By devoting a specific amount of time each month to patient safety-related observation, ED leaders can gain a better understanding of how well patient safety initiatives are working in the ED. When you pair this strategy with regular meetings and an open-door policy staff members feel comfortable taking advantage of, hospital and ED leaders can expect to gain valuable feedback.

One important note: patient safety encompasses a vast array of possible data sets and areas of measurement and assessment. Surveys, observation and direct communication with staff won’t garner all of the information you need to make the most accurate determination of the role patient safety plays within the ED. It’s also crucial to dig deep into the data and numbers generated by your emergency department, such as length of stay, leaving without being seen rates, patient volume and return visits. Patterns often emerge within these data sets to signal issues related to patient safety; however, they can be misleading.  While an EDs may rank among, or better, than the state or national average, it’s not always a sign that a strong culture of patient safety prevails. Using data is a great starting point, but assessment can’t stop there. Multiple avenues of measurement must be employed.

Hospital and ED leaders: what strategies do you use to assess patient safety within your emergency department? Schedule your complimentary phone consultation with Connie Donovan to discuss how to possibly improve your strategies.


Agency for Healthcare Research and Quality: “Hospital Survey on Patient Safety Culture”

How an Improved Patient Flow Process Makes Your ED Safer

Patient waiting a doctor in hospital

An optimized patient flow process offers several benefits for the emergency department. For example, efficient patient flow allows EDs to manage increased patient volume and throughput. It also reduces the costs incurred by EDs as a result of extended lengths of stay and boarding. EDs with an established and sound patient flow process experience higher staff morale and increased levels of patient satisfaction. Most importantly, improving patient flow increases patient safety in the emergency department, which is critical for ED and hospital leaders focused on patient experience.

We can all agree that emergency department crowding is, by and large, the greatest threat to patient safety. I discussed this correlation in a recent blog post, but I wanted to take some time to talk more about how an optimized patient flow process counters overcrowding and will lead to improved safety in the emergency department.

For patients experiencing life-threatening conditions— such as strokes, heart attacks and trauma — time is of the essence. Staff also must be able to have the confidence that bottlenecks or barriers to care do not appear when treating patients with these conditions. Inefficiencies in the ED may place undue stress on nurses, physicians and support and result in increased workloads, all of which pose a threat to patient safety. But when an optimized patient flow process is in place, ED and hospital leaders can be assured their patients will receive complete, comprehensive care without a risk to staff morale and patient safety.  

ED leaders must also understand the effects of bottlenecks and barriers to care in the ED can put a strain on other areas of the hospital, such as inpatient units. Rapidly admitting patients to inpatient units does little good if no beds are available. Efficiency isn’t really about the speed in which an ED admits, discharges or transfers a patient. It’s about providing quality care that’s appropriate while effectively managing the expectations of patients and their families along with relevant staff stationed throughout the hospital. If the ED is the front door of the hospital, it’s also where the flow of patients begins and the foundation for a culture of patient safety.

Delivering quality care promptly within the ED isn’t the only factor that contributes to this culture of patient safety. Effective communication and teamwork is also critical to patient safety and patient flow. Miscommunication takes an immense toll on an ED’s tally of preventable medical errors. If you’re an ED or hospital leader who has made the wise decision to revamp an inefficient patient flow process, make sure your communication strategy is tailored to the new plan. Communication is especially important during the implementation of any new or updated plan, no matter the performance areas you’re focusing on. Open-door policies, standardized communication practices and deep analysis of existing and potential communication structures are all proven strategies to increase patient safety and improve patient flow.

Need help improving your ED’s patient flow? Schedule a complimentary phone consultation with Connie Donovan to discuss what’s happening in your ED.


Agency for Healthcare Research and Quality: “Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals”

Agency for Healthcare Research and Quality: Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Emergency Department Overcrowding and Patient Safety

People Waiting For Doctor In Hospital Lobby

The correlation between emergency department crowding and a decline in patient safety is strong. Studies even suggest the risk to patients is twice as great during times of peak traffic, making interventions all the more necessary, considering the consequences to the patient experience.

Despite this study and a few others, there’s a severe shortage of research that reports on the relationship between crowding and patient safety.

In this article published in the Annals of Emergency Medicine, Jesse M. Pines, MD, MBA acknowledges that “the first reports of crowding in US EDs emerged in the late 1980s and early 1990s. Now, more than 20 years later, the first published claims-based, US-based, health services research report links what may seem to an everyday person to be an obviously unsafe environment to negative patient outcomes.” (This study the author alludes to found that patients had a 5-percent higher chance of death if they were admitted on days with increased crowding, along with longer stays, and higher costs per admission.)

Then the author makes another critical observation regarding how the very term, “ED crowding,” is outdated because “one of the main causes of ED crowding is ‘hospital crowding’ and its result: prolonged boarding of admitted patients in the ED.”

So what actions can ED and hospital leaders take to reduce crowding? I’ve written extensively about ways to combat overcrowding by optimizing patient flow and improving communication inside the ED and between departments. Real-time analytics is another important tool that can be used to reduce crowding and shows increasing promise. But the solution many EDs turn to — and, admittedly, the umbrella the tactics mentioned above fall under — is actually adaptation. To put it simply,  for EDs to continue providing high quality care safely and efficiently, they have to adapt to an ever-increasing volume of patients.

Adapting to crowded ED environments and developing ways to work with less than desirable circumstances isn’t discussed very often, as Pines’ article from the Annals of Emergency Medicine points out.

“Another unspoken issue in the relationship between ED and hospital crowding and quality outcomes is that some EDs may have actually adapted to the inhospitable crowded environment and have created safer mechanisms to deal with the dysfunction,” the article states. “These may include adding nurses or techs to the triage area, using point-of-care testing to identify high-risk patients (i.e., troponin or lactate), or creating hospital policies that ensure that patients who are likely to be harmed by crowding (such as boarders) are rapidly evaluated and cared for by inpatient teams in the ED.”

However, just like the dearth of research regarding overcrowding and patient safety, there’s also a lack of discussion regarding the adaptive responses EDs take in response to crowding, which place ED and hospital leaders in a difficult situation — fixing a problem that is ill-defined and understudied, even though the impact is obvious.  

So the question still remains, how do ED leaders, emergency care providers and other stakeholders fix a problem that is so ill-defined and understudied? The case can be made for further studies, specifically of hospitals that have successfully adapted to crowding and those that haven’t.  

How has your ED adapted to increasing patient volumes? Have you successfully reduced crowding in your ED, or are you still working to develop and implement customized solutions? Share what has and hasn’t worked, or feel free to drop me a line to share your experience.


Internal and Emergency Medicine: “Emergency department crowding and risk of preventable medical errors.”

Annals of Emergency Medicine: Emergency Department Crowding in California: A Silent Killer?

Annals of Emergency Medicine: Effect of Emergency Department Crowding on Outcomes of Admitted Patients

How to Effectively Transfer Patients From the ED to an Inpatient Unit

Motion Blur Stretcher Gurney Patient Hospital Emergency

An optimized patient flow process is critical to effectively transfer patients from the emergency department to an inpatient unit. Often, it’s not the patients in the waiting room that weigh heavily on an ED’s resources and signal an issue with crowding; it’s the number of patients waiting to be admitted to the hospital from the ED.

It’s not always easy as an ED leader to effect change in another department such as an inpatient unit. But it is important to work in tandem with other hospital leaders and administration to improve the patient experience for all patients whether they’re discharged straight from the ED or require more long-term care as an admitted patient. While the ED often functions as the front door to the hospital, it’s much more than an entryway — it’s a place where great care and treatment begins. High quality of care must continue in a safe and timely way as patients are transferred out of the ED.

Here are a few steps ED leaders can take to reduce the time needed to transfer patients from the emergency department to an inpatient bed.

Reduce your nurses’ patient loads.

This story from the Institute for Healthcare Improvement offers a great example of how implementing a few changes, such as improving the patient load of your nurses, can help reduce the amount of time it takes to transfer ED patients to an inpatient bed.

How did they do it? The patient flow team at Lee Memorial Hospital in Fort Myers, Florida, led by Linda Biittner, R.N., reduced their nurses’ patient loads from four patients to three patients per nurse. By reducing the nurse-to-patient ratio, nurses were far more productive, and patients were discharged faster. This “counterintuitive” strategy also proved critical to reducing transfer time by 80 percent.

Keep an eye on your metrics.

The flow team at Lee Memorial also implemented a computer-based system to track how long admitted patients had been waiting in the ED. According to Biittner, the system allowed her to have a better understanding of how patients were flowing through the ED, allowing her the opportunity to know how long patients were waiting and how much time doctors were spending with each patient.

Create a line of inter-department communication.

Opening a different line of inter-department communication was another tactic Biittner employed to help reduce the amount of time it took to transfer patients from the ED to an inpatient bed. When these changes were implemented back in 2004, ED staff replaced lengthy phone calls to inpatient units with faxesAdditionally, a bed turnaround team was created to ensure beds were ready for patients upon arrival, and bed turnaround time was reduced by more than 15 minutes.

But what happens if there are no inpatient beds available?

Don’t board them in the hallways of the ED, board them in inpatient hallways. Thisstudy from the Annals of Emergency Medicine provides evidence that admitted patients prefer to be boarded in inpatient hallways as opposed to the ED. There’s a direct correlation between ED boarding and overcrowding, so if ED and hospital leaders are able to move patients to an inpatient unit, even if no bed is available, patients are more likely to express higher levels of satisfaction, and ED crowding will be reduced.

Has your emergency department successfully reduced the amount of time it takes to transfer patients from the ED to an inpatient bed? Comment below, or feel free to drop me a line to share your experience.


Institute for Healthcare Improvement: “Reducing Transfer Time from the Emergency Department to Inpatient Bed: Lee Memorial Hospital”

Annals of Emergency Medicine: “27 Patients Prefer Boarding in Inpatient Hallways: Correlation With the National Emergency Department Overcrowding Score (NEDOCS)”

How an Interim Management Consultant Adds Value to a Hospital and its ED

Two Consultants Discussing Patient Notes In Hospital

Emergency departments are complex care delivery systems with many interdependent components such as medical and support staff, inpatient and ancillary services and the community they serve.

CEOs, CNOs, COOs and CFOs rely on ED leadership and management teams to ensure clinical operations are aligned with quality and patient safety initiatives, value-based reimbursements and patient experience demands. And even though your emergency department may have great managers and directors on staff, it may need to be energized with temporary assistance. 

Working with an ED interim management consultant can help engage your current leadership team and bolster internal resources with additional experience and talent. ED interim management consultants are experienced emergency department leaders with deep clinical operational, financial and regulatory-accreditation experience. They support existing hospital management and leadership, providing clinical processes and tools to optimize what is working well. They also identify inefficiencies in the ED and then develop and implement practical, customized solutions to combat them. 

Whether it’s for one week or three months, the benefits and practical knowledge these consultants bring to the emergency department are immense. Here are a few ways interim management consultants add value to a hospital and its emergency department.

Improved clinical operational performance and patient experience.

Interim management consultants establish a strong foundation within your ED to strengthen clinical operations for value-based reimbursement. By focusing on staffing and scheduling effectiveness, as well as patient flow, they can improve clinical operations and heighten patient experience. Interim management consultants will also develop and implement a comprehensive and sustainable improvement plan and build upon current strategies to craft long-term improvements.


At times your hospital may have an ED management vacancy, which may result in unnecessary disruptions. By filling the vacancy with an interim management consultant, ED leaders can ensure continued progress on any initiatives and reduce the likelihood of any communication breakdowns. They can ensure that new, incoming managers are brought up to speed while providing stability to existing ED staff. They’ll also engage your team and openly communicate goals, actions, timelines and milestones.  


It’s important to act fast when filling an open leadership position, but finding the right person takes time. Interim management consultants allow you to devote more time and energy to finding the perfect permanent replacement. 

A fresh perspective.

Interim management consultants are often able to identify problems or issues that have previously gone undetected in an emergency department. The fresh pair of eyes interim management consultants lend to EDs can quickly spot inefficiencies in the patient flow process and any issues that could cause harm to patient safety initiatives. And, drawing from their vast experience in the field, they will be able to develop and implement innovative and creative solutions promptly.

Experience and solutions.

Even the highest-rated EDs have room for improvement, whether it’s a leaving without being seen rate that’s slightly above the national average or a bottleneck in the patient flow process that results in an unnecessary increase in lengths of stay. The best interim management consultants seek ways to strengthen these areas in the emergency department, maintaining high expectations when it comes to quality of care, patient satisfaction and patient safety – always ensuring that goals are aligned with their client’s business and patient care objectives. To do this, they draw from their wealth of experience to improve the quality of care EDs provide. 

When your current staff and leadership need a boost, or you experience a vacancy in your leadership team, interim management consultants like myself can help sustain the infrastructure of your emergency department while continuing to improve the patient experience. Donovan and Partners always keeps patient quality and safety in mind when working with emergency departments no matter their needs and the amount of time we spend with them. That’s why we work hand in hand with existing leadership to make transitions seamless and ensure operations continue to run smoothly, even when leadership positions are in question.

4 Signs That Your Emergency Department Isn’t Properly Staffed

This week I’m revisiting a blog post from the summer related to the importance of proper staffing in the emergency department. Staffing isn’t just about having enough support on the floor at a given time — the best staffing procedures take into account the strengths and weaknesses of each team member with focus on patient safety and satisfaction, maximum efficiency and cost-effectiveness. If you’re a hospital or ED leader questioning whether your emergency department is properly staffed, this post identifies four key indicators to help you determine if staffing issues are present.


Proper staffing is an important component of emergency department efficiency. EDs that aren’t appropriately staffed may find it difficult to provide the high-quality and timely care patients seek and deserve.

Determining when and how to utilize your staff for maximum efficiency and cost effectiveness can prove challenging. Patient volume fluctuates and the effects can be difficult to predict even when taking historical data and real-time analytics into account. Additionally, the strengths and weaknesses of your staff must be considered when scheduling, as should the possibility of outside events beyond your control. When it comes to staffing, preparation is everything.

But how can ED leaders conclude whether or not their ED is properly staffed in the first place?

When working with EDs, I look at four indicators first to assess if staffing issues are present. These signs can be very telling when it comes to staffing and scheduling, and whether your team is being utilized in the most efficient and cost-effective manner.

1. Patient throughput time

The first place to look to determine whether or not your ED is properly staffed is your patient throughput times. If they are above the national or state averages, or are steadily rising from month to month, staffing issues may be the reason why.

Throughput times may increase for a variety of reasons, so it’s important to analyze other factors to determine which ones may be contributing to the rise. An increase could be related to an inefficient patient flow process; poor communication among staff and other departments; or a combination of factors that should be addressed with a tailored action plan.  

2. Leaving without out being seen (LWBS) rate

Just like high patient throughput times, increased LWBS rates are a key indicator that your ED isn’t properly staffed. Patients will leave if their concerns aren’t addressed in a timely manner. How your ED is staffed — specifically at triage — plays a crucial role in making sure all patients are seen.  

3. Patient satisfaction

If patient satisfaction scores are lower than expected, your schedule may be the reason why. While patient satisfaction scores aren’t the most telling of indicators when it comes to staffing issues your ED may be facing, they are important to consider. Communication and pain management are key drivers of patient satisfaction. However, staffing may be an underlying cause behind these and other issues leaving your patients unsatisfied. If staff is in a pinch for time, it can take longer for them to get patients the pain management solutions they need in a timely manner. And, a harried staff can make clear, empathetic communication challenging.

4. Staff morale

ED staff are under a considerable amount of stress even when an ED is appropriately staffed. If you notice that your turnover rate is on the rise or that there is a general sense of dissatisfaction among your staff, take a look at your schedule. Morale is closely related to the three indicators discussed above — patient satisfaction especially. If patients aren’t satisfied, your staff won’t be either. A solution may lie in a few tweaks to the staff schedule.

The most effective way to properly staff an ED is by first analyzing the strengths and weaknesses of your staff members and creating the schedule accordingly. Although, the natural inclination for many ED leaders facing issues related to staffing is to increase the number of staff on duty and on-call during a given shift. However, this strategy can be expensive and it doesn’t always address underlying issues like playing the right staff in the right positions.

If you believe your ED isn’t properly staffed, Donovan+Partners can assess the reasons why and create an action plan that maximizes efficiency while keeping your bottom line in mind. Contact Donovan+Partners today at or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.


Collins, Martha: “Staffing an ED Appropriately and Efficiently.”

3 Online Resources ED Leaders Can Use to Improve Patient Flow

Doctor using laptop computer isolated on white

Improving patient flow is one of the most important steps ED leaders can take to reduce crowding, boost patient and staff satisfaction and improve quality of care in the emergency department. A number of potential strategies, solutions and tactics exist — and experts and consultants like myself can aid in implementation.  However, developing a strong patient flow improvement plan can be daunting, especially in the initial stages.

Luckily, a number of online resources are available for those stakeholders interested in assessing their patient flow process and taking the steps necessary to make it more efficient.

Check out these three online resources ED leaders and staff can use to improve patient flow.  

George Washington University School of Medicine & Health Sciences | Urgent Matters

Urgent Matters describes itself as “a dissemination vehicle for strategies on emergency department (ED) patient flow and quality.” They’re a wealth of valuable information for ED and hospital leaders interested in improving patient flow. Urgent Matters develops and offers webinarspodcasts and a blog that cover timely issues related to emergency care. They also have a searchable toolkit stocked with case studies as well as strategies and solutions for common problems and concerns related to patient flow.  

ACEP | Emergency Medicine Crowding and Boarding

The American College of Emergency Physicians is a great resource for ED leaders investigating potential solutions related to the problems brought on by overcrowding and boarding. ACEP’s informative website is a must-visit for ED leaders, physicians and staff interested in improving patient flow.Admittedly, the information found on ACEP’s website may seem dated, but the material and examples available are still relevant and appropriate for EDs today, especially in regards to policy making, state legislation and advocacy. Additionally, ACEP provides access to lectures and seminars that address issues and best practices related to patient flow.

Institute for Healthcare Improvement

The Institute for Healthcare Improvement is another organization offering access to case studies, white papers and other resources on how to improve patient flow. IHI also features improvement tools that ED leaders may find useful such as ones to help track data related to patient flow.

While the sites mentioned above are just a few of the many online resources available that focus on improving patient flow, they’re  home to valuable information and resources related to patient satisfaction and quality of care. If you’re serious about improving the quality of care your patients receive and increasing satisfaction, patient flow is the first place to start. By implementing a few strategies to improve flow within your ED, you’ll see a positive impact when it comes to crowding, leaving without being seen rates and overall length of stay time, just to name a few benefits.

ED and hospital leaders: What online resources have you sought to help improve not just patient flow, but quality of care and satisfaction? Did you find them useful? Comment below or feel free to drop me a line to share your experiences.

Patient Safety: 2 Strategies to Battle Sepsis in the ED

Listening to heartbeat

In August, the Centers for Disease Control and Prevention released a study  that evaluated medical records of nearly 250 adults and almost 80 children from four New York hospitals. By uncovering common characteristics prevalent among patients with sepsis, the researchers hoped to better understand sepsis and identify strategies to prevent, recognize and treat this threat to patient safety. 

Emergency departments, already take sepsis very seriously. Strict protocols are in place to reduce transmission of pathogens that can lead to sepsis, and sepsis prevention is an important component of an ED’s overall patient safety strategy. But as the rate of sepsis cases continues to increase each year, EDs must revisit the protocols and programs they have in place to prevent this often fatal syndrome from affecting their patients.

Here are two strategies EDs can employ to prevent, reduce and better treat cases of sepsis within the ED.

1. Communicate With At-Risk Patients, Their Caregivers and ED Staff

Increasing awareness of sepsis among your patients and their caregivers is critical to preventing infection. Patients with risk factors for sepsis should be made aware of signs and symptoms. Though symptoms of sepsis often mimic other conditions, if a patient knows the warning signs, sepsis can be treated early and result in more positive outcomes.

Speaking with staff members is also vital to preventing and decreasing sepsis cases. Check in regularly to ensure ED staff are considering the risk factors associated with sepsis when assessing patients and are following established protocols to reduce transmission of pathogens within the ED.

2. Make Early Detection a Priority

Early detection of sepsis is critical for patient safety. Between 28 and 50 percent of the 1 million patients affected by sepsis each year die. If a patient presents with fever, increased heart rate and increased respiratory rate — and sepsis is the cause — early detection can be a matter of life and death. Work with your staff to develop a detailed sepsis plan for early detection in the ED, and reach out to other departments within the hospital to expedite treatment. Though the onset of nearly 80 percent of sepsis cases begins outside of the hospital and ED, many patients the CDC surveyed had visited a healthcare provider prior to infection.

CDC researchers from the study concluded, “While this likely reflects the vulnerability of chronically ill patients to infection, it also suggests that health care facilities and providers could play a central role in sepsis prevention by providing age-appropriate and condition-appropriate vaccination to all patients and optimizing the health status of patients with chronic conditions.”

Early diagnosis and treatment of sepsis in the ED can increase survival rates among patients. And for EDs, continued focus on reducing the transmission of pathogens will decrease cases of sepsis stemming from a patient’s interaction with the ED. Sepsis impacts emergency departments across the country, and being able to combat it effectively is critical to patient safety.  

What strategies has your ED implemented to prevent and reduce sepsis? Comment below, or feel free to drop me a line.


Centers for Disease Control and Prevention: Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention

National Institute of General Medical Sciences: “Sepsis Fact Sheet"

3 Strategies to Reduce Non-Urgent ED Visits

Emergency Room Sign

We know many patients presenting to emergency departments don’t necessarily need treatment there. Depending on the severity of a patient’s symptoms, quality care can be had in other, more appropriate settings such as a primary care physician’s office or urgent care. But redirecting patient traffic to these locations is often a challenge.

With more non-urgent visits come longer wait times, extended lengths of stay and decreased patient satisfaction within an ED. So, what can ED leaders do to reduce these non-urgent visits to their emergency departments?   

It’s important to first look at the data and determine the scope of the problem. Find out just how many, or the percentage of, patients each month visiting your ED could be treated elsewhere and identify the common causes of those visits. Once you determine the extent of the problem, only then can you begin to alleviate it.

These three tactics outlined below have proven to significantly reduce non-urgent visits to EDs. Hospital leaders will need to tailor a specific and strategic plan based on the issues their ED and community of patients are facing.  

1. Telephone Nurse Triage

Developing and implementing an in-house nurse triage system is one innovative way of reducing non-urgent ED visits. By offering patients 24/7 access to trained medical professionals via telephone, nurses can direct patients to quality care in the most appropriate setting based on their needs. 

Midland Memorial Hospital in Midland, TX, set up a telephone nurse triage system that employs a software-based algorithm to determine patient acuity. The system allowed nurses to direct patients suffering from non-urgent ailments to obtain the care they need in a more appropriate setting, while encouraging patients facing a serious condition to visit the ED. The result was a reduction in the number of patients present with non-urgent symptoms, which led to a decrease in LOS, wait times and leaving without being seen rates.

2. Real-time Video Consultation

Partnering with emergency medical services to provide real-time video assessments of patients outside the emergency department can also reduce the number of non-urgent visits.

When the City of Houston Fire Department implemented its own Emergency Telehealth and Navigation program (ETHAN), area EDs saw a decrease in unnecessary patient visits after ED-based physicians conducted video consultations with patients in the field. 

Once physicians via video determine that emergency care isn’t necessary for patients, the program takes the necessary steps to schedule and provide transportation for patients to a care partner — typically primary care medical homes — to provide continued treatment.

3. Collaboration

One key element or solution to curbing non-urgent ED visits is collaboration. It’s important to partners and stakeholders who can offer assistance and provide long-term care to specific high-frequency ED users such as individuals battling substance abuse and those experiencing homelessness. Without collaboration and teamwork, reducing non-urgent ED visits may be difficult. 

Has your ED successfully reduced the number of non-urgent ED visits? Or is it a problem your ED still faces? If so, feel free to comment below or drop me a line to share your experience.    



Agency for Healthcare Research and Quality: “Telephone Nurse Triage System Reduces Use of Emergency Department by Nonurgent Patients, Reducing Wait Times, Length of Stay, and Patient Walkouts”

Agency for Healthcare Research and Quality: “On-the-Scene Video Consultations With Emergency Physicians Reduce Unnecessary Ambulance Transports and Emergency Department Visits, Connect People to Medical Homes”

3 Ways to Encourage Continuity of Care Among Patients in the ED

Nurse Checking Patient's Heartrate

Many patients visiting emergency departments suffer from chronic conditions. They’re often older adults battling various ailments that require long-term care, such as asthma, diabetes and heart disease. And often, they aren’t receiving the treatment necessary for sustained health. That only increases the likelihood that they’ll have to visit the ED again in the near future.

It’s important that ED staff can identify these people and help transition them to an appropriate care setting or treatment center at discharge. The odds that these same people will return to the ED are high if no long-term care plan is implemented.

Not only is that bad for the patient, it can have a negative impact on wait times, crowding, patient safety and patient satisfaction. By taking a proactive approach and encouraging continuity of care for ED patients suffering from chronic conditions, your emergency department will be able to counteract those effects.

So, what can EDs do to ensure patients with chronic conditions seek out and receive appropriate care upon discharge from the ED?

Plan for Discharge

First, make sure your ED has a strong discharge checklist in place that has specific instructions about:

  • medication and dosage
  • information about follow-up appointments

contact information for organizations and healthcare providers in the community that can help the patient develop and follow an overall care plan

Make sure your staff takes the time to carefully go over the discharge checklist with their patients, as well as their families and caregivers. By taking a few extra moments to answer any questions about the treatment plan, along with where and how to seek care outside the ED you’ll likely reduce the chances of a return visit to the ED. A referral to a primary care physician, community support group or treatment center may all be appropriate.

Carefully Assess Patients, Including for Chronic Conditions

Additionally, EDs must accept that their role in healthcare has evolved into something much more than providing emergency care. Patients, understandably, aren’t always able to determine whether they’re symptoms or conditions merit emergency medical attention, as this issue brief from the Kaiser Family Foundation points out. As a result, EDs are often making the clinical assessments patients need to begin long-term treatment.

While these diagnoses and assessments are a first step, they shouldn’t be the last step taken in the emergency department. As the issue brief makes clear, these assessments can no longer be deemed an inappropriate use of the ED by patients. It’s now the norm, especially in EDs serving vulnerable populations who may have limited access to primary care.a first step, they shouldn’t be the last step taken in the emergency department. As the issue brief makes clear, these assessments can no longer be deemed an inappropriate use of the ED by patients. It’s now the norm, especially in EDs serving vulnerable populations who may have limited access to primary care.

Identify Barriers to Care

EDs must utilize all the resources at their disposal to empower their patients to take action outside the ED. This will require EDs to identify the barriers preventing their patients from seeking long-term care. Short surveys during the triage process can be an effective means to determining what these barriers may be. Whether it’s limited access to transportation, financial restraints or a lack of knowledge regarding available care options, EDs can be help patients navigate the healthcare landscape to overcome these hurdles.

Recent studies show that continuity of care reduces the likelihood that patients will visit the ED, or make a return visit. The emergency department should serve as a jumping off point to continued care and better health for its patients. As a bonus you’ll reduce the effects of crowding, increase patient satisfaction and provide the highest quality of care possible.

What do you think? What can EDs do to encourage continuity of care outside the emergency department? Share your thoughts below or feel free to drop me a line.



The American Journal of Nursing: “Transitional Care: Moving patients from one care setting to another.”

The Henry J. Kaiser Family Foundation: “Safety-Net Emergency Departments: A Look at Current Experiences and Challenges.”

Science Daily: “Seniors with more continuity of care use the ER less.”

How Great Emergency Nurses Impact Patient Experience

Emergency Nurse

It’s been quite a year for nurses working in emergency departments (EDs) across the country. From the opioid epidemic to the mental health crisis, emergency nurses have had to confront more than their fair share of difficulty. And they do it all while exceeding the high expectations placed upon them by the healthcare industry and the community in which they serve.

The responsibility faced by emergency nurses is immense. They not only have to perform lifesaving procedures on a daily basis, emergency nurses also have to ensure each patient that walks through the door has the best experience possible.

As we celebrate Emergency Nurses Week, it’s important for ED leaders to realize just how instrumental these team members are to the patient experience. How exactly do they do it?

Nurses Lower Stress While Juggling Multiple Patients

Especially noteworthy is how emergency nurses are able to make a positive impact on the lives of patients and their families during stressful times.

The ED isn’t a place most people enjoy or even plan to visit. Visits are often unexpected and can be a great cause of stress for patients and their loved ones. So for emergency nurses to be able to enhance the patient experience given these circumstances — also while caring for multiple patients suffering from varying conditions and all with different personalities and needs — says a lot about the skills theses nurses have at their disposal.  

They Are Master Communicators

For emergency nurses, the ability to communicate effectively is increasingly important and for many, the most important tool. It’s truly the key to a positive patient experience.Effective communication is much more than telling a patient what to do to regarding treatment. It’s being able to listen and connect with patients to understand their concerns, no matter how trivial, and to put them and their loved ones at ease as best one can. Empathy and compassion are important components of effective communication and are invaluable when it comes to making the ED experience one where patients are empowered to have a voice in their care.

Emergency Nurses Manage Expectations

Nurses also play a pivotal role when it comes to helping patients anticipate what to expect. Expectations that aren’t met or grounded in reality given the situation are likely to have a negative effect on a patient’s experience in the ED. This is especially true across the board in stressful situations.

Communication comes into play here again — nurses understand better than most what patients can expect during their visit. When they are able to relay this information in a kind and compassionate way, it will often counter the impact of an extended stay or crowded waiting room.

And for emergency nurses, managing expectations isn’t solely limited to those of the patient, they often play an important role in managing expectations of everyone who enters the ED, from family members to EMTs, all of which shape the patient experience.

In closing, emergency nurses deserve all the recognition and celebration that comes their way this week and beyond. This week should also be a reminder for ED leaders, doctors, patients and their families of just how critical emergency nurses are. They help to provide a positive experience for everyone who walks through the doors of an emergency department. What do you think are some of the qualities that make a great ED nurse? How are you celebrating Emergency Nurses Week? How do you recognize the nurses in your life? Share your ideas and plans below.

Do You Need a Patient Flow Coordinator in Your Emergency Department?

Two Nurses Meeting

It’s Emergency Nurses Week. Do you have someone filling the critical role in your ED? The role of the patient flow coordinator — or nurse — is to ensure patients receive the highest quality of healthcare in the timeliest manner. They do this two ways:

  • By streamlining the flow of patients through the emergency department from admission to discharge or transfer;
  • And by helping hospital staff, in and outside the ED, provide a level of care that exceeds expectations.

So, if patient flow coordinators are so vital to the quality of care and patient satisfaction, why aren’t they more common in the ED? Is it not worth the investment?

How Patient Flow Coordinators Can Improve Numbers

A 2012 research study published in the Journal of Emergency Nursing contends that the initial investments necessary to create these positions do pay off over time.

Researchers conducted their study at an urban academic medical center facing issues related to overcrowding within its ED. A “fast track” area was implemented, the size of the ED was increased, beds were placed in the hallway and ambulances were diverted. But only by assigning an emergency nurse as a flow coordinator to “affect patient throughput in the emergency department,” were researchers able to see a considerable decrease in patient length of stay, LWBS rate and monthly hospital diversion.

By the numbers:

  • Length of stay decreased by 87.6 minutes.
  • LWBS rate decreased by 1.5 percent.
  • Monthly hospital diversion decreased from 93 hours to 43.3 hours.

Patient Flow Coordinators Can Positively Impact Your Bottom Line

The researchers also remind us these decreases have a significant impact on a hospital finances:

  • Decreasing monthly hospital diversion by an average of 49.8 hours per month leads to a decrease of almost $20 million in lost potential charges annually.
  • By lowering the LWBS rate by 1.5 percent, nearly $5 million in lost potential charges are saved annually.

And of course, if length of stay can be decreased by nearly 90 minutes, patient satisfaction will surely increase.

Another example highlighting the benefits of patient flow nurses and coordinators is one out of Lexington, Kentucky.

Discharge Can Become a Priority

This article tells the story of Baptist Health Lexington COO and CNO Karen Hill, who created a patient flow nurse position when she realized her RNs weren’t consistently making patient discharge a top priority. Instead, they were focusing on those patients that were most unstable or had the highest acuity levels.

Hill tells Health Leaders Media, "I've seen a huge transition in my nursing career from high-acuity hospital focused care to, now, a focus on wellness across the care settings. As we've done that, one of the things that I've tried to do is to help develop a different way to look at hospital care."

By creating the discharge/flow nurse position at Baptist Health Lexington, Hill was not only able to improve quality metrics and transition care while lowering staff turnover, but patients were being discharged more efficiently, a decrease in readmission occurred along with an increase in patients’ levels of education regarding discharge.

The data makes it clear that patient flow nurses and coordinators are a valuable supplement to any ED. But creating these positions and integrating them within an already established ED dynamic and culture isn’t easy. Donovan and Partners can help you assess your ED and determine the best course of action when it comes to staffing your ED with patient flow coordinators. Contact us today.



Health Leaders Media: “How Patient Flow Nurses Help Cut Readmissions”

Journal of Emergency Nursing: “Does an ED Flow Coordinator Improve Patient Throughput?”

New Patient Flow Strategies? What to Keep in Mind for Implementation

Nursing Team

Improving the patient flow process in your emergency department relies heavily on not only what strategies and solutions you choose to implement but also how you decide to implement them.

A strong correlation exists between efficacy and execution. A detailed patient flow implementation plan acknowledges potential challenges and barriers, includes a detailed timeline and offers flexibility. By having one in place, you’ll increase your odds of success.

While your new patient flow process — and the strategies and solutions you’ve decided upon to create it — may seem foolproof on paper, below are  a few things you should consider before, during and following implementation.

Start slow. 

Improving patient flow isn’t a sprint; it’s a marathon. Expect to tweak your plan and strategy during the implementation process and adjust accordingly. Also, give a strategy or solution time to take effect. Like the medication prescribed to patients, relief isn’t always immediate. It takes time, and significant impact may arrive only after another component of the plan has been enacted.  

Create a communication plan. 

Ensuring your plan’s success will be a team effort. From hospital administrators to ED support staff, getting their buy-in will be critical and will require effective communication between stakeholders. Before launch, develop a communication plan with your patient flow team that will enable you and your team to troubleshoot any issues or concerns as they arise and to make sure everyone is on the same page.

Whether you schedule a daily in-person huddle, weekly Skype session, conference call, email thread or group chat, make sure the lines of communication are open and that all of your team members have an opportunity to share their voice as you implement your plan.   

Be realistic. 

This may be the most important thought to consider when implementing new patient flow strategies. To effect change in the ED, you have to take into account what your resources are and how they will determine your results.

For example:

  • Figure out early on whether or not you have the budget to implement new strategies. You must also determine if the results of implementation will provide a positive return on investment for both your bottom line and the quality of care your ED delivers to patients.
  • Consider personnel resources. If your patient flow plan consists of developing or adding a new position — think patient flow navigator — do you have the money to make it happen? If not, will you be able to secure more funds? How long will it take? Also, determine whether or not your plan will require staff to learn new skills.     

Take time to reflect. 

When you carefully consider each component or strategy you plan to implement it will prepare you for any hiccups along the way. It can give you time to create buy-in among your teammates and opens the lines of communication between one another. Devoting ample time for pre-launch review and dialogue among staff will make improving patient flow that much easier.

What else should one consider when working to improve patient flow within the emergency department? Share your comments below or feel free to drop me a line with your experience.


SOURCE: Agency for Healthcare Research and Quality: “Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals.”