Reducing patient placement errors in emergency department admissions: right patient, right bed

Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement.

We conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of "lateral transfers" or assignment errors in patient placement, 2) median length of stay (LOS) for "all" and "admitted" patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process.

In pilot 1, the number of "lateral transfers" (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for "all" or for "admitted" patients. In pilot 2, the number of "lateral transfers" was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for "admitted" ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for "all" patients and inpatient occupancy did not change.

Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of "lateral transfers." Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients.