Improving the wait time to admission by reducing bed rejections

Congestion at the emergency department (ED) is associated with increased wait times, morbidity and mortality. We have identified prolonged wait time to admission as a significant contributor to ED congestion. One of the main contributors to prolonged wait time to admission was due to rejections by ward staff for the beds allocated to newly admitted patients by the Bed Management Unit (BMU). We have identified this as a systemic issue and through this quality improvement effort, seek to reduce the incidence of bed rejections for all admitted patients by 50% from 9% to 4.5% within 6 months. We used PDSA (Plan, Do, Study, Act) cycles to implement a series of interventions, such as updating legacy categorisation of wards, instituting a 'no rejects' policy and performing ward level audits. Compared with baseline, there was reduction in rejected BMU allocation requests from 9% to 5% (p<0.01). The monthly percentage of patients with at least one rejection dropped from an average of 7% to 4% (p<0.01). With reduction in the number of rejections, the average wait time to the final request acknowledged by the ward for all admission sources decreased from 2 hours 19 min to 1 hour (p<0.01), thereby allowing the overall wait time to admission to decrease by 68 min, from 5 hours 13 min to 4 hours 5 min. Improvements in the absolute duration and variance of wait times were sustained. Although the team's initial impetus was to improve ED wait times, this hospital-wide effort improved wait times across all admission sources. There has been a resultant increase in ownership of the admissions process by both nursing and BMU staff. With the conclusion of this effort, we are looking to further reduce the wait time to admission by optimising the current bed allocation logic through another quality improvement effort.