Reducing unnecessary bed days to optimise flow and improve demand-capacity mismatch: learning from a system-wide...

Discharge delays and unnecessary bed days (UBDs) are known to cause increasing Emergency Department (ED) boarding and account for over 20% of inappropriate hospital bed use. The aim of this project is to reduce the number of UBDs by 25% (from 1500 days to 1100 days) and increase bed availability at 7 a.m. by 15% (from 0 to 1-2 beds) for medical inpatient beds over a year.

The implementation of change was facilitated by the Institute for Healthcare Improvement (IHI) Model for Improvement, with iterative testing through PDSA cycles. Quality improvement (QI) tools such as fishbone diagram, Pareto chart, and high-level flow diagrams were used to understand system drivers of delay and prioritise change ideas. Shewhart charts were used to distinguish between common-cause and special-cause variations.

The reasons for UBD and flow failures were classified as lack of capability, lack of capacity, lack of payment, patient refusal, and delayed planning. Within a year of initiating the QI project, UBDs decreased by 68% (from 1522.7 to 493.4 days), increased the availability of staffed beds at 7 a.m. by 87% (from 1.5 to 2.8 beds) and reduced ED pending admissions by 23% (from 12.1 to 9.3 patients). These improvements temporarily coincided with the implementation of several change ideas-integrated early discharge planning, the use of a CPS tool, and early involvement of social workers.

Several systems and throughput factors, in addition to staff capacity, may contribute to increasing the availability of hospital beds and reducing UBDs. QI methods and tools can rapidly uncover, test, and implement opportunities for improving patient flow from ED to inpatient units.