Hospitals may profit from small reductions in ED boarding time

A one-hour reduction in the average emergency department boarding time could result in millions of additional dollars per year in revenue for hospitals that implement active bed-management strategies. 

The results of a financial analysis and simulation model using real hospital data were reported April 25 in the online edition of Annals of Emergency Medicine in an article called "The Financial Consequences of Lost Demand and Reducing Boarding in Hospital Emergency Departments."

"This study helps debunk the conventional wisdom that boarding patients in the ED maximizes hospital profits," says lead study author Jesse M. Pines, M.D., of George Washington University in Washington, D.C. "Boarding is a major problem across the United States that results in poor patient care and worse outcomes. What we found is that it is possible for smart hospital managers to make more money and provide better ED service through less boarding if they are willing to cancel an occasional scheduled admission."

Researchers created models to determine what combination of ED admissions and scheduled admissions leads to highest hospital revenues. They determined that when hospital occupancy reached a certain point, a 5 percent reduction of scheduled admissions (generally only a few patients) would lead to an increase in hospital revenue of $7,418 per day. 

"From a medical standpoint, less boarding is better for patients," says Pines. "Patients who need treatment are seen faster and patients who have been admitted to the hospital get out of the hallway faster. Just one hour less of boarding could trigger a cascade of positive events— better health for our patients and better profits for the hospital."

Because ED admissions typically generate significantly less hospital revenue than scheduled admissions, hospital administrators have tended to favor scheduled admissions over ED admissions when allocating inpatient beds. Hard limits on beds allocated to ED admissions have led to patients being held in the ED for hours, a practice known as boarding. This study attempted to develop an admissions-management policy that could be used during periods of peak emergency admissions to maximize hospital revenue.

"The optimal strategies we tested resulted in at least $2.7 million more a year for the hospital," says co-author Robert J. Batt of The Wharton School at the University of Pennsylvania in Philadelphia. "A small adjustment in scheduled admissions now and then could have a big impact on both patient health and the hospital's bottom line."

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Nearly 60 percent of children with epilepsy do not take their prescribed anti-epileptic medications, study shows

Nearly three of every five children with newly diagnosed epilepsy do not take their anti-epileptic medications as prescribed over the first six months of therapy, according to a study published in the April 27 issue of the Journal of the American Medical Association.

This high rate of non-adherence was surprising and concerning, says Avani C. Modi, co-director of the New Onset Seizure Program at Cincinnati Children's Hospital Medical Center and lead author of the study.

"Non-adherence in children with epilepsy can interfere with reaching treatment goals and eliminating seizures," says Modi. "This study suggests the need to work with families of children with epilepsy to identify and remove barriers to taking medications early in the course of therapy."

The researchers studied 124 children and their caregivers seen at the New Onset Seizure Clinic at Cincinnati Children's. These children were newly diagnosed with epilepsy and just starting medication. Caregivers were given a cap and bottle that electronically monitored adherence to the prescribed drug. Families were asked to remove the medication from the bottle only at the time of dosing. The data collected from the caps was not shared with families or health care providers during the course of the study.

During each child's clinic visits, researchers examined a variety of factors that could affect adherence, including each child's family characteristics, seizure frequency and medication side effects. Medications were changed by the child's health care provider if seizure control was inadequate.

The researchers identified different adherence patterns. Severe early non-adherence was exhibited by 13 percent of the children; severe delayed non-adherence, 7 percent ; moderate non-adherence, 13 percent; and mild non-adherence, 26 percent. Only 42 percent demonstrated near-perfect adherence. Most patients established their patterns of adherence in the first month of drug therapy. Researchers found that the lower the socioeconomic status of the family, the more likely children and their families are to miss doses of their medication.

In the United States, epilepsy affects 325,000 children younger than age 15. Among adults with epilepsy, non-adherence to drug treatment regimens has been associated with continued seizures, higher mortality and higher health care costs.  It is unclear, says Modi, whether the consequences of non-adherence in children are similar to those in adults.

Modi is also a faculty member of the Center for Adherence Promotion and Self-Management at Cincinnati Children's. The Center addresses the high prevalence of problems surrounding adherence to medical treatment and the impact on clinical care and research.

Co-authors of the study, funded by a grant from the National Institutes of Health, are Tracy A. Glauser, M.D., director of the Comprehensive Epilepsy Center at Cincinnati Children's, and Joseph R. Rausch, Ph.D., a quantitative psychologist at Cincinnati Children's.

Modi has been a consultant for Novartis Pharmaceuticals Inc., which has an interest in anti-epileptic drugs. Glauser has been an adviser to, speaker for and received grants from companies with interests in anti-epileptic drugs.

Increasing registered nurse staffing, reducing overtime hours can improve a patient's hospital discharge experience and reduce readmission, ED visits

Health care experts often consider it a failure of the system when patients use emergency departments or are readmitted to the hospital within 30 days after discharge. Patients who are inadequately prepared for being discharged are more likely to visit the ED or be readmitted than patients who are well-prepared. In many hospitals, the responsibility for discharge teaching and preparation lies with staff nurses.

A study published in the Health Services Research, finds that having more registered nurses working on a hospital unit and reducing their overtime hours are correlated with fewer patients being readmitted or visiting the ED within the first 30 days after discharge, and also reduced costs. The study also found a positive correlation between the number of nurse-staffing hours and patient satisfaction with the quality of discharge teaching and subsequent readiness to go home.

Marianne Weiss, R.N., associate professor and Wheaton-Franciscan Healthcare/Sister Rosalie Klein professor of women's health at Marquette University College of Nursing, is one of the study's lead investigators. She led an interdisciplinary team that studied nurse staffing levels, patients' reports on quality of the discharge teaching process and their readiness for discharge, along with post-discharge readmissions and ED visits for 16 medical-surgical units at four hospitals in a single Midwestern health care system. The final sample included 1,892 patients.

Researchers found that when RN non-overtime staffing was higher, the odds of patient readmission were lower and when RN overtime hours were higher, emergency department use also was higher. In addition, a cost-benefit analysis estimated that increasing non-overtime staffing by 0.75 hours per patient per day increased hospitals' cost by $197.92 per hospitalized patient, but saved payers $607.51 per patient. Reducing RN overtime staffing by 0.07 hours per patient day resulted in hospital savings of $8.18 per hospitalized patient and $10.98 in savings per hospitalized patient to payers. Using a cost-analysis projection for the 16 nursing units in the study, the researchers estimated an annual net savings of $11.64 million associated with increasing non-overtime hours and an annual net savings of $544,000 associated with decreasing overtime hours. However, in current payment models, payer savings accruing from reduction in readmissions or ED use would not be applied to offset hospital costs for increased nurse staffing.

"We know that patients who aren't properly prepared to be discharged are more likely to be readmitted to the hospital, and we also know that if nurses have more hours allocated to work with patients, they have more time to perform critical functions that require RN-level expertise, like discharge teaching," Weiss says. "This study shows us that investing in nursing care hours potentially could be offset by the savings that could be realized in reductions in readmission and emergency department use."

The study's authors write that their findings support recommendations to: monitor and manage unit-level nurse staffing to ensure optimal post-discharge results; implement assessment of the quality of discharge teaching and patients' readiness for discharge as part of the discharge procedure; and realign payment structures so that the cost of nurse staffing is offset by the savings that result from reductions in unplanned readmissions and ED visits after discharge.

The study was funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. INQRI supports interdisciplinary teams of nurse scholars and scholars from other disciplines to address the gaps in knowledge about the relationship between nursing and health care quality. It is helping to advance the recommendations of the Institute of Medicine's landmark report, The Future of Nursing: Leading Change, Advancing Health, which include fostering interprofessional collaboration and preparing and enabling nurses to lead change.

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