ORIGINAL CONTRIBUTION

Reduction of Admit Wait Times: The Effect of

a Leadership-based Program
Pankaj B. Patel, MD, Mary A. Combs, and David R. Vinson, MD

Abstract
Objectives: Prolonged admit wait times in the emergency department (ED) for patients who require
hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is
associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction,
increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen
(LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to
assess the effect of a leadership-based program to expedite hospital admissions from the ED.
Methods: This before-and-after observational study was undertaken from 2006 through 2011 at one
community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait
times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The
team collaboratively and consistently moved ED patients to their inpatient beds within an established
goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real
time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the
60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted
to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS,
patient satisfaction, LWBS rate, and ambulance diversion hours were also measured.
Results: After ED census, hospital admission rates, and ED bed capacity were controlled for using a
multivariable linear regression analysis, the admit wait time reduction program contributed to an
increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95%
confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of
46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes
(95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to
23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001).
Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS
patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance
diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001).
Conclusions: A leadership-based program to reduce admit wait times and boarding times was
associated with a significant increase in the percentage of patients admitted to the hospital within
60 minutes and a significant decrease in boarding time. Also associated with the program were
decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.
ACADEMIC EMERGENCY MEDICINE 2014; 21:266–273 © 2014 by the Society for Academic Emergency
Medicine

admitted to their inpatient beds in a timely fashion.1

I
nternationally, emergency medical care systems are
overburdened with patients backing up in the emer- This predicament of overcrowding led the Institute of
gency department (ED) because they cannot get Medicine (IOM) to describe emergency medicine (EM)

From the Department of Emergency Medicine, The Permanente Medical Group, Kaiser Permanente Medical Centers (PBP, DRV),
Sacramento and Roseville, CA; and the Biostatistical Consulting Unit, Division of Research, Kaiser Permanente (MAC), Oakland, CA.
Received June 16, 2013; revision received August 16, 2013; accepted September 12, 2013.
Funded by a Kaiser Permanente Northern California Central Research Committee Community Benefit Grant, The Permanente
Medical Group, Division of Research, Kaiser Permanente. The authors have no relevant financial information or potential conflicts
of interest to disclose.
Supervising Editor: Sandra M. Schneider, MD.
Address for correspondence and reprints: Pankaj B. Patel, MD; e-mail: Pankaj.Patel@KP.org.

ISSN 1069-6563 © 2014 by the Society for Academic Emergency Medicine

266 PII ISSN 1069-6563583 doi: 10.1111/acem.12327
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
as in crisis, even at the breaking point.1 Prolonged
admit wait times for patients being held in the ED until
the inpatient ward can accept them (a practice known
as “boarding”) is a significant cause of ED congestion
and crowding.2–11 The adverse effects of prolonged
admit wait times and the concomitant ED crowding are
profound and include measurable increases in patient
morbidity and mortality, longer lengths of stay (LOS),
more patients who leave without being seen (LWBS),
and increased costs.5,6,12–26 Prolonged admit wait time
is a major cause for ambulance diversion, which directs
patients away from their desired hospital destinations
and delays their care.1,19,27–29 Patient satisfaction is also
adversely affected by ED crowding and admit wait time
delays.30,31
Because boarding admitted patients contributes sig-
nificantly to ED crowding, the IOM has recommended
an end to this practice.1,32 Several studies have demon-
strated the significant advantages that result from
reducing admit wait times, which can relieve ED con-
gestion by decreasing ED LOS,13,27,33 ambulance diver-
sion hours,27,29,33 patients who LWBS,29 and costs.34
Although various solutions to reduce ED boarding have
been identified, these proven strategies appear to be
underutilized, as most hospitals report having imple-
mented very few of them.35,36
ED crowding can be reduced by expediting the trans-
fer of admitted patients out of the ED, thereby reducing
boarding times for patients held in the ED awaiting
transfer to inpatient units. Our ED implemented a lead-
ership-based admit wait time reduction program and
then measured and analyzed the effect of this approach
to expediting ED hospital admissions on admit wait
times, boarding times, LOS, patient satisfaction, LWBS
patients, and ambulance diversion hours.
METHODS
Study Design
This was a retrospective, observational, before-and-
after study to compare the effects of a leadership-based
intervention on admit wait times and boarding time.
The Kaiser Permanente Northern California Health Ser-
LOS for admitted
patient = from step #1
to step #7
4.
6.
Admission wait time =
from step #5 to step #7
(goal = 60 minutes) 7.
Figure 1. Flow diagram for ED process time intervals. LOS = length of stay.
267
vices Institutional Review Board reviewed this study
and granted it an exemption from full review.
Study Setting and Population
We conducted this study between January 2006 and
December 2011 at one urban community hospital within
a large integrated health care delivery system serving
approximately 3.3 million members at 21 hospitals and
over 160 medical offices. The study hospital has 287
licensed beds with units for intensive care, telemetry,
general medical–surgical, neuroservices (includes neuro-
surgery), and oncology, but is not a designated trauma
center. The hospital is affiliated with the University of
California, Davis, School of Medicine with rotating resi-
dents from allergy/immunology, EM, family medicine,
internal medicine, neurosurgery, obstetrics/gynecology,
ophthalmology, orthopedics, pediatrics, plastic surgery,
podiatry, radiology, surgery, and urology. The ED is
staffed by one group of EM board-certified or board-eli-
gible physicians and provides care to a broad spectrum
of patients that include pediatric and obstetric patients
(even though the hospital does not have inpatient pedi-
atric or obstetric services). There were no significant
changes to ED staffing during the study period. The
average annual ED census during the study period was
76,169 patients.
Study Protocol
A process improvement plan was developed to reduce
admit wait times, including all hours of the day and
week (nights, weekends, and holidays). A team of ED
and hospital leaders was convened to work toward
admit wait time reduction. A computerized tracking sys-
tem called HealthConnect (Epic Systems Corporation,
Verona, WI) was used to monitor inpatient and ED bed
status in real time to assess admit wait times for every
ED patient who required admission to the hospital.
Measurable steps, goals, and reports were identified
and developed. Top leadership collaboratively and con-
sistently tracked wait time metrics to assure progress
toward the goal of admit wait time reduction (see
Figure 1). No significant changes were made in ED
work flow or emergency physician staffing during the
1. Patient enters ED
2. Evaluation by ED physician
3. Evaluation by consultant/hospitalist
Decision to admit patient by consultant/hospitalist
5. Inpatient bed requested by ED staff
Hospital target interval = 30
minutes from step #5 to step #6
Patient accepted by hospital and inpatient bed assigned
ED target interval = 30 minutes
from step #6 to step #7
Patient leaves the ED for inpatient bed in hospital unit
268
study period. Consulting physicians were responsible
for determining which patients required admission to
the hospital and alerted the ED staff to their decisions
to admit by entering the order “admit to hospital” into
the tracking system, which initiated the request for the
appropriate inpatient bed. This electronic entry became
the starting time for the admit wait time interval. Once
the overall goal was established to admit ED patients
within 60 minutes of the bed requests, the overall admit
wait time was divided into two interval segments that
were captured on the tracking system: 1) from the time
an inpatient bed was requested to the time the hospital
ward accepted the ED patient (this was the primary
responsibility of hospital staff) and 2) from the time the
ED patient was accepted by the inpatient ward to the
time the ED patient left the ED (this was the primary
responsibility of ED staff). Hospital and ED staff each
sought to achieve their respective interval segments
within 30 minutes. If hospital staff and ED staff each
met their target goals, admission was achievable within
the overall 60-minute goal (less than 30 minutes by hos-
pital and less than 30 minutes by ED).
The period from January 2006 through January 2008
was the preintervention period. In February 2008, the
admission wait time reduction program was implemented.
Interventions included the following: hospital and ED lead-
ership meetings with nurse managers, charge nurses,
admitting department, discharge planning, information
technology, housekeeping and environmental services,
physicians, and pharmacy; the systematic dissemination of
tracked admit wait time data for everyone to review; and
the real-time contact between leaders and their staff, to
improve the flow of admitted patients from the ED to the
inpatient wards. At regular meetings and via e-mail distri-
bution, daily, weekly, and monthly tracking data were
made available for everyone to review. Top leadership
reviewed this information frequently and often made
direct contact with their staff in real time if delays were
observed in either of these two interval segments, allowing
immediate resolution of issues that were causing the
delays. The admit wait time reduction program required
collaborative staff involvement from the ED, admitting
department, hospital inpatient ward, discharge planning,
housekeeping and environmental services (to get beds
cleaned and ready for newly admitted patients), and infor-
mation technology (to assure tracking system functioning).
The ED had 36 rooms and nine urgent care rooms
which were physically separate from the main ED, for a
total of 45 rooms. In January 2010, the urgent care sec-
tion was closed, resulting in a total ED bed capacity of
36 rooms, with all patients managed thereafter in the
36-room ED (including those who had previously pre-
sented to the ED and had been triaged to the urgent
care section). The urgent care closure did not affect the
processes for admission, as the admission rate for this
group of patients was well below 1%. All of these
patients who previously came through the ED had med-
ical screening examinations performed by credentialed
ED nurses and were then sent to the urgent care
located on site, but outside the footprint of the ED. As
the admit wait time process was streamlined, these
patients were kept within the ED itself, incorporating
the urgent care staff into the ED as well. The postinter-
Patel et al. • ADMISSION WAIT TIME REDUCTION
vention period was from February 2008 through
December 2011.
Outcome Measures
Emergency department bed capacity, ED census, and
overall admission rates were collected. The primary out-
come measures were the percentage of ED patients
admitted to inpatient beds within 60 minutes from the
time the beds were requested and ED boarding time
per admission. Explicit measures of ED throughput and
patient satisfaction were collected, both before and after
the implementation of the admit wait time reduction
program. Summarized monthly outcome data included
percentage of patients admitted within 60 minutes,
boarding time per admission, LOS (for admitted
patients, discharged patients, and all patients), overall
boarding time, patient satisfaction scores, percentage of
patients who LWBS, and ambulance diversion hours.
The patient satisfaction survey used in this study was
not specifically designed for this project and has been
previously described as a proprietary survey for our
organization.37 Briefly, our medical group’s regional
Department of Access and Service Assessment sends
out surveys to patients who have been seen in each of
the 21 hospital EDs in our Northern California region.
Questions on the survey cover a variety of parameters
of ED care, including evaluation of the ED physician,
the coordination of care during the ED visit, and cour-
tesy and helpfulness of the staff. The patients are asked
to rate each item using a five-point Likert scale: poor,
fair, good, very good, and excellent. The reported score
is the total percentage of patients who rank their overall
ED care as very good or excellent. Annually, the regio-
nal department sent approximately 10,000 surveys to
patients who had been treated in the study ED, with
approximately 2,500 returned surveys from which
patient satisfaction scores are reported for this study.
Data Analysis
Descriptive measures of the variables were calculated.
We present continuous data as medians with interquar-
tile ranges (IQRs). Variables were compared for signifi-
cance pre- and post–program implementation using the
Wilcoxon-Mann-Whitney rank-sum test. Spearman cor-
relations and significance were calculated to assess the
bivariate influence each continuous confounder had on
each outcome. A categorical variable indicating the
decrease in ED bed capacity from 45 to 36 beds after
January 2010 was used in the analysis. The bivariate
effects of this categorical variable on each outcome
were calculated using the Wilcoxon-Mann-Whitney
rank-sum test.
To determine if there were any trending, seasonal, or
autoregressive effects that needed to be controlled for
in the outcomes, we first chose to conduct an inter-
rupted time series analysis. We used an autoregressive,
integrated, moving average (ARIMA) model for each
outcome. Ultimately, multivariable linear regression
models were used to assess the effect of program imple-
mentation on the outcome measures when controlling
for continuous and categorical confounders. Data were
analyzed using SAS 9.3 for Windows (SAS Institute
Inc., Cary, NC).
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org 269

RESULTS

Ambulance
Diversion
(Hours)

(54)
During the study period (2001 to 2011), average annual

68
116
138
107
31
13
0
census was 76,169 with average annual admissions of
9,364 (12.3%). Annual mean data are presented in Table 1.
Actual pre- and postimplementation data (median,

Satisfaction

(3.3)
IQR) at the program site on patients admitted within

Patient

67.6
67.1
69.7
73.4
73.4
76.0
71.2
(%)
60 minutes are shown in Figure 2. Boarding time per
admission, LOS, patient satisfaction, LWBS patients,
ambulance diversion hours, ED census, hospital admis-
sion rates, and ED bed capacity are noted in Table 2.

Being Seen (%)

Left Without
We examined the correlation between the confound-

(0.5)
ing variables and the outcomes to directly assess the

1.7
1.1
1.1
0.3
0.5
0.6
0.9
effect on ED throughput that can be attributed to these
factors. Spearman’s correlation coefficients and corre-
sponding p-values were calculated between the three
confounding variables (ED census, hospital admission

Patients (hr:min)
LOS Discharged
rates, and ED bed capacity) and each of the outcome

(0:28)
variables (results not reported).

3:57
3:52
3:55
3:33
2:53
2:50
3:30
We used an ARIMA model to assess for trends and
autoregressive factors. When no autoregressive factors
were identified (including seasonal trends), we contin-
ued the analysis using multivariable linear regression
for parsimony. In our multivariable linear regression

(hr:min)
Patients
LOS All

(0:41)
4:57
4:46
4:48
4:09
3:21
3:14
4:12
analysis (see Table 3), after controlling for the con-
founding variables listed above, there was an increase
in patients being admitted within 60 minutes to the hos-

LOS Admits
pital of 16 percentage points (95% CI = 10 to 22;

(hr:min)

(0:56)
p < 0.0001), an average decrease in boarding time per

8:35
8:35
8:26
7:10
6:40
6:19
7:37
admission of 46 minutes, and an average decrease in
LOS for admitted patients of 79 minutes. There was also
an average increase in patient satisfaction of 4.9
Minutes/Admit

percentage points, a decrease in LWBS patients by 0.9

Boarding

percentage points, and a decrease in ambulance diver-

(29)
93
85
88
41
32
21
60
sion of 8.2 hours per month
Staff from the urgent care were absorbed into the ED
after the urgent care was closed. A review of physician
and nonphysician staffing during the entire study per-
Time (Hours)

iod was performed and found that staffing matched

(5,047)
Boarding

15,627
13,365
14,539

census trends. Nursing staff changes closely reflected

6,221
4,893
2,938
9,597

census changes, in line with state-required nurse staff-

ing ratios.
60 Minutes

DISCUSSION
Admit*

(13.2)
Within

33.5
34.4
36.4
52.6
59.7
66.9
47.3
(%)

A leadership-based program to reduce admit wait times

was associated with a significant increase in the percent-
age of patients admitted to the hospital within 60 minutes
Rate (%)
Admit

and a significant decrease in boarding time per admis-

(0.8)
13.7
12.5
12.6
11.4
12.3
11.3
12.3

*January–April 2006 data not available

sion. This admit wait time reduction program was also

associated with decreased LOS, reduced LWBS patients,
reduced ambulance diversion hours, and improved
Admissions

patient satisfaction. Of note, ambulance diversion reduc-

(536)
10,130
9,403
9,934
9,093
9,070
8,556
9,364

tion efforts were ongoing prior to this study.28,38

Regulatory agencies have delved into the issue of
LOS = length of stay.

overcrowding and admitted patients who are boarded

in EDs. The IOM called for an end to ED boarding
Annual Mean Data

(2,208)
Census
74,164
75,044
78,818
79,551
73,907
75,532
76,169

through strong standards set by The Joint Commis-

ED

sion.1 Multipronged approaches to reduce boarding

have been identified and used in various hospitals
around the country.4,23,35,36,39–43 It has been noted that
Table 1

(SD)
Mean
2007
2008
2009
2010
2011
2006
Year

failure by hospitals to address boarding in a voluntary

fashion could result in penalties, public reporting
270 Patel et al. • ADMISSION WAIT TIME REDUCTION

and admitting hospitalists.30 Some hospitals have given

Figure 2. Percent admitted within 60 minutes. Points graphed
are percentages of patients admitted within 60 minutes for each
month with program start date identified by arrow. Lines on fig-
ure represent least-squares regression for the pre- (January
2006–January 2008) and postintervention (February 2008–
December 2011) data separately.
imperatives, and increased regulations.35,42 Although
eventually vetoed by the state’s governor, California state
legislation to address ED crowding and boarding was
introduced that would have required EDs to develop a
crowding scale and implement protocols to address
crowding when certain scores were reached.44 While out-
side forces help support our efforts to reduce ED crowd-
ing, we implemented an internal process with active
leadership involvement to address admit wait times.
Multiple means have been employed to expedite the
transfer of admitted ED patients to their inpatient beds.
One successful approach was achieved by improving
direct communications between emergency physicians
emergency physicians the authority to initiate the
admission process to directly move ED patients to the
inpatient setting, effectively reducing admit wait
times.27,39 An active hospitalist bed management pro-
gram improved ED throughput for admitted patients by
98 minutes (from 458 minutes to 360 minutes) and
reduced ambulance diversion (but with no effect upon
patients who were discharged from the ED), resulting
in improved collaboration with other physicians, nurses,
and case managers.40,45 Admit wait times for ICU
patients were similarly reduced by 99 minutes (from
353 minutes to 254 minutes) when hospitalists were
actively involved in bed management.46 Although our
study did not specifically address consultant wait times,
communications between emergency physician and
hospital staff using a hospital-wide computer tracking
system had already been implemented across our hospi-
tal system with some measure of success.47 However,
this practice was in place prior to our interventions and
alone was insufficient to reduce admit wait times to the
levels we desired.
Effective strategies to reduce admit wait times require
involvement by all personnel within a hospital sys-
tem21,23 to systematically address admit wait times and
ED boarding problems.11,41,42 Senior management
(effective ED leaders who get buy-in from their ED
group and who work with hospital administration
through a quality improvement group) is especially
important in this effort. This was the design of our lead-
ership-based program, and admit wait time reduction
was eventually achieved in our study through collabora-
tion between the hospital and ED, with active involve-
ment and commitment by top leadership, using a
hospital-wide computer tracking system to quantify and
monitor admit wait times.

Table 2
Pre- and Postintervention Outcomes

Pre- and Postimplementation*

Preimplementation
(25 Months, Jan. Postimplementation
2006–Jan. 2008), (47 Months, Feb. 2008–Dec.
Variable Median (IQR) 2011), Median (IQR) p-value
Outcomes
Patients admitted within 60 minutes (%)† 35 (28–40) 58 (49–64) <0.001
Boarding time per admission (min) 82 (61–112) 26 (20–42) <0.001
LOS
Admitted patients (hr:min) 8:47 (7:56–9:17) 6:49 (6:29–7:19) <0.001
Discharged patients (hr:min) 3:53 (3:49–4:01)) 3:03 (2:53–3:41) <0.001
All patients (hr:min) 4:46 (4:41–5:06) 3:31 (3:17–4:21) <0.001
Patient satisfaction (%)‡ 66.9 (66.3–68.1) 73.6 (72.2–75.4) <0.001
Patients LWBS (%) 1.2 (0.9–1.6) 0.6 (0.1–0.9) <0.001
Monthly ambulance diversion (hours) 10 (3–15) 1 (0–3) <0.001
Confounders
Monthly ED census 6,204 (6,051–6,407) 6,385 (6,107–6,640) NS
Hospital admission rate (%) 12.8 (12.4–13.8) 11.9 (11.2–12.8) <0.001
ED bed capacity (exam rooms) 45 36§ NS

IQR = interquartile range; LOS = length of stay; LWBS = leave without being seen; NS = not significant.
*Program implemented February, 2008.
†Patients admitted within 60 minutes data not available January 2006–April 2006.
‡Patient satisfaction reported as percentage of patients who rate their care very good or excellent.
§ED bed capacity decreased January 2010 from 45 to 36 beds.
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
Table 3
Multivariable Regression Results: Average Contribution of Program to Outcomes*
Changes Between Preintervention (Jan. 2006–Jan. 2008) and Postinter-
Variable Change
Admission within 60 minutes,% 16
Boarding time per admission, minutes –46
LOS, minutes
Admitted patients –79
Discharged patients –17
All patients –34
Patient satisfaction,% 4.9
LWBS,% –0.9
Monthly ambulance diversion, hours –8.2
LOS = length of stay; LWBS = leave without being seen.
*Controlling for ED census, hospital admission rates, and ED bed capacity.
An organization-wide program in nine EDs in
England uncovered findings similar to ours. The study
highlighted the need to 1) emphasize the responsibility
of the entire organization, not just the ED; 2) focus on
improving patient care, avoiding premature movement
of patients at risk; and 3) identify all stakeholders to
achieve the target for optimal throughput.48 Organiza-
tional efficiency and effectiveness improvement resulted
from the collaboration and shared ownership of the
process. Similarly, the University Health System ED in
San Antonio, Texas, worked with its inpatient unit and
housekeeping staff to reduce bed turnaround time from
160 minutes to less than 30 minutes, resulting in an
8.5% decrease in overall length of ED throughput
time.41 Similar to our findings, involvement and active
support by top management was critical to reduce ED
congestion and improve hospital patient flow.35,41,48
One successful method for reducing admit wait times
is to take admitted ED patients who would otherwise be
boarded in ED hallways and move them directly to the
hallways of their designated inpatient floors while they
await open beds.49 This practice has been implemented
in some areas of the United States and was shown to be
safe.3 In fact, surveys have reported that patients prefer
to wait in the hallways of the inpatient ward rather than
in the hallways of the ED,7,50,51 and it is estimated that
this idea has spread to hundreds of hospitals nation-
wide.49 Once patients have been admitted to inpatient
hallways, inpatient ward staff have been able to more
promptly identify inpatient beds for these admitted
patients than if they had remained in the ED.10 Despite
the success of this practice elsewhere, moving boarded
ED patients to inpatient hallways is prohibited by regu-
latory issues in California. Despite various efforts to
evaluate its potential for success locally, we were unable
to implement this option.
LIMITATIONS
The high-level summarized data used are likely to be
influenced by external factors not included in the analy-
sis, such as differences in the acuity of the populations
served, as well as monthly variations in ED volume, as
seen during the winter flu seasons. We mitigated the
271
vention (Feb. 2008–Dec. 2011)
Parameter Estimate
95% CI p value
10 to 22 <0.0001
–63 to –28 <0.0001
–104 to –55 <0.0001
–23 to –12 <0.0001
–43 to –25 <0.0001
3.8 to 6.0 <0.0001
–1.2 to –0.6 <0.0001
–11.8 to –4.6 <0.0001
facility-specific variations by controlling for a number of
measurable factors, including ED census, hospital
admission rates, and bed capacity. When we performed
a time series analysis, no autoregressive patterns were
uncovered.
This was an uncontrolled before-and-after study.
Therefore, the observed changes could be due to the
intervention or due to other secular trends that affected
this particular ED, limiting the ability to invoke causality.
CONCLUSIONS
A leadership-based admit wait time reduction program
was associated with an increase in the percentage of
patients admitted to the hospital within 60 minutes and
a reduction in ED boarding times. Following the imple-
mentation of this program, the reduction in physical
bed capacity that resulted from the closure of the urgent
care section of the hospital was manageable without
significant repercussions due to an increase in effective
ED bed capacity. The ED also achieved additional bene-
fits that included decreased length of stay, reduced the
number of patients who left without being seen,
reduced ambulance diversion hours, and improved
patient satisfaction.
The authors thank the Kaiser Permanente Northern California
Community Benefit Program for their financial support of this
study. We appreciate Mary Anne Armstrong, MA, Director of the
Biostatistical Consulting Unit, Kaiser Permanente Northern Califor-
nia Division of Research, for her review of our manuscript. We
gratefully acknowledge members of the admit wait time reduction
team from our hospital and ED, as well as our ED and hospital
nurses for their tireless efforts to implement this program. Pro-
gram implementation would not have been possible without active
and enthusiastic involvement of Beverly Werntz, Chief Operating
Officer, who worked closely with Kathy Miles, RN, ED Director.
We also acknowledge the leadership role played by Dr. Jack
Rozance, Physician in Chief. Finally, we appreciate the support of
our emergency department leadership group.
References
1. Institute of Medicine Committee on the Future of
Emergency Care in the United States Health System.
Hospital-based Emergency Care: At the Breaking
272
Point. Washington, DC: National Academies Press,
2006.
2. Schneider S. A letter from ACEP president Sandra
Schneider. Emerg Phys Monthly 2011;18:3.
3. Viccellio A, Santora C, Singer AJ, Thode HC Jr,
Henry MC. The association between transfer of
emergency department boarders to inpatient hall-
ways and mortality: a 4-year experience. Ann Emerg
Med 2009;54:487–91.
4. Moskop JC, Sklar DP, Geiderman JM, Schears RM,
Bookman KJ. Emergency department crowding,
part 1–concept, causes, and moral consequences.
Ann Emerg Med 2009;53:605–11.
5. Stolte E, Iwanow R, Hall C. Capacity-related interfa-
cility patient transports: patients affected, wait times
involved and associated morbidity. CJEM 2006;
8:262–8.
6. Clark K, Normile LB. Influence of time-to-interven-
tions for emergency department critical care
patients on hospital mortality. J Emerg Nurs
2007;33:6–13.
7. Garson C, Hollander JE, Rhodes KV, Shofer FS,
Baxt WG, Pines JM. Emergency department patient
preferences for boarding locations when hospitals
are at full capacity. Ann Emerg Med 2008;51:9–12.
8. Hoot NR, Aronsky D. Systematic review of emer-
gency department crowding: causes, effects, and
solutions. Ann Emerg Med 2008;52:126–36.
9. Olshaker JS, Rathlev NK. Emergency department
overcrowding and ambulance diversion: the impact
and potential solutions of extended boarding of
admitted patients in the emergency department.
J Emerg Med 2006;30:351–6.
10. Derlet RW, Richards JR. Ten solutions for emer-
gency department crowding. West J Emerg Med
2008;9:24–7.
11. Millard WB. Stand by to repel boarders. Ann
Emerg Med 2011;57:A15–19.
12. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR,
Jelinek GA. The association between hospital
overcrowding and mortality among patients admit-
ted via Western Australian emergency departments.
Med J Aust 2006;184:208–12.
13. Lucas R, Farley H, Twanmoh J, et al. Emergency
department patient flow: the influence of hospital
census variables on emergency department length
of stay. Acad Emerg Med 2009;16:597–602.
14. Gilligan P, Winder S, Singh I, Gupta V, Kelly PO,
Hegarty D. The Boarders in the Emergency Depart-
ment (BED) study. Emerg Med J 2008;25:265–9.
15. Schull MJ, Vermeulen M, Slaughter G, Morrison L,
Daly P. Emergency department crowding and
thrombolysis delays in acute myocardial infarction.
Ann Emerg Med 2004;44:577–85.
16. Phua J, Ngerng WJ, Lim TK. The impact of a delay
in intensive care unit admission for community-
acquired pneumonia. Eur Respir J 2010;36:826–33.
17. McCarthy ML, Zeger SL, Ding R, et al. Crowding
delays treatment and lengthens emergency depart-
ment length of stay, even among high-acuity
patients. Ann Emerg Med 2009;54:492–503.
18. Plunkett PK, Byrne DG, Breslin T, Bennett K, Silke
B. Increasing wait times predict increasing mortality
Patel et al. • ADMISSION WAIT TIME REDUCTION
for emergency medical admissions. Eur J Emerg
Med 2011;18:192–6.
19. Falvo T, Grove L, Stachura R, et al. The opportunity
loss of boarding admitted patients in the emergency
department. Acad Emerg Med 2007;14:332–7.
20. Huang Q, Thind A, Dreyer JF, Zaric GS. The impact
of delays to admission from the emergency depart-
ment on inpatient outcomes. BMC Emerg Med
2010;10:16.
21. Pines JM, Batt RJ, Hilton JA, Terwiesch C. The
financial consequences of lost demand and reducing
boarding in hospital emergency departments. Ann
Emerg Med 2011;58:331–40.
22. Bernstein SL, Aronsky D, Duseja R, et al. Society
for Academic Emergency Medicine, Emergency
Department Crowding Task Force. The effect of
emergency department crowding on clinically ori-
ented outcomes. Acad Emerg Med 2009;16:1–10.
23. Verdile VP. Sutton’s Law need not apply. Ann
Emerg Med 2011;58:341–2.
24. ACEP Board of Directors. Policy statement: defini-
tion of boarded patient. Ann Emerg Med
2011;57:548.
25. Sills MR, Fairclough D, Ranade D, Kahn MG. Emer-
gency department crowding is associated with
decreased quality of care for children with acute
asthma. Ann Emerg Med 2011;57:191–200.
26. Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The
association between length of emergency depart-
ment boarding and mortality. Acad Emerg Med
2011;18:1324–9.
27. Quinn JV, Mahadevan SV, Eggers G, Ouyang H,
Norris R. Effects of implementing a rapid admission
policy in the ED. Am J Emerg Med 2007;25:559–63.
28. Patel PB, Derlet RW, Vinson DR, Williams M, Wills
J. Ambulance diversion reduction: the Sacramento
solution. Am J Emerg Med 2006;24:206–13.
29. Kelen GD, Scheulen JJ, Hill PM. Effect of an emer-
gency department (ED) managed acute care unit on
ED overcrowding and emergency medical services
diversion. Acad Emerg Med 2001;8:1095–100.
30. Howell EE, Bessman ES, Rubin HR. Hospitalists
and an innovative emergency department admission
process. J Gen Intern Med 2004;19:266–8.
31. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer
FS, Datner EM. The effect of emergency department
crowding on patient satisfaction for admitted
patients. Acad Emerg Med 2008;15:825–31.
32. Asplin BR, Magid DJ. If you want to fix crowding,
start by fixing your hospital. Ann Emerg Med
2007;49:273–4.
33. Fatovich DM, Nagree Y, Sprivulis P. Access block
causes emergency department overcrowding and
ambulance diversion in Perth. Western Australia.
Emerg Med J 2005;22:351–4.
34. Moloney ED, Smith D, Bennett K, O’riordan D, Silke
B. Impact of an acute medical admission unit on
length of hospital stay, and emergency department
‘wait times’. QJM 2005;98:283–9.
35. Rabin E, Kocher K, McClelland M, et al. Solutions
to emergency department ‘boarding’ and crowding
are underused and may need to be regulated.
Health Aff 2012;31:1757–66.
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
36. Sullivan L. Hospitals failing to address patient
boarding. ACEP News 2012;31:11.
37. Patel PB, Vinson DR. Team assignment system:
expediting emergency department care. Ann Emerg
Med 2005;46:499–506.
38. Patel PB, Vinson DR. Ambulance diversion reduc-
tion and elimination: the 3-2-1 plan. J Emerg Med
2012;43:e363–71.
39. [No authors listed]. Study offers solutions for bottle-
necks: treat and move patients in record time. ED
Manag 2000;12:25–9.
40. Howell E, Bessman E, Kravet S, Kolodner K,
Marshall R, Wright S. Active bed management by
hospitalists and emergency department throughput.
Ann Intern Med 2008;149:804–10.
41. McClelland MS, Lazar D, Sears V, Wilson M, Siegel
B, Pines JM. The past, present, and future of urgent
matters: lessons learned from a decade of emer-
gency department flow improvement. Acad Emerg
Med 2011;18:1392–9.
42. Ault A. Many ways to be waylaid between ED and
inpatient bed. ACEP News 2012;31(1):12.
43. Johnson G. How one hospital curbs boarding.
ACEP News 2012;31:13.
44. California Senate Bill SB 366. Emergency Room
Crowding. Available at: http://www.leginfo.ca.gov/
273
pub/11-12/bill/sen/sb_0301-0350/sb_336_bill_20110516_
amended_sen_v97.html. Accessed Dec 1, 2013.
45. [No authors listed]. ED/hospitalist plan improves
throughput. ED Manag 2009;21:70–1.
46. Howell E, Bessman E, Marshall R, Wright S. Hospi-
talist bed management effecting throughput from
the emergency department to the intensive care
unit. J Crit Care 2010;25:184–9.
47. [No author]. Milestones on the journey to world-
class hospitals. TPMG Forum 2012;24:1–5.
48. Weber EJ, Mason S, Carter A, Hew RL. Emptying
the corridors of shame: organizational lessons from
England’s 4-hour emergency throughput target.
Ann Emerg Med 2011;57:79–88.
49. Greene J. Emergency department flow and the
boarded patient: how to get admitted patients
upstairs. Ann Emerg Med 2007;49:68–70.
50. Bartlett S, Fatovich DM. Emergency department
patient preferences for waiting for a bed. Emerg
Med Australas 2009;21:25–30.
51. Walsh P, Cortez V, Bhakta H. Patients would prefer
ward to emergency department boarding while
awaiting an inpatient bed. J Emerg Med 2008;
34:221–6.