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Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department
  1. Benjamin Bodnar1,
  2. Erin M Kane2,
  3. Hetal Rupani3,
  4. Henry Michtalik1,
  5. Veena G Billioux4,
  6. Ashley Pleiss3,
  7. Linda Huffman3,
  8. Kimiyoshi Kobayashi5,
  9. Rohit Toteja3,
  10. Daniel J Brotman1,
  11. Carrie Herzke1
  1. 1 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2 Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
  3. 3 Johns Hopkins Hospital, Baltimore, Maryland, USA
  4. 4 Biostatistics, Epidemiology and Data Management (BEAD) Core, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  5. 5 UMass Memorial Medical Center, Worcester, Massachusetts, USA
  1. Correspondence to Benjamin Bodnar, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; benjamin.bodnar{at}


Background Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time.

Methods After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric ‘bed downtime’—the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre.

Interventions Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures.

Results This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit.

Conclusion Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

  • efficiency
  • hospitalisations
  • management
  • performance improvement
  • quality improvement

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  • Handling editor Simon Smith

  • Twitter @BenjaminBodnar

  • Contributors All contributors are authors of the piece. BB, the corresponding author, will serve as the guarantor for the manuscript content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.