Increasing Throughput: Results from a 42-Hospital Collaborative to Improve Emergency Department Flow

Jt Comm J Qual Patient Saf. 2015 Dec;41(12):532-42. doi: 10.1016/s1553-7250(15)41070-0.


Background: An 18-month collaborative in 42 hospitals across 16 communities in the United States to improve emergency department (ED) flow was conducted from October 2010 through March 2012.

Methods: Hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program. Each participating hospital identified one or more interventions to improve ED flow and submitted data on four measures of ED flow: discharged length of stay (LOS), admitted LOS, boarding time, and left without being seen (LWBS) rates. Participating hospitals also provided quarterly progress reports on challenges encountered and lessons learned. Univariate linear regression was used to assess the effectiveness of interventions at the hospital level, where an improvement was defined as a negative slope in one or more of the throughput indicators. Challenges and lessons learned were tabulated and described.

Results: A total of 172 interventions were implemented across the 42 hospitals. Two thirds (n = 28) demonstrated improvement on at least one measure of ED flow. Among hospitals demonstrating improvement, the average reduction in discharged LOS was 26 minutes (95% confidence interval [CI] 11 to 41); admitted LOS, 36.5 minutes (95% CI 20 to 53), boarding time, 20.9 minutes (95% CI 12 to 30), and LWBS seen rates decreased by 1.4 absolute percentage points (95% CI 0.2 to 2.7). Teams were frequently challenged by issues related to leadership, staff buy-in, and resource constraints.

Conclusion: The majority of hospitals in this collaborative improved on one or more ED flow measures. Many challenges were shared across hospitals, demonstrating that successful approaches to ED flow improvement require certain fundamental elements, including engaged leadership and staff, and sufficient resources.

MeSH terms

  • Cooperative Behavior*
  • Crowding
  • Efficiency, Organizational*
  • Emergency Service, Hospital / organization & administration*
  • Hospital Administration*
  • Humans
  • Leadership
  • Length of Stay
  • Patient Care Team / organization & administration
  • Quality Improvement / organization & administration*
  • Quality of Health Care / organization & administration
  • Time Factors
  • United States
  • Waiting Lists