Optimising Patient Flow Between Emergency Department and Acute Medical Unit

Why this topic matters

Delayed transfers of care from the ED to inpatient wards, particularly AMU, contribute significantly to ED overcrowding. This has direct implications for patient safety, staff morale, and the ability of the ED to meet national performance standards. Patients held for extended periods in the ED are at increased risk of clinical deterioration, delayed investigations, and poorer patient experience. Furthermore, ED crowding is associated with increased inpatient mortality, highlighting the urgency of effective solutions.

Optimising flow between ED and AMU not only improves patient safety and experience but can also unlock potential capacity within the system. Releasing ED bed space more quickly allows for earlier assessment of new arrivals, reducing ambulance handover delays and improving overall access to urgent care. This ultimately contributes to a more sustainable and responsive healthcare system.

Practical explanation

Efficient patient flow from ED to AMU relies on a complex interplay of factors, including clinical decision-making, bed management, diagnostic pathways, and effective communication. It’s not simply about having enough beds; it’s about having the right bed available at the right time, with the right clinical team ready to receive the patient.

Key aspects to consider include:

• Clear Admission Criteria and Pathways: Well-defined, locally agreed criteria for admission to AMU versus direct admission to specialty wards, or discharge, are crucial. This minimises inappropriate AMU admissions and ensures patients are directed to the most suitable care environment promptly.
• Early Senior Clinical Decision-Making: Prompt review by senior clinicians (e.g., consultants or advanced practitioners) in ED can expedite decisions to admit, discharge, or refer to specialty teams, reducing unnecessary ED stays.
• Standardised Handover Processes: Structured handovers ensure that essential clinical information is transferred efficiently and accurately when a patient moves from ED to AMU, facilitating continuity of care.
• Bed Management System Integration: Real-time visibility of bed availability across the hospital, integrated with patient tracking systems, is vital. This requires coordination between ED, AMU, and central bed management teams.
• Rapid Access to Diagnostics: Delays in accessing blood tests, imaging (e.g., X-ray, CT), and specialist opinions in the ED can prolong stays. Streamlined diagnostic pathways are essential.
• Discharge Planning at the Front Door: For patients who are likely to be discharged from AMU within 24-48 hours, commencing discharge planning from their point of entry can significantly reduce length of stay.

Common pitfalls

Several common issues can hinder effective ED to AMU flow:

• Lack of Agreed Pathways: Ambiguous or absent local pathways for common urgent medical conditions can lead to inconsistent decision-making and delayed transfers.
• "Offloading" Mentality: Viewing the AMU primarily as an "offload" area for ED rather than a unit with specific clinical purpose can lead to overcrowding in AMU itself, and a lack of timely initial medical review.
• Capacity Gaps: A persistent mismatch between patient demand and available AMU beds, exacerbated by delayed discharges from inpatient wards (downstream capacity issues).
• Communication Breakdown: Poor communication between ED clinicians, AMU staff, bed managers, and specialty teams regarding bed availability, patient readiness for transfer, and clinical handovers.
• Insufficient Senior Review: Junior doctors in ED feeling unsupported or unable to make definitive admission/discharge decisions without prompt senior input.
• "Blame Culture": A non-constructive atmosphere where departments blame each other for delays, hindering collaborative problem-solving efforts.
• Data Silos: Inability to access comprehensive, real-time data on patient flow metrics, bed availability, and reasons for delay across departments, making it difficult to identify and track problem areas.

Step-by-step approach to improving ED to AMU flow

Improving flow requires a systematic, multi-disciplinary approach. Here’s a framework to guide your efforts:

Step 1: Understand Your Current State (Diagnosis)

• Data Collection: Gather data on ED length of stay for AMU admissions, time from decision to admit to transfer, reasons for delay, and AMU occupancy levels. Analyse peak times and common bottlenecks. Use Lazomis tools to visualise this data.
• Process Mapping: Map the current patient journey from ED arrival to AMU bed, identifying all touchpoints, decision points, and potential delays. Involve staff from all relevant areas.
• Stakeholder Engagement: Conduct interviews and focus groups with ED staff, AMU staff, bed managers, portering teams, and specialty clinicians to understand their perspectives and identify pain points.

Step 2: Define and Agree on Future State (Design)

• Establish a Multi-disciplinary Working Group: Include senior clinical and operational leaders from ED, AMU, bed management, diagnostics, and IT.
• Develop Clear Admission/Discharge Criteria: Review and update local guidelines for admission to AMU, direct specialty admission, and criteria for early discharge from AMU. Aim for consistency.
• Optimise Clinical Pathways: Design specific pathways for common conditions (e.g., chest pain, sepsis, cellulitis) that integrate ED assessment, AMU management, and potential rapid discharge or specialist referral.
• Standardise Handovers: Implement a structured electronic or verbal handover tool (e.g., SBAR) for patients transferring to AMU.
• Review Staffing Models: Assess current staffing levels and skill mix in ED and AMU, particularly during peak times, to ensure adequate senior decision-making capacity.

Step 3: Implement and Test Changes (Do)

• Pilot Small Changes: Start with piloting interventions in a controlled manner (e.g., a specific shift, a defined patient group). This allows for rapid iteration and learning.
• Communication Strategy: Clearly communicate changes to all affected staff. Provide training on new pathways, criteria, and handover processes.
• Bed Management Huddles: Implement regular (e.g., twice daily) operational huddles involving ED, AMU, bed management, and ward teams to proactively manage bed capacity and address immediate bottlenecks.
• Empower Front-Line Staff: Encourage staff to identify issues and propose solutions, fostering a culture of continuous improvement.

Step 4: Sustain and Scale (Study & Act)

• Continuous Monitoring: Establish key performance indicators (KPIs) and regularly monitor flow metrics. Use run charts or control charts to track improvement over time.
• Feedback Loops: Create mechanisms for ongoing feedback from staff and patients on the effectiveness of changes.
• Regular Review: Periodically review pathways and criteria to ensure they remain relevant and effective. Adapt as needed based on new evidence or changes in demand.
• Celebrate Successes: Recognise and celebrate achievements to maintain momentum and motivation within the team.

Example in clinical practice: Implementing a 'Decision to Admit' board round

A large NHS Trust consistently experienced delays in transferring patients from ED to AMU, with average ED length of stay for admitted medical patients exceeding the 4-hour target significantly. A multi-disciplinary team identified that delays in initial senior medical review and subsequent bed allocation were major contributors.

They implemented a twice-daily 'Decision to Admit' (DTA) board round. The ED consultant or senior registrar, an AMU consultant or registrar, and the bed manager met physically (or virtually) at 10 AM and 4 PM. During this 20-30 minute meeting, all medical patients awaiting admission in ED were briefly presented. Joint decisions were made on the most appropriate destination (AMU, direct specialty, or discharge), potential early investigations were planned, and bed allocation was prioritised.

Outcomes: Within three months, the average time from decision to admit to transfer to AMU reduced by 30 minutes. This improved ED flow, reduced ambulance handover delays, and improved the initial clinical review for patients entering AMU. Regular review of the DTA board round agenda and participant feedback ensured its ongoing effectiveness.

How Lazomis can help

Lazomis provides tools to support each stage of your flow improvement project:

• Data Collection & Visualisation: Use Lazomis to aggregate data from various hospital systems (e.g., EDIS, PAS) to create real-time dashboards showcasing ED length of stay by disposition, time to decision to admit, bed occupancy, and ambulance handover times. This helps identify persistent bottlenecks and measure the impact of interventions.
• Process Mapping: Utilise our inbuilt tools to collaboratively map your current patient journey, highlighting delays and potential improvement areas.
• Project Management: Plan, track, and manage your improvement initiatives using Lazomis QI project templates. Assign tasks, set deadlines, and monitor progress across your multi-disciplinary team.
• Reporting & Communication: Generate clear, concise reports on your project's progress and outcomes, demonstrating impact to stakeholders and aiding wider dissemination of successful strategies.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Key takeaways

• Efficient ED to AMU flow is critical for patient safety, experience, and overall hospital capacity.
• Bottlenecks are often due to poor communication, unclear pathways, and insufficient senior decision-making.
• A systematic, multi-disciplinary approach using data, process mapping, and stakeholder engagement is essential.
• Prioritise clear admission/discharge criteria, standardised handovers, and early senior clinical review.
• Continuously monitor KPIs and adapt strategies to sustain improvements and address new challenges.