Healthcare Inspection: Patient Flow, Quality of Care, and Administrative Concerns in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland

OIG conducted a healthcare inspection to assess allegations made regarding patient flow and quality of care in the Emergency Department (ED) at the Baltimore VA Medical Center (facility), part of the VA Maryland Health Care System (system). We substantiated patients remained in the ED for more than 4 hours while waiting for an inpatient bed, and found the median ED length of stay (LOS) for admitted patients, the delay in inpatient admission, and the percentage of patients boarded exceeded Veterans Health Administration (VHA) targets and thresholds during the period October 2013–December 2016. We did not identify patients who were clinically impacted by delays. We found that the accuracy of the ED metrics could be compromised when a provider encountered challenges using Emergency Department Integration Software (EDIS). We found that system policy did not include the maximum number of ED boarders as required by VHA. We found that staff failed to consistently utilize the Bed Management Solution software. We also found that Environmental Management Services staff schedules and cleaning processes were inadequate to support the patient flow process. We found that Patient Flow Committee members did not take adequate action to improve patient flow. We substantiated the system’s capping practice may limit the number of patients the admitting teams can treat and that facility managers had not established alternative processes to improve patient flow. Although we substantiated that on a day in 2015, ED patients waited extended times, we found no reports of adverse patient events. We substantiated that inpatient nurses were sometimes unavailable to receive the handoff report from ED nurses. We substantiated that the ED administrative support staffing level was not compliant with the VHA requirement. Further, we found that the lack of timely after-hours coverage of computerized tomography scan services contributed to the extended LOS for some ED patients. We made 11 recommendations.