Lead articles by Carol Haraden, PhD; Roger Resar, MD; Suzanne S. Horton, RN; and Diana Henderson, Christy Dempsey and Debra Appleby

(Taken from Audrey Kaufman's Editorial)

What comes to mind when you have to go to a hospital emergency room, either as the patient or as a companion to the patient? Other than the immediate illness, most people think of crowded rooms and hours of waiting. Overcrowded and bottlenecked emergency departments are a chronic problem that has now reached crisis proportions. Emergency departments are so overcrowded that patients are being "parked" in the hallways for hours waiting for a hospital bed or are turned away altogether and sent to another institution. This is not only frustrating for the patients and their companions, but it is also unsafe, non-patient-centered care.

This issue of Frontiers takes a look at the patient flow/capacity management problem from a systems perspective. Carol Haraden, PhD, vice president at the Institute for Healthcare Improvement (IHI) in Boston and Roger Resar, MD, IHI fellow at the Mayo Health System in Eau Claire, Wisconsin, draw from their work with more than 60 hospitals, where they evaluated what factors are involved in achieving the smooth, timely flow of patients through hospital departments and helped develop methods for improving flow. These authors suggest that reducing delays and bottlenecks in the emergency department depends on assessing and improving flow between and among departments. Hospitals "must view the problem in terms of an interdependent system rather than individual departments." Improving the flow in on area alone, increasing nurse staffing ratios, and placing patients "off service" (in the hallways) have not solved the bottleneck problem and could significantly increase the risk of harm to the patient. However, they argue, by managing the flow of elective surgeries, achieving timely and efficient transfer of patients from the intensive care units to medical/surgical units, and improving the flow of inpatients to long-term-care facilities, the emergency department will be able to more efficiently move patients onto floors and into beds where they can get appropriate care.

Complementing the article by Haraden and Resar are two case studies.