Key takeaways:
- Admission delays from the ED can adversely affect mortality, length of stay, medical errors and quality of care.
- One VA center reduced its admission delay by almost one-third with a series of three interventions.
- Those interventions included standardizing both bed assignments and nursing handoffs while having ED providers—not an inpatient team—enter skeletal orders when deciding to admit a patient.
LIKE MOST HOSPITALS, Veterans Affairs facilities across the country track admission delays, the amount of time it takes to move a patient who’s being admitted out of the ED and into an inpatient bed. Such delays can compromise patient care by increasing mortality, medical errors and length of stay.
Hospitalist Nathan Baskin, MD, who’s with the San Francisco VA Medical Center, notes that his facility has had a history of longer admission delay times. “Our local leadership group wanted to focus on it,” says Dr. Baskin, who serves as chief physician utilization management advisor. While the median VA admission delay nationally was 146 minutes, a six-month audit held at the San Francisco VA that ended in early 2021 found that the median delay there was 207 minutes.
That’s when an interdisciplinary task force that included Dr. Baskin was convened to find the bottlenecks causing delays. Within just a couple of months, the task force decided to implement three separate interventions to drive that delay time down.
“Three big bottlenecks all needed to be addressed, so we thought it reasonable to approach them all at the same time.”
Nathan Baskin, MD
San Francisco VA Medical Center
And they succeeded. As Dr. Baskin and his task force colleagues pointed out in a Journal of Hospital write-up in April 2025, the median admission delay at the San Francisco VA fell to 145 minutes within three months of those interventions being launched, a 29.5% reduction. Since those interventions were introduced in 2021, the San Francisco VA has sustained that reduction.
Here’s a look at the bottlenecks the task force uncovered and the interventions devised as countermeasures.
Skeletal orders and standardized processes
Mapping out the admission process, the task force realized that three major barriers contributed to admission delays. First, beds were being assigned in an inconsistent manner, with procedures varying between routine business hours and after hours and among the administrative staff who performed that task.
Next, the nursing handoff between the ED and the floors also wasn’t standardized. But perhaps most importantly, bed assignments (and the nursing handoffs that followed) couldn’t take place until the admitting team placed admission orders—and those orders often weren’t being completed for an hour or more after the ED had decided to admit.
To remove that key barrier, the task force began requiring the ED provider who decided to admit a patient to enter “skeletal orders,” the minimum orders required to get an inpatient bed assigned.
As for standardizing bed assignment procedures, the solution was to give that staff extensive education. “We found that during the day, we have a regular group of staff in those roles who’ve done it for a while,” says Dr. Baskin. “But overnight, a rotating group of people fill those roles, a lot of whom do only a shift or two a month. We needed a very broad, consistent educational process or else we weren’t going to capture every staff member doing this on a day-in, day-out basis.”
To standardize the nurse handoff, the task force created a protocol for the ED nurses to follow with a standardized checklist that streamlined the transfer from the ED to the wards. That checklist includes patient demographics and the individual patient’s clinical needs.
Both the bed assignment countermeasure and the nursing handoff come with time expectations. The goal is for bed assignments to take place less than 30 minutes after the admit decision is made and skeletal orders are entered. The nursing handoff is then expected to occur in less than 30 minutes after a bed has been assigned. The entire process—between the admit decision and the transfer to an inpatient bed—is supposed to take less than 150 minutes.
Simultaneous interventions
As Dr. Baskin explains, one reason why this series of interventions succeeded was because they were all introduced at about at the same time, instead of one by one.
The standardized bed assignment and nursing-handoff checklist were launched nearly simultaneously. Starting the skeletal orders from the ED took another month to put in place to give the informatics department time to craft and embed menus for those orders in the EHR.
The admission delay task force decided to implement all three interventions at the same time because of “the interconnectedness of all three parts,” Dr. Baskin says. “We realized that there were three big bottlenecks that all needed to be addressed, so we thought it reasonable to approach them all at the same time.”
And as he and his colleagues pointed out in their write-up, some hospitals create the role of a “flow” or triage hospitalist to speed up the process of admitting a patient from the ED. Typically, such hospitalists decide which level of care a patient should be admitted to and they write initial orders.
But as Dr. Baskin points out, “we found that changing workflows and standardizing processes were key to our success—and letting parallel processes work at the same time.” Not opting to create a new position also saved the expense of having to hire another clinician to fill it.
Push, not pull, patients from the ED
Still, the interventions did require some clinicians to take on additional tasks. ED nurses handing off a patient to inpatient nursing, for instance, are now supposed to follow a checklist. Dr. Baskin says that wasn’t a hardship.
“ED nurses have a vested interest in trying to move patients upstairs,” he points out. “Otherwise, patients stay in the ED and are at higher risk of adverse outcomes associated with prolonged ED stays.”
However, the ED doctors who had to start entering skeletal orders for admissions did push back against that process, at least initially. The fact that the ED chief was a member of the admission-delay task force and was onboard with ED doctors performing that new task helped smooth the way.
Also, given the reality of their institution, task force members realized that they needed to have admissions “pushed” from the ED, rather than expecting inpatient teams on the floors to “pull” patients being admitted.
“Typically, our ED providers are attendings who’ve been at the VA for years,” says Dr. Baskin. “By contrast, our admitting inpatient providers are by and large trainees, residents who rotate through the VA a few times a year. Training that group of people in a new process is a much more laborious path because you’d have to educate a new group of residents every month.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
