Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates

In this study of the establishment and early outcomes of the first AMU in the UAE, the authors found that the aggregation of acute medical admissions on a dedicated ward, with early assessment and treatment by a multidisciplinary team, was successful in reducing LOS and increasing early discharges without an increase in readmission rates or deaths. The intervention also successfully reduced the number of patients boarding in the ED and the number of outliers. These results are similar to international studies that show AMUs reduce LOS [7, 8]. While patient-level characteristics influence LOS, research has shown that organizational factors, including delays in assessments, obtaining diagnostic and medical interventions, and shortages in service coverage, especially on weekends and after-hours, also contribute to discharge delays [20].

There are several potential reasons why the implementation of the AMU has led to an increased number of discharges and a reduction in LOS. Clustering all new medical patients in a single location and assigning a dedicated group of healthcare providers to the unit creates an environment designed to promptly meet the patients’ clinical and non-clinical care needs, focusing on early discharges. Concentrating acute medical admissions in a single ward within a large health center also eliminates unproductive time traveling through the hospital, thereby maximizing the medical team’s time and energy. Further, the consultant-led service delivery in the critical first hours of an admission facilitates early review and clinical decision-making, which supports timely decisions on treatment and disposition. Early input by senior physicians has been shown to positively impact patient outcomes for acute medical admissions [21]. Studies suggest that increased consultant presence is associated with improved outcomes of care, with a reduction in mortality and readmissions and an increase in same-day discharges [22, 23]. However, there is limited evidence on the optimal staffing of AMUs [10]. Medical staffing needs to consider the workload over a 24-hour period, with local service reviews to audit the unit’s performance and validate staffing needs [24]. Research also shows that the provision of multidisciplinary care and rapid assessment of patients improve the quality and efficiency of care [25, 26].

Procedural inefficiencies, including waiting for tests, investigations, and input from consult services, contribute to delays in discharges [27, 28] A study examining causes of delayed discharge from the general medical wards of a metropolitan teaching hospital showed that 48.2% of patients experienced delays waiting for a service that extended their LOS [29]. The AMU received expedited access to imaging and diagnostic testing and interventions, which aided in timely decision-making. Additionally, concentrating all new patients in one geographically defined area helped subspecialties refine their workflows to prioritize new patient assessments and provide prompt consultation services.

Paramount to the discharge process was the dedicated multidisciplinary team huddles that proactively identified discharge barriers and needs, as research has revealed that the lack of timely discharge planning negatively impacts LOS [27]. Interventions that address information sharing, such as those done during the team huddles, can best address discharge delays [20]. The multiple daily meetings ensured smooth coordination of the discharge process and clear communication with all healthcare professionals.

Similar to other studies, the introduction of the AMU in the hospital led to a decrease in the number of patients boarding in the ED and on non-medical wards [13]. The United States General Accounting Office highlights that the inability to transfer a patient from the ED due to the lack of inpatient beds is most the common factor associated with ED overcrowding [6]. Inpatient beds that are occupied by patients awaiting discharges cause bottlenecks in patient flow and create access blocks at multiple levels in the hospital system [30, 31]. By reducing LOS and increasing early inpatient discharges, timely access to acute hospital beds for patients requiring emergency admission was facilitated. The early identification of patients who were expected to exceed the AMU’s 48-hour LOS ensured that a contingency plan was in place to help coordinate transfers into other inpatient wards and reduce ED waiting time for patients waiting for an inpatient bed.

Unplanned patient readmission is a significant patient safety concern. The authors are encouraged that readmission rates did not increase after the implementation of the AMU model, despite the increased early discharge rate and reduction in mean LOS. Senior physician oversight on all aspects of care contributed to appropriate and timely discharge decisions. In addition, the daily multidisciplinary team meetings and active engagement of the dedicated case managers placed a focus on safe discharges, which likely positively impacted readmission rates.

The problem of delayed discharges and increasing LOS is a system-level issue and requires a whole-system approach [32, 33]. Best practices to address discharge delays target practice changes and information sharing [20, 34]. The implementation of the AMU involved both an organizational change by restructuring the internal medicine service to improve patient flow and enhance the system’s efficiency, as well as improved departmental communication to facilitate information sharing and frequent opportunities for interprofessional collaboration. The development of this model required a hospital-wide approach and support from senior leadership. The clinical team had extensive discussions with all stakeholders, including hospital administrators, nursing and bed management representatives, clinical departments, and allied health care teams. Workflows were restructured to streamline the process of admitting all non-critically ill adult inpatients to a designated geographic location. The hospital leadership facilitated converting an existing ward in-close proximity to the emergency and radiology departments into the AMU.

As the UAE faces an aging population with increased prevalence of chronic diseases [17], studies of interventions that increase access and improve the quality of patient care, while reducing healthcare costs are essential. The study’s findings must be viewed in light of some limitations. First, the study was conducted in a single hospital in the UAE, thus limiting generalizability. Second, the overall number of admissions in 2020 was less than in 2019, which may have contributed to the reduction in the number of patients boarding in the ED and other wards. This trend is consistent with changes in hospitalization patterns for patients with non-COVID-19 diagnoses during and after the COVID-19 pandemic [35]. Finally, other interventions addressing patients with a prolonged LOS were conducted during the same time as the introduction of the AMU [34]. However, these interventions focused on complex discharge planning in patients with prolonged hospitalization and did not address early discharges from the AMU. Despite these limitations, this study adds to the literature on AMU and the feasibility of implementing this model in a non-Western healthcare system.

As a result of the model’s success, other departments within the hospital, such as Pediatrics, are now considering developing an AMU. In addition, results of the intervention have been shared in local health conferences and through senior leadership meetings with neighboring healthcare facilities. Several government and private hospitals in Abu Dhabi are currently in the process of adopting the AMU model.