Smoothing Hospital Admissions: A Simple Fix for ED Crowding, Staffing & Costs

The American healthcare system, much like a patient with unhealthy habits, often continues practices that predictably lead to negative outcomes. For decades, issues like staffing shortages, medical errors, and clinician burnout have been documented, yet systemic changes have been gradual. A surprisingly simple intervention – smoothing elective hospital admissions – offers a potential path toward improvement, yet remains underutilized despite decades of evidence.

The concept, first proposed over 25 years ago, involves distributing scheduled admissions, primarily surgeries, more evenly throughout the week, rather than concentrating them on Mondays and Tuesdays to accommodate physician schedules. This approach addresses a core operational problem: the variability of patient demand. While emergency admissions arrive unpredictably, elective admissions are scheduled, and clustering them creates artificial surges that overwhelm hospital resources.

Easing the Strain on Emergency Departments

The benefits of smoothing elective admissions are far-reaching, with a particularly significant impact on emergency departments (EDs). Hospitals that have implemented this strategy have reported substantial reductions in ED boarding – the practice of holding admitted patients in the ED while awaiting inpatient beds. This is a critical issue in American healthcare, often leading to delays in care and increased risk for patients. In fact, this intervention is widely credited as one of the most effective operational strategies to reduce ED boarding, according to research highlighted in NEJM Catalyst.

But the positive effects don’t stop there. Smoothing admissions has been linked to safer patient-to-nurse ratios, fewer medical errors, lower mortality rates, reduced readmissions, and faster access to surgeries. Clinicians similarly report improved working environments, a crucial factor in addressing the ongoing crisis of healthcare worker burnout.

Financial Gains and Operational Efficiency

Beyond patient care, smoothing elective admissions can also have a significant financial impact. Hospitals that have adopted this approach have reported millions of dollars in additional annual revenue. Cincinnati Children’s Hospital, for example, saw an increase exceeding $100 million. This is largely due to more consistent utilization of operating rooms – the financial engine of most hospitals – and a reduction in postponements caused by inpatient bed shortages.

Surgical volume also tends to increase. One hospital experienced a 7% annual increase in surgical cases for three consecutive years after implementing the smoothing strategy, as demonstrated in a video case study. This improvement isn’t just about volume; it’s about efficiency. Surgeons gain more reliable access to operating rooms, reducing overtime and ensuring patients are placed in preferred beds post-surgery. Crucially, it also allows for faster access to the operating room for urgent and emergent cases, potentially saving lives.

Addressing Nurse Staffing Challenges

The intervention also offers a potential solution to the ongoing debate surrounding nurse staffing levels. While legislative efforts to mandate nurse-to-patient ratios have faced challenges, smoothing elective admissions addresses a fundamental operational reality: safe staffing is impossible when workload fluctuates wildly. Stabilizing patient demand allows hospitals to accurately determine staffing needs, creating a more predictable and sustainable work environment for nurses. Hospitals adopting this approach have reported significant reductions in nurse turnover, lessening the reliance on costly traveling nurses, as noted in a presentation on re-engineering the operating room.

A National Economic Impact

The aggregate effect of widespread implementation could be substantial. Estimates suggest that smoothing elective admissions could reduce overall U.S. Healthcare spending by more than $200 billion annually – exceeding the projected savings from other proposed healthcare reforms. This reduction in waste could also have implications for the solvency of federal programs like Medicare, which, according to the 2025 Trustees Report, is projected to become insolvent by 2033.

Why Isn’t This More Common?

Despite the overwhelming evidence and endorsements from organizations like the National Academy of Medicine and the National Academies of Sciences, Engineering, and Medicine, nationwide implementation remains limited. Possible reasons include a lack of awareness among hospitals and a perceived lack of technical expertise required for implementation.

To address these barriers, federal leadership could play a crucial role. The Centers for Medicare and Medicaid Services (CMS) could support technical assistance programs or pilot implementations, potentially starting within the Department of Veterans Affairs or the Department of Defense hospital systems. Collaboration with the American Hospital Association could further facilitate the adoption of this proven strategy.

Without such action, the healthcare system risks continuing to grapple with persistent challenges – overcrowded emergency departments, unsafe staffing levels, clinician burnout, rising costs – while a viable solution remains largely untapped. The analogy holds true: continuing to operate in a dysfunctional manner while wondering why outcomes don’t improve is a pattern that needs to change.

Eugene Litvak is president of the nonprofit Institute for Healthcare Optimization and an adjunct professor at the Harvard T. H. Chan School of Public Health.