Providing Financial Incentives to Residents Does Not Improve Emergency Department Length of Stay

Patient flow through the emergency department (ED) is a health system problem that requires a system-wide approach to interventions. We sought to address ED flow by reducing consult-to-decision times for discharged and admitted ED patients requiring a specialist consultation by providing a financial incentive to residents to expedite the decision-making process.

This was a before and after study that involved implementing a pay-for-performance patient flow initiative that provided a financial incentive to residents from all specialty services for reducing consult-to-decision times for ED patients requiring consultant input by 20% for at least 6 months of the academic year. Patient flow metrics from the electronic health system were retrospectively collected to calculate the mean patient length of stay (LOS) by consulting service. The weighted LOS accounted for the proportion of consults completed by each clinical service.

From 7/1/2022-6/31/2024, there were 38,840 ED specialty consultations. Before the intervention, the overall weighted mean LOS for patients requiring a consultant was 733 minutes (95% CI 726-740 minutes): 784 minutes (95% CI 776-792 minutes) for admitted patients and 531 minutes (95% CI 524-538 minutes) for discharged patients. At the end of the 2-year period, the overall weighted mean LOS was 1175 minutes (95 CI 1160-1190 minutes): 1348 minutes (95% CI 1336-1360 minutes) for admitted patients and 608 minutes (95% CI 601-614 minutes) for discharged patients. In the first year, 7 services met their improvement goal. In the second year, 2 services met their improvement goal.

Patient flow through the ED is complex and challenges are multifactorial. Offering financial incentives to trainees to reduce their consultation times did not overcome the systemic barriers to reducing ED LOS. Prioritizing patient flow without compromising resident education may require reimagining traditional team workflows.