title: Emergency Department Holding Orders.
abstract: BACKGROUND
  Holding orders help transition admitted emergency department (ED) patients to hospital beds.
  
  
  OBJECTIVE
  To describe the effect of ED holding orders.
  
  
  METHODS
  We conducted a single-site retrospective study of ward admissions from the ED to the hospital internal medicine (HIM) service over 2 years. Patients were classified based on whether the ED did (group 1) or did not (group 2) write holding orders; group 1 was subdivided into patients sent to the floor with only ED holding orders (group 1A) vs. with subsequent HIM admission orders (group 1B). Outcomes were ED length of stay (LOS), time from decision to admit to ED departure (D→D), transfer to a higher level of care within 6 h (potential undertriage), and discharge from admission ward within 12 h (potential overtriage).
  
  
  RESULTS
  There were 9501 admissions: 6642 in group 1 (2369 in group 1A and 4273 in group 1B) and 2859 in group 2. Reductions in mean LOS between groups (with 95% confidence intervals [CIs] of the differences) were as follows: group 1 vs. 2: 44 min (39-49 min); group 1A vs. 1B, 48 min (43-53 min); group 1B vs. 2: 27 min (22-32 min); group 1A vs. 2: 75 min (69-81 min). Mean D→D was shorter in group 1A than 1B by 43 min (40-45 min). Holding orders were not associated with increases in potential undertriage or overtriage.
  
  
  CONCLUSIONS
  ED holding orders were associated with improved ED throughput, without evidence of undertriage or overtriage. This work supports the use of holding orders as a safe and effective means to improve ED patient flow.
authors.affiliation: Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Traub
authors.affiliation: Division of Health Sciences Research, Mayo Clinic Arizona, Phoenix, Arizona.
authors.forename: M'Hamed
authors.initials: M
authors.lastname: Temkit
authors.affiliation: Harvard Kennedy School, Harvard University, Cambridge, Massachusetts.
authors.forename: Soroush
authors.initials: S
authors.lastname: Saghafian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001130:Arizona; D001509:Bed Occupancy / Q000706:statistics & numerical data*; D003266:Continuity of Patient Care / Q000592:standards / Q000639:trends; D004636:Emergency Service, Hospital / Q000639:trends*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000639:trends; D010360:Patient Transfer / Q000379:methods* / Q000639:trends; D012189:Retrospective Studies; D013997:Time Factors
keywords: holding orders; length of stay; throughput