No More ‘Code Black’: Intervention to Improve Inpatient Flow at a Large Public Hospital

Abstract Code Black is a documentary movie, and now television series, whose name derives from a term used to describe critical hospital overcrowding resulting in dangerously inadequate patient flow. The Los Angeles County + University of Southern California (LAC+USC) Medical Center is a large, urban, public hospital with a long history of spending substantial amounts of time in Code Black—indeed the movie was created by a former Emergency Medicine resident at LAC+USC Medical Center. To change years of inadequate inpatient flow, we implemented time-limited cardiac monitoring criteria and empowered existing staff to enforce admission and downgrade criteria for our telemetry, step-down care unit, and intensive care units. We evaluated the interventions' effects by comparing census and bed utilization before and after implementation of the criteria, and by evaluating the proportion of time the hospital spent in critical ("Code Black") or severe ("Code Red") overcrowding based on National Emergency Department Overcrowding Scores (NEDOCS) of ≥180 or ≥140, respectively. Implementation of utilization criteria allowed substantially better matching of unit occupancy with hospital occupancy, creating intensive care unit capacity despite a rising ward and hospital occupancy. The proportion of time spent in severe overcrowding/surge conditions declined from a baseline of 55% to less than 5%, and the time spent in critical overcrowding (Code Black) declined from 19% to less than 1%. Thus, simple, low-cost interventions markedly improved inpatient flow at a large, public hospital that has historically suffered from chronic overcrowding.