Accreditation

Learn how to move patients more quickly through your ED

Accreditation Connection, March 22, 2004

The emergency department (ED) throughput subprocess begins when the patient arrives at the ED for a work-up and treatment. Depending on the patient's acuity and illness, ED throughput involves the following:

 -Bed placement and an initial bedside nursing assessment

 -Examination by a physician, physician assistant, or nurse practitioner

 -Laboratory, radiology, and other diagnostic testing

 -Consultation from specialists

 -Administration of medications and other treatments

 -Invasive procedures

This subprocess is the most complex of the three ED subprocesses-which also include intake and output. The duration of this segment of care depends on the timeliness of other departments. However, when one thinks about ED overcrowding, it is the last of the subprocesses that usually comes to mind.

Normally, one thinks of boarded inpatients or waiting room overflows when envisioning an overcrowded ED. However, the efficiency and timeliness of ED throughput significantly impacts the functional capacity of the department.

Caution: Beware of "patient hoarding" practices. Staff sometimes wait to discharge a patient to delay the admission of the next one. Staff do this to give themselves a breather. Although breathers are important and make for better care, patient hoarding is not the best way to take a break. Using a white board system and having effective charge nurses is essential if direct bed placement is to be implemented.

We know of one ED that invested significant resources on throughput. It worked on laboratory and other turnaround and consultation response times. After much effort, it reduced the average length of stay from six hours to less than three hours. By cutting the ED length of stay in half, it essentially doubled the number of patients it could see. Without adding staff or spending millions on new examination space and equipment, the department increased its ability to serve the community. Satisfaction and profitability skyrocketed.

One chief of emergency medicine at a prominent Northern California hospital wished to improve operations in the ED, so he assembled a group of staff to work on the problem.

It was clear from performance data that patients tended to pile up toward the end of a provider's shift. This particular setting was unusual in that it didn't offer incentives to physicians for seeing more patients. Nevertheless, all providers worked hard. Some were faster and some were slower, but all were thorough and appropriate.

This stack of patients that accumulated toward the end of a provider's shift put the next provider "behind the eight-ball," forcing him or her to play catch-up for the entire shift.

The following solution worked almost immediately and cost almost nothing. Consider this when the median patient in your ED waits longer than 60 minutes to be seen by a provider:

  • A nurse was assigned to be the permanent partner of the physician throughout the shift.

  • Each physician was given a section of "real estate" within the ED.

  • Patients were assigned to the physician/nurse team at the end of triage while still in the waiting room.

  • Except for the critically ill, patients were assigned on a rotational basis. If there were three physician/nurse teams on duty, every third patient would be assigned to a given team.

  • A rack system was established inside the ED, near the triage station. Patient records were placed in the rack set aside for the assigned team.

  • Patients would no longer be assigned to the team toward the end of the shift.

  • The physician would not leave until all of his or her patients were worked up.

  • Although handoffs to the next shift were allowed, they rarely happened.

    The results were dramatic:

  • The "bolus" of patients was no longer there for the oncoming physician

  • Physicians began to work-up patients while they were still in the waiting room, sometimes ordering a test based on the triage or their nurse partner's assessments

  • Wait times were reduced

  • Fewer patients left without being seen

  • Patient satisfaction increased

  • Provider and staff satisfaction increased

    The bottom line: Patient flow and populations change daily. The assumptions made at the beginning of a design process rarely fit the true scenario by the time the process is put into place. Therefore, whenever possible, insist on an improvement model that will not tie your hands by making certain beds appropriate for only one patient type. Make multiple rooms appropriate for many uses. In short, keep the mantra "a room is a room is a room" in mind, even though this will never be completely true.

    These strategies were adapted from HCPro, Inc.'s new book, Solving Emergency Department Overcrowding: Successful Approaches to a Chronic Problem, written by Bud Pate, REHS, director of clinical operations effectiveness for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Derenda S. Pete, RN, MBA, an emergency services clinician and managing partner of the healthcare consulting firm InSight Advantage in Houston. To find out more or to order a copy, call our Customer Service Department at 800/650-6787.

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