Keys to Better Flow, Better Care in EDs

Joe Cantlupe, for HealthLeaders Media , May 13, 2013
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The nurse then makes an initial evaluation and directs patients to the appropriate specialized unit, whether that is prompt, urgent, or rapid assessment care, or pediatric care. Prompt care is for minor injuries, such as a sprained ankle. Urgent care is for severe illnesses that could result in hospital admission. Rapid assessment is what the hospital calls a "resource-intensive process" in which studies and tests are done, and then a patient is moved to a private area for treatment decisions.

Patients also are moving quicker through the ED, says Zimmer. Since 2005, the door-to-doc time decreased from about 45–50 minutes to 20–25 minutes in 2013, he says. In the meantime, he says "length of stay dropped 40 minutes" from 344 minutes to 304 minutes, based on Hospital Compare data.

According to Hospital Compare, the average time a patient spent in the ED before they were seen by a healthcare professional at St. Mary was 28 minutes in 2012, while the state average was 31 minutes and the national average was 30 minutes.

Just getting to the point of initiating the split-flow model was complicated, Zimmer says.

The hospital embarked on a six-month plan that focused on workflow process redesign, which involved 30 employees, including staff interacting with the ED, lab, floor nurses, physician assistants, and leadership, Zimmer adds.

St. Mary initiated the changes after reviews by hospital leadership and staff. It was an exhausting and
sometimes aggravating cultural shift, he says. In a two-day Lean workflow analysis, hospital officials whittled down what had been a lengthy process—68 steps from when a patient arrived until care was completed—to about 48 steps, he says.

"During those two days, we retooled people's jobs," Zimmer adds. "Some people were unhappy, but we listened to their concerns. There were some sleepless nights. But the process wasn't designed in a vacuum; it involved staff, and that was the key. There was an attitude, 'We can do this,' and we all pushed each other. We also had many site visits in ancillary departments that were impacted."

Zimmer says the hospital worked to "adopt a really different way of thinking. We really hardwired the process and didn't allow people to deviate from it." Eventually, the champions of change—including nurses and physicians who were "process owners of the change"—narrowed down the pool of ideas to those that could be implemented, he says.

"The basic concept of sorting out the middle-acuity patients was the key to our success," Zimmer says. "We committed ourselves to continue to evolve the process."

Success key No. 2: Bed control
Keeping tabs on hospital bed usage—how many patients are on the floor, who is ready to be discharged, what kind of patients are arriving—helps hospital personnel efficiently process patients from the ED to other areas of the healthcare facility.

Several years ago, Ingalls Memorial Hospital "didn't have a strong process in place for bed control," says Mikos, the CNO who oversees the ED and projects designed to increase hospital efficiencies. "It might have taken three hours to find a bed."

Implementing an electronic bed request system has significantly improved the hospital's ability to coordinate care for patients, especially those transferred as inpatients from the ED. A computer system monitors the beds and determines which ones are open, filled, or need to be cleaned. "Having an electronic bed management system has drastically improved the hospital's ability to find a range of beds and coordinate care," Mikos says.

Bed control. Central transportation. Housekeeping. "It all ties together; all three are important," she says.

The hospital receives about 49,000 visits a year to its 26-bed ED, an increase of 7,000 from five years ago. During that period, the hospital reduced its ED length of stay from 335 minutes to about 200 minutes. Mikos attributes the results to what she termed improved efficiencies in the hospital's ED throughput, especially its bed request or "tele-tracking" system.

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