Flow strategies cover processes in and out of ED

Door-to-doc time drops 16 minutes

Because many throughput problems experienced by EDs are not caused by EDs, those managers who find themselves operating in a vacuum have little chance of success. Cincinnati Children's Hospital Medical Center can point to a comprehensive approach to improving flow that addresses ED-specific issues and hospitalwide issues — and to an effective partnership between the ED manager and the hospital's patient flow expert.

"We look at flow from two different perspectives: flow through our department and flow out of our department," says Julie Shaw, RN, MSN, MBA, CEN, senior clinical director of the ED. "Our pediatric ED admits fewer patients [into the hospital] than an adult ED would, so internal flow is important to us, and of course, when we do decide to admit and send children to the inpatient area, external flow becomes important, so we've had some efforts in both areas."

Shaw has been working with Pamela Kiessling, RN, MSN, director of patient flow & clinical integration, clinical & business integration, and patient services. "Our goals throughout all of this is that patients should not experience delays," says Kiessling. "We want to deliver timely, efficient, effective care."

Although the changes have been in place for only about six months, the hospital already is seeing results. Comparing the May-July period door-to-doc times have dropped from 61 minutes in 2008 to 45 minutes in 2009.

The ED has tried several strategies to address internal flow and had to abandon some of the earlier attempts, says Shaw. "We tried the idea of having a physician in triage, as well as a nurse whose main assignment was managing flow," she says. "We used those two in tandem with each other, but it was not sustainable in terms of personnel. The ED docs were not able to keep staffing levels high enough."

One of the more important initiatives implemented began in January 2009, Shaw says. "Under our old system, when the patient arrived, there was a clerical person who was the first person the patient saw when they came in the door," she says.

Now, Shaw says, every patient is seen by a nurse immediately upon arrival for a "quick look." "She asks a few questions, such as if they are in pain," says Shaw. "She also determines if they need immediate help, such as resuscitation, and if so, they move them into the resuscitation area." If they don't require such immediate help, they then go through a more complete triage process.

Shaw says the changes have ensured a safe flow as well as a smoother flow. "We do a high-level immediate sort before triage — meds, allergies, history — so patients with significant respiratory distress, bad fractures, those requiring pain management, all those get recognized right away," she says.

Data on door-to-doc times and length of stay still are being formalized.

Addressing external flow

Ironically, one of the greatest challenges to external flow grew out of an effort to improve safety.

"We developed safe handoff care with the three general care units that represent the greatest 'exports' from the ED, but when we put it in place, ED wait times grew exponentially," says Kiessling. "Handoff was blamed, and the thought was that we just had to accept it, but we couldn't. For us, two hours is a really long time."

So this year, an interdisciplinary team of test units and involved departments have been "mapping" the entire process, Kiessling says. "We looked at nonvalue-added steps and tried to eliminate those," she says. "We tried to decrease redundant or unnecessary communication points." Thus far, one of the steps that seem to have made a difference is removing the nurse-nurse verbal report and replacing it with a faxed report, Kiessling says. "The opportunity to question and clarify is still there, but it is positively impacting wait times: In our small tests of change, we reduced the bed request to occupy time by as much as 40 minutes," she says. "It eliminates the whole telephone-tag situation you get with two people who are busy."

This was "a major culture change," says Shaw. How was it accomplished? "First, we had significant support from leadership on those three units as well as the lead level above them, the assistant vice president to whom they all report," she says. "Everyone wanted make the process better."

The initiative advanced incrementally. First, it was tested on one nurse and one patient. Next it was tested on one team, then on the entire unit, then for a whole day, then on two units, then for 16 hours a day with two units, and so forth. "It's the whole PDSA [plan-do-study-act] quality improvement process," says Shaw. "We went back and did daily huddles, saw where we were failing, and made changes. For example, we learned we had to pull the patient escort folks in as part of the group."

The patient escort staff move the patient from the ED to the floor, notes Shaw. "We might be working to handoff and transfer in a timely manner in the ED and on the receiving floor, but if the patient escort department is not focusing on the same need for timely response when a transport was requested, it can erase the gains made in other parts of the process," she says. "The patient escort leadership was able to educate their staff, change some supervision patterns, and change the priority of ED transport calls in our electronic system that handles requests for patient transports to ensure priority was given to ED requests. This helped us with consistency in response time and maintaining and sometimes improving on gains made with other parts of our improved process."

For the first couple of weeks, says Shaw, "we had handwritten data collection forms, and the leadership in all units was very involved talking to the nurses about how things were going, what was working, and what wasn't." When you start with small tests, "you can talk and bring information back to the table every single week," she says.

The units still meet weekly in an ongoing improvement effort, Shaw says.

The testing started last summer, she continues, "and we've had some success with decreasing [the handoff] piece of the transfer time."

The H1N1 outbreak ironically helped engender the needed culture change, Shaw says. "Our clinics expanded hours," she says. "We were running an overflow clinic to funnel off patients who were not high-level emergencies, and it kind of pulled the whole organization into thinking about what kind of things they do in their areas to support patient flow time in this area." They now understood that they were an important part of ED flow, because it was affecting them and their families, she says. "I couldn't have planned it, and I certainly wouldn't have asked for it, but we tried to optimize the opportunity to have everyone be involved," Shaw summarizes.

Overall, she says, "Our LOS actually holds steady across the past three years, which probably makes sense since the triage flow processes that we changed are very early in the patient encounter, and many other things would affect overall LOS," Shaw says.

What's most important? "The patients are getting where they need to go in a more reliable manner," Shaw says.


For more information on internal and external flow strategies, contact:

  • Pamela Kiessling, RN, MSN, Director of Patient Flow & Clinical Integration, Clinical & Business Integration, and Patient Services, Cincinnati Children's Hospital Medical Center. Phone: (513) 636-8678. E-mail: Pam.Kiessling@cchmc.org.
  • Julie Shaw, RN, MSN, MBA, CEN, Senior Clinical Director, Emergency Department, Cincinnati Children's Hospital Medical Center. Phone: (513) 636-8517. Fax: (513) 636-3943. E-mail: julie.shaw@cchmc.org.

Predicting admits, discharges vital

The numbers don't lie, and having a handle on the numbers is a critical part of developing effective strategies for improving patient flow, says Pamela Kiessling, RN, MSN, director of patient flow & clinical integration, clinical & business integration, and patient services at Cincinnati Children's Hospital Medical Center.

"We knew that we were not as efficient as we could be with the whole process around discharges," Kiessling recalls. "For those who just needed antibiotics to take at home, for example, we did not plan in advance sufficiently to discharge them as soon as they were ready to go."

To improve in this area, you have to be able to predict discharges, she says. "The adult world has been doing this for a long time because of their payer structure. Pediatric facilities are paid differently [i.e., in terms of DRGs], so we have not been driven to be as proactive," Kiessling says. "But now we're doing it for the right reasons: to have the patients leave on time and have no delays."

Discharge prediction is a two-level process, Kiessling explains. First, the patient has to have discharge criteria. Goals need to be specific and well communicated to the entire team, including the patient and family. The second level of readiness has to do with the team tasks that need to be completed, such as home care arranged, prescriptions written, and orders written. "The goal is to have the team tasks completed prior to the patient's readiness for discharge whenever possible so that there is no delay for the patient once she or he is ready to go home," she explains.

Communication regarding the predicted discharge date and time is critical so that the entire team can execute the plan in a timely manner. For the ED, this timely discharge means a greater likelihood of a bed on the appropriate unit when it is needed and that any delay would be intentional and predictable and only to allow the right bed to be available.

In the absence of the ability to build new beds, Kiessling summarizes, timely discharge is a legitimate way to increase capacity in a hospital that operates with very few open beds at any given time.

In developing the predictive process, says Kiessling, "you have to build in the factor that you'll be wrong some percent of the time — anywhere from 20%-30% — not because you've not planned well, but because the child may not progress as well as you've planned." Still, she insists, "for any given unit, we can be right seven times out of 10." When planning for beds, then, you should look at your predictions and build in processes to account for the "unpredicted" beds that will be needed.

Where appropriate, you can write conditional discharge orders, i.e., when the patients meet these criteria, they can go home, she says. These criteria must be patient-specific, Kiessling emphasizes. Discharge medication orders and discharge summaries are among the things that can be done ahead of time, she says.

At this point, says Kiessling, some units are 80% correct in their predictions, while others are closer to 50%. While the discharge predictions are mainly done on the inpatient side, she notes, it still benefits the ED. "Oftentimes there are delays in the ED because of bed availability," she observes. "In order to set the stage for improvement, we had to have beds."

It's difficult to track time saved by this process, she says. "Some patients may meet the criteria at 2:30 in the morning," she explains. "Should we tell them to get up and leave because our numbers need to be good?"

At the same, says Kiessling, she began to look at how to predict admissions. "We have three kinds of admissions: scheduled, ED, and direct," she notes. "The trick is to know what's going on in the population you are looking at."

In January 2009, she says, a math formula was developed that allowed the ED to predict its admissions. The formula takes into consideration admissions from the ED "yesterday," "same day last week," "two weeks ago," "three weeks ago," and "four weeks ago," she says. These data are averaged. "We then look at trends for the last month in terms of percentage of ED visits admitted to the hospital and adjust accordingly," she notes. "It isn't an exact science yet, but we're working on it."

"We are within 90%-95% accuracy most of the time," Kiessling says. "Folks in my department and the ED clinical manager figured [the formula] out, and it's pretty good."

Clinical Tip

Handoffs must focus on current issues

Whether face to face, on the phone, in a written report, or by other means, it is key that patient handoffs focus on current patient problems and care — or follow-up needed in the time immediately following the handoff, says Julie Shaw, RN, MSN, MBA, CEN, senior clinical director of the ED at Cincinnati Children's Hospital Medical Center.

"A standardized hand-off process will help clinicians provide consistent information every time. An opportunity for questions and clarification is needed and should be focused on immediate care needs," she says. "A process that allows for communication that does not create flow delays is also essential." (At Cincinnati Children's, a fax handoff system has helped avoid delays.)