To cut diversions, get other units involved

ED achieves 72% reduction

By addressing ED problems as hospitalwide problems, the ED leadership at Shady Grove Adventist Hospital in Rockville, MD, has reduced ambulance diversions by 72%, reduced average length of stay by 25 minutes (from 397 to 372), and boosted patient satisfaction from 3.96 to 4.11 on a scale of 1-5. Also, the number of patients boarded in the ED has dropped from an average of 190 per month to 120 per month.

At the same time, Shady Gove has earned its facility national recognition. The Joint Commission on Accreditation of Healthcare Organizations has named Shady Grove a 2005 winner of the ninth annual Ernest Amory Codman Award, which recognizes excellence in the use of outcomes measurement by health care organizations to achieve improvements in the quality and safety of health care. The Joint Commission noted that the facility was specifically being recognized for its initiative to relieve ED overcrowding and move patients through the hospital process more efficiently, thereby ensuring community access to care. 

"One of the main reasons for our success is that we actually coordinated the effort [among several departments]," says David Klein, MD, vice chair of Shady Grove’s ED.

The hospital put together three teams representing various groups within the hospital, says Debbie Foshee, vice president of quality and medical staff services. These teams, all of which had ED reps, included:

  • AM Discharge Team ("backdoor" of the hospital);
  • Patient Throughput Team ("middle");
  • ED Admission Team ("front door" of the hospital).

"We also made sure that we avoided focusing on whom or what was to blame for problems and kept our focus on finding a solution that improved access to care," says Foshee.

Seeking solutions

The initiative began in 2003, when rapid growth in the state impacted diversion hours.

"We are the second-busiest ED in the state, and our diversion hours had become much higher than in the past," says Klein, who says the ED had 87,000 visits in 2004.

Every time the department goes on diversion, he continues, the charge nurse and physicians meet together and determine what can be done to relieve the situation. In examining the root causes of these diversions, they realized how interrelated the ED and other hospital departments were and that they all had to take responsibility for their role in overcrowding.

"Lab or radiology may believe the amount of time they take to do their tests doesn’t affect the ambulances, but it does," says Klein, "Just like the inpatient side impacts whether we can get our admitted patients a bed."

So Klein participated in meetings with radiology, the lab, and the facility’s hospitalists. "I started at the joint Radiology/ED Quality Committee and made them understand that if we could get our patients to radiology quicker, it could help stop diversions," he says.

For example, because of the increased use of abdominal scans, some patients were being kept in the ED for more than six hours, Klein recalls. Through joint meetings with radiology, 40-50 minutes were cut off the process.

The solution? "We now keep contrast in the ED, and have the doc or nurse mix it up and give it to the patient," says Klein. "In the past, I would come out of the room, write an order for the scan, give it to the secretary, then the radiology tech would see the order, mix up the contrast, and go to the ED and give it."

A different approach was used with the hospitalists. Klein approached them with the following argument: "We know you never want to discharge a patient when they’re not ready, but if you are going to do it today, and it doesn’t make a difference if it’s 8 a.m. or 2 p.m., then let’s work on discharging them sooner." A "think noon, bed ahead" policy was initiated, and inpatient and discharge nurses now meet every morning to discuss who can go home that day.

Internal changes effective

Of course, says Klein, changes had to be made within the ED itself as well. To start treatment earlier, he initiated an Advanced Triage Protocol, which enabled nurses to start ordering X-rays and labs to facilitate appropriate evaluation and rapid treatment of patients presenting with conditions that include abdominal pain/vaginal bleeding, asthma, chest pain, extremity injuries, fever, seizures, and wound care. "We also added an extra nurse, when available, in triage," he says.

In the past, when patients needed to be admitted, inpatient physicians would come down to the ED and write the orders. "Now, I call them on the phone, talk about the patient, agree on where they should go, and write the initial orders to get the bed moving," Klein notes.

Instead of taking patients from the minor injury treatment (fast-track) unit to the radiology department, the ED purchased a portable X-ray machine and hired a tech who was solely based in the ED. That alone saved 10-15 minutes per patient, Klein notes.

"The most important thing for me was to get everyone on board, to let them know they have a piece of this," says Klein. "It has become a culture change."


For more information on working with other departments, contact:

  • Debbie Foshee, Vice President, Quality and Medical Staff Services; David Klein, MD, Vice Chairman, Emergency Department, Shady Grove Adventist Hospital, 9901 Medical Center Drive, Rockville, MD 20850. Phone: (301) 279-6000.