Hospital emergency department (ED) visits have increased by nearly one-third since the mid-1990s, and these high volumes have led to increased problems, such as overcrowded EDs and greater numbers of patients being diverted to other facilities or leaving without being seen, studies show.1
This is a problem that can be addressed with quality department leadership, as one health system demonstrates: Universal Health Services (UHS) of Delaware in King of Prussia, PA, helped 26 EDs improve their time to seeing patients, says Paula Antognoli, PhD, RN, project manager for performance and process improvement, acute care for UHS of Delaware.
The first step was to design a project about the overcrowding, looking at throughput metrics in the following increments:
-
arrival to provider,
-
provider to disposition, including turnaround time for lab and radiology, and
-
disposition to discharge for patients going home or for disposition to admission for those being admitted to the hospital.
“We analyzed data to identify where opportunities existed,” Antognoli says.
“When we started down this path in 2012, we had 26 acute care facilities experiencing annual increases in ED volume at a rate of 3% per year,” she says.
“With that volume increase, leaving-without-being-seen issues plague all EDs, and we noticed our leaving-without-being-seen rate was well above 2%,” she explains. “Our goal was to achieve a rate of 1%.”
When patients leave without being seen by a clinician, they either go somewhere else for care or their condition might worsen by the time they return, and those are undesirable outcomes, Antognoli notes.
“It’s a question of patient safety and quality care,” she adds.
In addressing the problem, Antognoli and other process improvement leaders looked at the ED throughput in terms of phases. “We carved off the initial phase of when the patient arrives at your door until the time in front of a physician or advanced practitioner,” she says.
“And we asked ourselves what were the steps for intake; which steps do we currently do, and what steps can we eliminate,” Antognoli says. “We wanted to take whatever wait time we could identify that was external to the process and eliminate it.”
For instance, external waste occurs when patients arrive in an ED and have a seat in the waiting room.
One way to eliminate this is to have the patient immediately greeted by a nurse and taken back to a treatment space and reduce their wait time to see the physician, Antognoli says.
“Not every patient needs to have a bed. By using treatment chairs in a designated space, they feel equally cared for,” she adds.
The goal was to reduce the time frame from arrival to seeing a provider to less than 25 minutes, she says.
To make this happen, ED treatment space needed modifications: “We looked at the physical layout of the ED and reallocated physical treatment space to rapid medical exam areas where the patient is brought in and seated immediately in a chair, where a nurse could begin their lab work or get an x-ray,” Antognoli says. “Then a physician or mid-level practitioner can see them and discharge them from that space.”
The low-acuity patients are kept in the front of the ED to be discharged quickly. The rapid medical exam areas are self-contained and staffed with nurses, ED technicians, advanced practitioners, and registration clerks. The rapid medical exam area volume varies, based on the time of day with peak volumes — typically occurring between 10 a.m. and 10 p.m., depending on the communities they’re in, Antognoli says.
“For example, one ED in Bradenton, Florida, area sees 220 patients per day, and of that volume, one-third of their patients are treated in a rapid medical exam area without ever being admitted to a bed in the ED,” she adds.
Having so many patients who do not use ED beds helps to declutter an ED and lessens patient overcrowding, she says.
“Patients who are back in the ED beds are typically very sick and will require extensive work-ups, as well as admission to the hospital,” Antognoli explains.
“After the change, most of the health organization’s EDs began to see positive results. By the fall of 2015, the overall 26 hospital rate of people who left the ED without being seen had fallen to 1.07% — more than half the rate of where we started as a company,” she adds.
“We felt this project was about being a good steward for the business we’re in,” Antognoli says. “It’s important in this day and age — particularly because patients coming into the ED are sicker than before and can’t be sitting around in waiting rooms,” she adds. “We tell our teams: ‘Everyone is a fast track patient, so everyone should be treated that way — seen quickly, assessed quickly, and given quality care as quickly as possible.”
REFERENCE
-
Cunningham P. Nonurgent use of hospital emergency departments. Testimony at Hearing before the U.S. Senate, Health, Education, Labor and Pensions Committee, Subcommittee on Primary Health and Aging. May 11, 2011: http://hschange.org/CONTENT/1204/1204.pdf.
SOURCE
-
Paula Antognoli, PhD, RN, Project Manager, Performance and Process Improvement, UHS of Delaware, King of Prussia, PA. Telephone: (610) 768-3300. Email: [email protected].
