EXECUTIVE SUMMARY

Through two related initiatives, University Hospital in San Antonio, TX, has significantly improved throughput in the ED and communications with other hospital services and departments. First, the ED tackled its own internal operations, overhauling its intake process and expanding the number of treatment spaces. Then, the ED began working with the inpatient side to ensure beds were available in time to accommodate admissions from the ED and reduce the need for boarding.

  • The ED instituted a true split-flow model, dividing patients into two flow streams based on acuity.
  • To facilitate this transition, a 12-bed fast track was transformed into a “power pod” area with 23 treatment spaces.
  • Patients designated as Emergency Severity Index (ESI) levels 3, 4, or 5 are sent to the power pod for care while more acute patients (ESI levels 1 or 2) receive care in the ED’s main treatment area.
  • In addition to the internal process improvements, the ED worked with inpatient staff on discharge scheduling to better accommodate daily admissions from the ED.
  • The hospital’s push to facilitate discharges by noon has made a significant dent in the time between bed request and bed occupied or boarding time in the ED. Administrators note this number had dropped from 240 minutes before the improvements were made to 120 minutes in October and November 2019.

In 2017, the administrative and clinical leadership in the ED at University Hospital in San Antonio, TX, knew they would need some help from inpatient staff to address all their throughput challenges. But first, ED leaders knew they had to put their own house in order.

“I can talk to hospital administration, and we can work together to try to come up with solutions, but [the hospital] is not my house,” says Christina Bird, DO, explaining the mindset of leaders in 2017. “The ED is my house, and that is what we had to try and fix.” The need for change was clear in the ED’s operational metrics at the time. Bird, who now serves as medical director of the department of emergency medicine, notes the overall average length of stay (LOS) was about 475 minutes, and the total LOS in the ED for admitted patients was 625 minutes.

Further, the time between a decision-to-admit order in the ED and the designated inpatient bed becoming occupied was well over 200 minutes. Excessive boarding was an issue. However, it quickly became clear that nibbling around the edges was not going to fix the problem, Bird observes.

“We tried to siphon off the fast-track patients, but we were not running that as efficiently as we probably could have. Then, we put an advanced practice provider [APP] in triage to try and improve our door-to-provider time,” she explains. “It helped with our leave-without-being-seen rate, but then our left-without-treatment-complete rate went up. Patients would be seen by our provider who would order a workup, but then patients would go back to the waiting room and they would wait for hours.”

Many patients would leave in frustration because there was no room to put them in, Bird explains. “It was like we were trading one metric for another,” she says. “We did small Band-Aids here and there that we thought were doing something, but they really weren’t.”

Ultimately, ED leaders concluded a complete overhaul of the intake process was needed. Dubbing this effort the “power up” initiative, department leaders created a true split-flow model, dividing the ED into sections based on acuity.

“Looking at our data, we realized we really didn’t have a lot of fast-track patients, our ESI [Emergency Severity Index] 4s and 5s,” Bird notes. “We were only seeing about 20 to 25 fast-track patients a day. That wasn’t enough to justify the amount of resources we were using for our fast track.”

Consequently, model developers replaced the fast track with a new area dubbed the “power pod,” designed to manage ESI level 5, 4, and so-called “vertical 3s,” or patients designated as ESI level 3 who can remain seated and most likely will be discharged. “The other stream of flow is our ESI level 1s, 2s, and the horizontal or sicker level 3s,” Bird adds.

Under this configuration, patients designated as ESI level 1 or 2 will go directly to a bed in the ED’s main treatment area. Patients designated as ESI level 4 or 5 will go to the power pod for care. Then, ESI level 3 patients will be seen by a physician in triage who will determine which space is best and begin the appropriate workup. “That is our highest volume of patients,” observes Bird, referring to the ESI level 3 designees.

In place since May 2018, the approach has proven to provide a more efficient use of space and resources, Bird reports, noting the department’s former 12-bed fast-track area has been transformed into a power pod with 23 treatment spaces to accommodate both fast-track and what she refers to as mid-track patients.

While ED leaders were working with frontline staff on the front-end overhaul, they also began working to optimize their connections with the other hospital departments and services the ED relies on in caring for patients. “We brought together all of the stakeholders from multiple ancillary services,” Bird explains. “We also had hospital administration be a part of it.”

The idea was to demonstrate the ED was doing everything possible to fix what it could internally, but that it now needed the hospital’s active involvement to work on the ED’s boarding problem — an issue that was beyond the ED’s full control.

By this point, the ED had made significant progress on its operational metrics. As of December 2018, Bird notes the leave-without-treatment-complete rate was down to 5.1%, the left-without-being-seen rate was at 1.1%, the door-to-provider time was 29 minutes, and the ED’s discharge LOS stood at 348 minutes.

To make further progress, beginning in January 2019, hospital administration initiated its own “power through” initiative, aimed in part on relieving throughput pressure on the ED. “We had already been working on this for a year, so [the inpatient side] was using some of our data and some of our suggestions,” Bird shares. “They decided to hone in on [facilitating] discharges before noon ... because our arrival curve starts to pick up between 9 a.m. and 11 a.m. By the time these ED workups are finished, that is when admissions really start to [increase].”

In the push to bring all inpatient units on board with earlier discharges, the “power through” team members began holding weekly lunches to review data and any ongoing challenges or issues that cropped up.

“In April or May [2019], they invited [ED representatives] to begin attending the lunches to try to bring us into the conversation more and also so that we could present some of our data,” Bird recalls. “They could see how what they are doing impacts what we are doing.”

During these sessions, the ED nursing director typically takes charge of presenting the relevant metrics from that area, and then the panel talks through what is or is not working, Bird shares. However, there is no question the concerted push to facilitate earlier discharges is paying off.

“In the last three or four months, we have had a significant drop in our boarding,” Bird observes. “At our worst, the time between bed request to bed occupied was about 240 minutes ... and in October and November 2019, [that number] was down to 120 minutes.”

To be sure, there have been some months when boarding times in the ED have surged, but the overall trajectory of the effort is positive. Still, the “power through” team is pushing for continued progress. The goal is to shorten the bed-request-to bed-occupied time to 45 minutes for patients admitted from the ED, Bird offers.

While the “power up” and “power through” initiatives have not solved all the throughput challenges, there have been some additional benefits beyond reduced boarding levels. “When we started [the power up] initiative, because of how collaborative it was and how much time we all spent together ... it really created this awesome teamwork aspect,” Bird shares. “It really kind of regenerated a lot of people.”

Several champions were identified to drive the various aspects of the overhaul, and the ED leadership stayed involved. “We took point on a lot of the smaller group sessions ... and I reviewed all of the workflows when we revised them,” Bird notes.

Further, Bird says that standards for work were established to describe what the expectations for each job or role in the new workflows were. The team developed guidelines and restrictions regarding which patients can be sent to the power pod area.

To keep the team on track, leaders follow up on any staff complaints regarding patients who are placed in the power pod for care even though they do not meet the appropriate criteria. “We review [these cases], and then we talk to the team. We also do frequent messaging,” Bird reports. “Any time you create new processes and protocols ... a lot of it is just continuing to message people, to remind them of the guidelines.”

Bird acknowledges that sustaining the improvements is a continuing challenge. “People can slip back a little bit, but also when you become more efficient and you do things well, you in turn get a higher volume of patients,” she says. “Every month, we have beaten our volumes from last year.”

Bird’s advice to other ED leaders planning efforts to address throughput challenges is to first gather good data.

“That is something we struggled with in the beginning, not really knowing what our numbers represented and whether they were correct,” she says. “If you can’t trust the metrics, you are going to have a hard time making improvements on them.”

Also, do not get caught up trying to fix little issues here and there; look at the whole process, from patient arrival to patient disposition, Bird advises. “We had tried lots of smaller Band-Aids, and they all failed,” she says. “We had to make everything work together in unison. We couldn’t just fix one small part of it.”

Bird adds that it is critically important to bring all stakeholders to the table to achieve meaningful improvement. One might be surprised what is revealed. “Even though we had radiology and the lab [on board] right from the beginning, we realized they weren’t aware of some of our targets and our initiatives,” she explains.

For instance, radiology always tended to queue imaging tests based on patient acuity, where the sicker patients always received X-rays first. However, in some cases, the ED needed tests performed on lower-acuity patients first.

“We realized that we weren’t telling [radiology] when we needed those tests done,” Bird notes. Today, the ED is in the process of figuring out a better way of queuing needed services, and how the department can most effectively work with allied services.

“I think really engaging with all the parties is what you need to do,” says Bird, adding the effort has proven worthwhile there. “We are routinely now having zero patients in the waiting room.”