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 goal 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 to 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.