ED cuts LWBS from 5% to 0.5%

Input required from several departments

Recognizing that ED wait times and throughput are affected by the entire hospital, the leaders at King's Daughters Medical Center in Ashland, KY, engaged all the departments that interface with the ED and slashed the rate at which ED patients leave before treatment from 5% to 0.5%. This accomplishment is all the more remarkable because the ED sees 76,000 patients a year and volume has not declined during the implementation period.

During that same time period, turnaround time for admitted patients decreased by 22%, from 312 minutes to 242 minutes, and turnaround time for patients discharged from the ED fell by 9%, from 183 minutes to 166 minutes. "We still have a long way to go," says Mona Thompson, MBA, RN, CPHQ, CENP, vice president of patient services and chief nursing officer.

Brandi Boggs, RN, MSN, director of emergency services, says, "Throughput is a high priority for us for lots of reasons: patient satisfaction, quality of care, overall decline in length of stay."

Senior leaders outlined the goals and methods to achieve them. "We had a goal of reaching best practice in terms of left without being seen as defined by The Advisory Board — which is 0.55%," says Boggs. (Editor's note: The Advisory Board, based in Washington, DC, is a provider of performance improvement services to the health care and education sectors.)

Thompson says, "Brandi and her team came up with this plan. She involved radiology, bed placement, doctors and nurses, housekeeping, the pharmacy, the customer satisfaction team, the laboratory, case management, social workers, and IT — all the stakeholders." These stakeholders worked on actions specific to their discipline needed to achieve the 0.55% goal, she says. "That's really important," says Thompson. "Teamwork is important to us, and the team members who do the work know how to make things better." So, for example, ED charge nurses and triage nurses accept responsibility for patient-left-without-being-seen rates and actively interact with patients to explain the benefits of receiving a medical screening exam, she says.

After several months of meetings, the plan was implemented in February 2009. Boggs says that in the ED itself, "one of the things we do differently now is triage patients directly to the back when there is an open bed. Triage is a function, not a location. If there is an open bed, and you bring the patient straight back, it increases quality of care and customer satisfaction."

This step eliminates the "funnel," Thompson says. "Most ED teams will tell you that patients arrive at triage in clusters, not in a steady stream, so if you funnel all of them through one or two triage nurses, it makes it slower for the last person in the cluster," she says. Now if there is a bed open, the patient can be triaged by the bedside nurse, Boggs says.

"We also do hourly throughput assessments in the ED," she says. "We developed a worksheet where we can look at things that define throughput — patients in the lobby, current wait time, boarders" who are waiting more than two hours for a bed. Based on the worksheet, the charge nurse will assign a color (green, yellow, orange, or red) to indicate throughput status. [A copy of the worksheet is available. For assistance, contact customer service at (800) 688-2421 or customerservice@ahcmedia.com.] If there is a problem, all of the departments will swing into action. (For more details, see the story, below.)

This team approach has led to steady progress, says Thompson, who notes that the 0.5% figure was first achieved in January 2010. "In the last two fiscal years [which end in October], we averaged 4.55% and 3.49%, respectively," she reports. "Year to date, we are at 1.33%."

Other units can 'rescue' the ED

The decrease in the rate of ED patients leaving before treatment at King's Daughters Medical Center in Ashland, KY, from 5% to 0.5% was not achieved by the ED alone. It took a concerted effort on the part of all of the major departments that interface with the ED.

Hourly throughput assessments in the ED result in the charge nurse assigning a color (green, yellow, orange, or red) indicating the current throughput status. "Based on that level, different actions are taken to elevate the urgency of getting resources to the ED to get it moving," explains Mona Thompson, MBA, RN, CPHQ, CENP, vice president of patient services and chief nursing officer.

A page is sent to the hospital's leadership council twice a day indicating the overall status of the organization and specifically the ED. This page goes to every individual with the title of manager, director, or above.

"When the ED gets to orange or red [indicating that throughput is becoming seriously impaired], we do individual hourly pages until that is resolved," says Thompson. This page includes leaders who are at home, adds Thompson, noting that the previous night, a Code Orange was called at 1 a.m. "The expectation is that the entire leadership team will either come in or call to ensure their department is appropriately responding to meet the needs of the ED," she explains.

Brandi Boggs, RN, MSN, director of emergency services, says, for example, "if we are at orange, on the inpatient side, they will look at their units to see if any patients are ready to go home and discharge them in a timely manner to free up a bed. Housekeeping is notified so they can get the beds cleaned."

Thompson adds, "The lab may put an extra phlebotomist in the ED, or the radiologist may call out another tech, depending on what the needs of the particular patient population are at that time. Pages may even be sent to the laundry to make sure there are adequate linens or to have them bring an extra linen cart."