Ambulatory Care Quarterly

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.

If there is a problem, all of the departments will swing into action. 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%."