Novel Strategies Decrease ED Delays

Numerous patient satisfaction surveys show that long waits are the ED’s No. 1 patient complaint. Unnecessary delays can heavily impact patient care and the bottom line. Reducing the amount of time a patient spends in the ED is a top priority for ED managers and an essential part of practicing emergency medicine in the ‘90s.

"It’s always been an important issue, but with pressure from managed care organizations to maintain high service quality, it’s now something we need to pay intimate attention to," says Fran Damian, MS, RN, Director of Nursing and Patient Services in the emergency services department at Boston Children’s Medical Center.

Long waits for care in the ED is a key issue. "It’s definitely the thing that upsets parents the most," says Damian. "They get turned off by the wait, with good reason. They’re not necessarily waiting in the most comfortable quarters, and kids are tired, crying, and hungry, so every minute seems like an eternity."

Although reducing patients’ overall length of stay is always a major goal, looking at the big picture can be daunting at first. Dividing an ED visit into specific segments can motivate staff. "From a staff perspective, when they are trying to hustle and take advantage of every second they have, to see the time data come out the same is discouraging," she observes. "But when we break it up into aspects of the visit or look at a subset of the population, they can see huge gains and it feels rewarding."

Tackling wait times in the ED is especially challenging because many changes hinge on the practices of other departments. "It’s hard because so many things contribute to waits and delays, many of which are out of our control," notes Damian.

In recent months, the Institute for Healthcare Improvement in Boston has completed a series of studies on reducing ED waits and delays. Nine EDs participated in the project, each with the goal of reducing wait times for a different aspect of the ED visit. Here is an overview of some of the results.

Get patients from triage to treatment faster

The ED at St. Mary’s Health Center in St. Louis reduced the time it took to get a patient from triage to a treatment room. "We started with the cycle we had most control over, which was the door-to-room time, so we looked at the registration process first," says Marianne Fournie, RN, BSN, Clinical Director of the ED at St. Mary’s.

Previously, patients were triaged, went through registration, and then waited to be brought to a treatment room. The ED switched to registering patients during the visit. A small amount of information is obtained from the patient initially. This information generates a chart and an account number. "Then we register them during the visit, which shaves off between 20 and 40 minutes of wait time," says Fournie.

The ED chose to focus on this segment of the patients’ visit for two reasons. "We knew results would be immediate, and it was also the one cycle that we as a department had total control over," says Fournie.

It took some time for employees to get used to the process changes. "We brought in laptop computers that interfaced with the main system, so the secretaries could enter the registration information at the patient’s bedside without ever leaving the room. But, at first, they were reluctant to use them," she says. "Also, staff were still of the old mindset that patients had to be triaged first instead of being brought right back."

Improved patient satisfaction was the benefit, which helped the department’s bottom line. "Customer complaints have gone down, and the number of patients leaving without being seen has decreased," says Fournie. "Just having six patients a day leave without being seen is enough to impact your numbers of visits per full-time employee."

Expanding process to other areas

After the process change showed results, the ED focused on reducing delays in other areas, including X-ray and lab-result times and the length of time it took urgent care patients to get through the department. A 20-minute delay from the moment an X-ray order was placed until the patient was brought to radiology was reduced to 6-8 minutes. Length of stay for urgent care patients was reduced from 109 minutes to 88, with a final goal of 60 minutes.

"We’ll continue to reduce delays in other areas," says Fournie. "It’s not an end process. As you improve one cycle, you move on to another one."

To reduce some of the bottlenecks in the ED, some managers are making innovative use of hospital areas that are left unused after hours. Boston Children’s Hospital uses a day surgery space in the evenings to increase throughput in the ED. "We did it as a pilot for five nights, and it made a huge difference," says Damian. The ED has access to the area from 5 p.m. to 1 a.m., which coincides with its peak volume.

On one extremely busy night in the ED, the average wait was about four hours. "Within an hour of opening up the day surgery area, the wait decreased to about a hour, and the system was mobilized," says Damian. "We were able to get more patients through than we normally would have."

Flexibility increases with added space

The ED’s use of the space varies depending on the volume and acuity of patients on a given night. If there are several patients in the waiting room who need to be observed for 3-5 hours, the day surgery area functions as an observation unit. Asthmatics or patients who need a few hours of IV rehydration are brought upstairs and monitored, opening up the ED rooms for other patients.

Some nights, there aren’t enough patients requiring observation to use the day surgery area for that purpose. "We don’t always have that perfect mix to be able to keep the area filled. To have a nurse up there taking care of only one or two patients didn’t impact the department enough," explains Damian.

On those occasions, the day surgery area functions as a fast track. The area is staffed with a physician and nurse who treat all of the ED’s nonurgent patients. The ED’s nonurgent area is then opened up for urgent patients. "We find it to be an efficient use of the day surgery space because it allows us to open up five more rooms down in the ED for urgent patients," says Damian.

Removing patients from the ED waiting room seemed to have an impact on overall waiting times. "On a few of the nights when we opened up the day surgery area, we were seeing about 200 patients a night, which is 50 more than our normal volume, and waiting times were still a little bit better than usual," says Damian.

Reducing delays for asthma patients

The ED at Children’s Medical Center decreased the amount of time its asthma patients spent waiting for treatment by administering medications during triage. Asthma patients are treated in a secluded alcove behind the triage desk. The treatment area is clearly visible to the nurse but out of the view of other patients in the waiting area.

The ED nurses’ role expanded to include administering medication, instructing the patient, and doing reassessment and documentation. "The nurse is assuming a greater responsibility for patient care," says Damian. "At first, this met with resistance because we were adding something onto the nurse’s role, but after [the nurses began] doing it and seeing the benefit, it’s become a way of life."

Though not a perfect solution, the arrangement is effective. "In some ways it’s a Band-Aid approach for the reason a patient isn’t getting into a room quicker," says Damian. "It’s not ideal because it makes triage more chaotic in some ways, but it’s better than having the patient sit in a waiting room not getting breathing treatments. We make good use of the time a patient spends waiting."

Wait times were reduced dramatically. Before the change was made, most patients waited over two hours for treatment. "Nurses sometimes initiated meds once the patient got into a room, but waiting two hours for an exam room meant waiting two hours for treatment," says Damian. Currently, most patients are treated within 10 minutes, and the median wait time was reduced from 50 minutes to 24 minutes.

Nonurgent febrile infants who need blood drawn now have the procedure done before they enter an exam room. "That way, the results are often back by the time the physician sees them," says Damian. "We have a phlebotomist on evenings, which helps enormously, and when they aren’t here, the nursing staff does it."

Other procedures are also done before children enter the exam room. "If we’re really backed up, the nurses will put IVs in patients before they get into an exam room," says Damian. "During overlap time when we’re changing shifts, the nurses will see who’s out in the waiting area and maybe start two or three lines before they go home. We try to be creative and do the best we can with the resources we have."

Reducing LOS for extremity patients

St. Joseph’s Mercy of Macomb Hospital in Clinton Township, MI, reduced length of stay (LOS) for its simple extremity patients, which comprise 15% of the ED’s ambulatory volume. "By decreasing the length of stay for simple extremity patients, it has given us more capacity to serve all of our patients in a more efficient manner," says Jan Bolton, RN, the ED’s clinical decision support analyst.

As part of the process change, nurses began ordering X-rays for extremity patients during triage. A treatment room off of the triage area is used as a "subwaiting room" for these patients. "At this point, we only put simple extremity injuries in the subwaiting room, but there are times when there is more than one patient there, so we’re utilizing the space effectively."

A radiology suite was constructed in the ED to streamline patient care. After the order prints out in radiology, an X-ray tech comes directly to the patient, instead of waiting for a transporter to bring the patient to radiology. "The patient doesn’t have to travel to another department," says Bolton. "The X-ray results are now back before the physician examines the patient."

A fax machine was installed so the results could be immediately faxed directly back to the ED. "We had something in our hands sooner that way, rather than making phone calls and waiting for someone to bring them back," Bolton explains. This enabled the ED staff to complete the patient’s chart before the physician saw the patient, so the disposition could be made at the time of the exam.

The physician now does the initial exam with the X-ray results in hand or while the X-rays are in progress. "This decreases the overall throughput time for simple extremities because the X-ray is performed earlier in the process," says Bolton.

The turnaround time for extremity patients was reduced from a median of 132 minutes to 80 minutes. "We decreased the number of handoffs these patients experience," says Bolton. "Patients feel like they are moving through the system sooner, so our satisfaction rate has improved."

It took time for staff to become familiar with the new system. "The ED registrar also enters the orders, and at times we would be sent an admitting associate from another part of the hospital who didn’t know the process, so X-ray wasn’t notified to come and get the patient," says Bolton. "Overall, the whole process was accepted very well because they could see the impact of getting those patients through the system sooner."

ED improvement projects often depends on the cooperation of other departments which service the ED. In such situations, it helps to have the support of administration. "You need people working in the system to help identify the problems, and the management level to support those changes, but you also need administration to bring the different departments together," says Bolton.

Collaboration between departments is essential. "You need to have a common goal," she says. "Initially, it was difficult working between the two departments because we were asking radiology to change their process."

Involvement of personnel in both departments helped pave the way for the changes. "Nursing staff, physicians, and radiology were all involved in the project," Bolton notes. "Without any one of them, it would not have been effective."

Reduce delays in admitting patients

At York (PA) Hospital, a significant amount of the ED’s waiting room space was functioning as a holding area for patients awaiting admission. As in many EDs, this situation created bottlenecks. "It was very important for the ED to decrease the holding time, but we were also looking to provide a smoother continuum of care for patients," says Gale Thomason, RN, BSN, the ED’s operations manager.

The first step was establishing direct communication between the two care providers. "Instead of the roundabout way of going through the admissions clerk who had no clinical knowledge and supervisors who hadn’t even seen the patient, it made a lot more sense for the provider in the ED to talk to the provider on the floor," says Thomason.

The process change eliminated several steps. "Before, a physician ordered the admission, gave it to the secretary who entered it into the computer and called admissions, who contacted the floor supervisor, who talked with the charge person. Next, the supervisor called admissions, who called the ED secretary in the ED, who would then tell the ED nurse what room they were going in, then the nurse would call the floor to give a report," says Thomason.

The complicated process didn’t ensure that correct choices were made. "All too often, we’d say this patient isn’t appropriate for that floor based on their current condition, then we’d have to start the whole process over again to find a different bed," Thomason recalls. "We can now get the patient correctly placed the first time around."

The ED charge nurse is now called a "team leader" to reflect the expanded role that entails having an awareness of potential admissions and knowing which floors are appropriate for different types of patients. "She now has the hospital bed board at her desk to see how many transfers each floor is getting—so we can spread the wealth—and also a housekeeping tracking board to check on the status of beds," says Thomason.

The floor charge nurses are now paged directly and asked to take a patient. "Nine times out of 10, they’ll say yes and give us the bed number," says Thomason. If the hospital is busier than usual, an administrative coordinator gets involved to avoid confusion.

The ED moved away from its traditional role of "pushing" patients onto the floors. "There was a history of us pushing and pushing them to take the patient, and they were pushing back saying, ‘No we can’t’ for 10 different reasons. There’s still some of that, but not nearly as much," says Thomason.

Communication between the ED and the floors improved with mutual respect. "We’re being a little more honest with each other now," says Thomason. "If they tell us they just got two transfers in, we say, ‘Fine, we’ll give you a half hour.’ On the other hand, if we tell them, ‘We have two traumas here, and you need to get them right now,’ they’ll pull the patients up immediately."

The hospital’s inpatient nurses have come to appreciate the new system. "They feel they have more control without admission [personnel] or supervisors getting in the middle of things," says Thomason. "They like the control of knowing which patients they’re getting ahead of time so they can manage their work load and divide up the patients."

Another major change on the floors was a "first come, first served" policy. "Beds used to be reserved for chemo, post-op, and direct admissions. Some days, three quarters of the beds were reserved," says Thomason. "We put in 30-50 admissions a day through here, and it was real tough to fit them in with all the reserved beds."

The ED now takes No. 1 priority over any expected patients. "They plan for these patients but don’t actually reserve the bed because if ED patients need them, they take them," says Thomason. "The only thing that takes priority over ED admissions is a patient on the floor becoming unstable. Otherwise, our patients are here, so they have to come up with a different plan for the other patients when they do arrive."

There is still some resistance to this policy, but the floors have started to accept the new mindset. "From the floors’ perspective, if we fill them up, they don’t get any more admissions," says Thomason. "We also tend to have the patient evaluated and stabilized, whereas their directs are more work. So if we fill up the surgical beds before the OR gets their last cases through, the floors aren’t too upset about that because it tends to be less work."

A problem sheet is filled out whenever the ED encounters a difficulty with an admission. The sheet includes a checklist to explain what occurred with such options as "nurse too busy," "nurse at lunch," and "bed not ready." "The ED nurse fills them out so we can track any problems, but we average only a few a week," says Thomason. "When you look at the volume of admissions, it’s a small percentage."

If an admissions encounter doesn’t go well, the administrative coordinator is immediately notified. "If we get a refusal and can’t negotiate with a floor, the coordinator is responsible for getting us a bed," says Thomason. "We see 55,000 patients a year and can’t take the time to keep calling floor to floor."

The administrative coordinator is closely involved in the interface between the ED and the floors. Strategically positioned in an office down the hall from the ED, the coordinator is provided with an ED tracking board. "It’s really helped to improve their understanding of our flow because when we’re full they see it," she says.

Staff training took place on an ongoing basis. "After we set up the new policy, people misinterpreted certain things or only did certain parts of it, so we were constantly going back and reviewing," says Thomason. "We also had separate meetings with team leaders to give them an increased knowledge base about which floors take which patients."

After the new policies took effect, the average holding time for patients in the ED decreased 26%, from 59 minutes to 44 minutes. A less tangible benefit was the improved relationship between the ED and the floors. "It’s really increased understanding between the departments, which is an age-old problem," says Thomason.

[Editor’s Note: The Institute for Healthcare Improvement (IHI) will present the results of its second collaborative on waits and delays,which includes data from more than a dozen EDs, at the annual National Forum on Quality Improvement in Healthcare, to be held in New Orleans on Oct. 14-15, 1997. IHI has also published a "breakthrough series," Guide to Reducing Delays and Waiting Times Throughout the Healthcare System. The 187-page guide has a section on the ED. For more information about the Breakthrough Series programs or publications, contact Lisa Green at IHI, 135 Francis Street, Boston MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848.]