Common problems plague IHI participants
Improve admission and X-ray cycle times
Although every emergency department has its own unique set of problems, the majority of participants in an Institute for Healthcare Improvement (IHI) recent program on wait and cycle times have three in common. "Almost all of the participants had three major goals: improving admission cycle time, X-ray cycle time, and time to see the physician," reports James Espinosa, MD, FACEP, FAAFP, chairman of the department of emergency medicine at Overlook Hospital in Summit, NJ.
Here are tips for improving each:
• Admissions. "Reducing cycle time for admission has been the Holy Grail of ED management," says Espinosa. "There have been papers listing dozens of possible causes of delays in the ED or on the floors — but no experience has been brought [as to] how teams are likely to attack the problem, and to politically move through the work of getting institutional buy-in."
Reducing admissions time is the number one problem for ED managers, says Espinosa. "Admission cycle time can be related to insufficient capacity at triage, lack of bedside registration, or downstream delays. If you cannot get someone out of the department, you cannot bring someone in."
Having slow ancillary services and a long cycle time to get patients upstairs, will also impact admission, adds Espinosa. "You can call physicians slow and lazy; say there are not enough of them; bring in elaborate on-call systems, but you can’t move a system that is slowed down by downstream delays."
Motivate floor nurses
Use data to figure out the problems created by admissions delays. "The math is frightening, in terms of what it does to the ED’s capacity," says Espinosa. "If you have a 20-bed ED, at any given moment, three patients may be waiting to go up to a bed to admission. Two might be waiting for a prolonged CT scan result. If five people are in your ED waiting, you have just reduced your capacity by 25%.[Some] times, you run a 15-bed ED, and at [other] times a 10-bed ED."
That is often the key source of delays. "Some hospitals have a 30-bed ED that would be well served; because of system problems, they are really working with a third of that, and sometimes less," he says. "No wonder we have delays."
There should be incentives for floor nurses to get beds back into service, says Linda Kosnik, RN, MSN, CEN, Overlook ED unit manager and co-chair of the collaborative. "If patients sit down and wait for hours because the floors are too busy, they will be angry by the time they get upstairs. You [have] to put that into the floors’ patient satisfaction survey."
Bed control was turned over to the ED. "A nonclinical party we call the czarina of bed control’ keeps the ED in the loop," Kosnik explains. "If there is a problem, the nurses calls the czarina, who immediately calls the floor. Before, there were all kinds of excuses and hostility. Now there are certain expectations from both sides."
If a bed wasn’t assigned within 15 minutes, bed control will assign it. "If there are delays, and we know bed 224 — male and male — is empty, we assign it to the patient ourselves," says Kosnik. "We only have to do that once or twice because the floors don’t like losing control of that."
A report must be taken within a half hour; otherwise, the patient is sent upstairs.
• Time to physician. "There is a terrible gnawing sense of frustration in attempts to reduce arrival to physician contact cycle times," says Espinosa. "Hospitals across the country are starting to provide service guarantees, such as seeing a physician within 30 minutes without any understanding of how to achieve [it]."
Bedside registration is one effective way to reduce time-to-physician. At Ravenswood Hospital in Chicago, bedside registration was implemented during the IHI project. "It’s a wonderful concept to have a patient walk in the door and be seen by a physician first," says Bruce McNulty, MD, medical director of the ED. "It conveys to them that you care more about their medical problem than insurance information. "Previously, patients were spending the first 15 minutes out in the lobby. You can shave that off your door-to-discharge times, if doctors have access to patients right away."
Still, you can’t register patients at the bedside if your beds are full, notes McNulty. "First you need to have an efficient ED in terms of cycle times and labs. Our goal is to register 60% of patients at the bedside. We are at 50% right now, because occasionally we are clogged. As we reduce delays in other cycle times, such as X-ray, we expect to exceed our goal."
Previous attempts to implement bedside registration had failed. "My department has no direct influence over the admitting department; this is more work for them, because they have to get out of their chairs and walk into the department. My saying Let’s do this’ is not enough. Their administrators needed to mandate it," says McNulty.
Hospital switches to bedside registration
After repeated patient satisfaction surveys indicated patients were dissatisfied with delays, administrators agreed to switch to bedside registration. Getting physician buy-in was key, McNulty recalls.
"At first, physicians didn’t want to see patients until they were registered. They came to acknowledge that the patient’s physical exam isn’t going to change after they’re registered."
Patient care was emphasized. "I explain that if we can cut 20 minutes off our average patient wait time with bedside registration and other improvements, and multiply [that] by the 75 patients we see a day, we have created 25 hours a day out of nowhere that we can spend at the bedside talking to patients who really need us — who are sick or uneducated about their condition," says McNulty.
The ED’s subsequent patient satisfaction surveys reflected the change. "Twice as many patients who included written comments about time said they’d been treated quickly," McNulty reports. "For the first time ever, we received more compliments than complaints." (See chart, p. 146.)
• X-ray turnaround time. Overlook Hospital’s ED reduced its median X-ray turnaround time from 90 minutes to 30 minutes.
"The initial impetus was our goal to reach a benchmark of one hour for our fast track patients," Kosnik explains. "However, because 70% of these patients required radiologic studies, we could never accomplish this result with the protracted radiology turnaround times."
The goal was achieved only after several years of attempts. "It was a struggle because groups couldn’t come together, which ultimately required us bringing in an administrator," says Kosnik. "Once we were able to get that commitment, we were able to drop our time."
Physicians read X-rays in ED
A close look at the system revealed problems. "We found that the whole radiology system was set up to benefit the radiologists, not the patients," says Kosnik. "After the techs took X-rays, they went to get the old X-rays from [the] library just to have them all together, but that wasn’t necessary at that point."
A CQI team was formed, with representation of ED and radiology. "Data were collected through a tracking system in which both departments owned the process," Kosnik says. "The ED unit secretary started the clock when the order was made, and the radiology technician stopped the clock when the radiograph was completed and brought to the ED."
The following changes were made:
o Use of a flowsheet (with physician-provided patient history) that follows the radiology process and provides accurate information.
o Completion of the file room patient data entry after, rather than before, the radiograph is completed.
o Use of dedicated radiology technicians for consistency.
o First read of all radiographs by ED physicians. The films are read later by the radiologist, with expeditious handling of any discrepancies. The false-negative radiograph interpretation rate has remained well below 0.5% (Joint Commission on Accreditation of Healthcare Organization recommendations are less than 3%).
o Use of an ED X-ray film holder that allows all ED radiographs to "hang" for two hours. Having ED physicians read X-rays in the ED is a time saver. "For the majority of films, an ED physician interpretation is absolutely all that’s necessary," says McNulty. "We are looking at whether radiology will allow us to read our own films using the radiologists as consultants, with a 100% reread within 24 hours."
Often radiologists are reluctant to allow that to happen. "There are some risk management issues that need to be addressed, but adding a radiologist review of every film before the patient is discharged adds 30 to 40 minutes to their stay," notes McNulty.