Identify best practices to improve patient flow in your ED

More than 80 EDs identify best practices for patient flow in national benchmarking study.

A 1998 Veteran’s Hospital Administration (VHA) National Benchmarking Consortia Study surveyed more than 80 emergency departments (EDs) to identify best practices in patient flow management. "It’s very helpful to be aware of benchmarking data to see what others tried, failed, or succeeded at," says Michelle Myers, RN, MSN, program manager for emergency and trauma services at Elmhurst Memorial Hospital (IL). "Administrators want to hear innovative ideas for improving patient flow along with hard data, since throughput times are closely linked with patient satisfaction scores."

The VHA study entailed two primary surveys. A data collection survey covered general practices in emergency services, while a second survey was completed on a patient sample for each ED to measure patient cycle times.

Having hard data can demonstrate that patient flow effects ED revenues, stresses Myers. "If patients are waiting too long for an x-ray to come back, they’ll leave," she notes. "Show your administrator that 300 patients per year leave without being seen because wait times were too long, with an average charge of $280. They won’t want to see those dollars walking out the door."

Benchmarking data can be used to compare efficiency with other EDs, which is a valuable negotiating tool, stresses Myers. "By using the data from the VHA study, we could compare our turnaround times to others," she says. "We can use it to justify our resources, in case our administrators want to cut x-ray techs or services that contribute to turnaround times. You can look at hospitals A, B, and C who didn’t have those resources, and explain that our times could increase if they took away a tech in our radiology room."

Even EDs with efficient patient flow management can benefit from sharing information. "Our waiting times have been below the national average, but this was an opportunity to take a look at our practices and participate in benchmarking with other organizations," says Tom Alinder, RN, BSN, emergency medical services manager for United Hospital in Grand Forks, ND. "We were able to study the best practices of more than 80 EDs, which helped us to come up with strategies for improvement."

Here are some of the best practices in patient flow management identified by the study’s participants. Some of the strategies are fairly common, but they all help save time in the ED.

Specimens transported via pneumatic tube system. "We have a tubing system that expedites our specimens so they go right down to a stat receiving specimen area. That is staffed 24 hours a day, so somebody is always there to collect a stat specimen," says Myers.

ED staff perform phlebotomy and EKGs. "Our ED nurses and techs draw blood, so we don’t have to rely on a phlebotomist to come from another area in the hospital to do it," says Myers. "Even if you have a stat lab tech, you still have to wait for them to come to the ED. This way, when the patient comes in, we immediately start drawing blood."

At Methodist Hospital in Omaha, NE, all nurses and techs are certified in phlebotomy and EKG. "This had a significant impact on our flow times," reports Pat Lenaghan, RN, MS, CEN, service executive for emergency services. "Our door-to-EKG time went from 25 to about 10 minutes, and door-to-drug time for thrombolytics decreased from 40 to 29 minutes."

The ED’s clinical nurse specialist sets up competency training for EKGs and phlebotomy. "We sent our nursing assistants through the same training that our phlebotomists go through, until they were competent," says Lenaghan. "We had to gain a lot of cooperation between the two departments to make that happen. For example, the cardiologists were supportive of getting our door-to-drug time below the national average, so they supported this."

A radiology department in the ED. "We have two x-ray areas, one for the fast track and one for the ED," says Myers. "The ED physicians do a wet reading, with a final reading by the radiologist in the ED. We also have a runner budgeted out of radiology who runs the films back and forth. Also, the radiology techs come and get our patients when we order an x-ray, so the staff does not have to bring patients to the x-ray rooms."

Good communication to resolve delays in ancillary services. "You need to have constant, ongoing communication with the directors of lab or radiology. We meet every two weeks so we can resolve any issues that come up regarding wait times," says Myers. "In many EDs, you leave messages at the other department and never get a call back for days."

One patient called to complain about the ED staff drawing blood. "She is a difficult stick and a frequent visitor in the ED, and let us know that she preferred the lab to come and draw blood instead of my staff," says Myers. "I made arrangements that the staff will contact a phlebotomist to draw this particular patient. If our staff is sticking this patient two or three times or the patient becomes upset, that could delay turnaround time and the patient will be dissatisfied."

Use of headphone cellular system. "We have purchased headphone sets for our registration staff, triage and charge nurses, so we have constant communication in trying to move patients faster," says Myers. "When a patient walks in the door, somebody can dial up and say, this patient has a laceration, where do you want them? Otherwise somebody would have to walk to the back. If you can’t find the charge nurse, it looks like a chaotic, crazy scene. This way, the charge nurse can delegate where this patient should go."

Put extra carts in the hallway during peak volumes. "You can go on diversion and bypass but that doesn’t stop the walk-ins, so you have to provide extra resources during busy times of the year. During the viral season, we get inundated, so we ask each shift to put an extra half-dozen carts in hallway for overflow if the beds are all taken," says Myers. "In order to move patients through the system, you don’t want patients in the waiting room who need to be brought back."

Use of an incentivized oncall system. "If we have to hold a patient in the ED because the census is high on the inpatient side, we have an on-call list we use. There is an incentive plan for nurses who get called in, with an extra salary benefit to come in," says Myers. "It’s better to pay the nurse time-and-a-half than have to transfer patients out because you don’t have the space."

RN-initiated standing orders. "To facilitate ancillary tests, our triage protocols have standing orders for 30 standard diagnoses," says Lenaghan.

Use of nurse practitioners. "Our nurse practitioners see some patients independently and they see others collaboratively with physicians," says Lenaghan. "We have 2.6 FTEs [full time employees] from noon to midnight, and our patient satisfaction scores went up 8 percentage points after we started using them."

Use of a behavioral health consult. "We worked together with a psychiatric hospital and established a call list for licensed behavioral therapists. After the ED physician determines the patient may be at risk, the consult comes and does a more detailed assessment," says Lenaghan. "They decide whether to admit the patient to a behavioral health facility, make the arrangements to transfer, and do the placement."

As a result, patients are not in the ED as long. "Before we used behavioral consults, it took us five or six hours to make all it happen. The consults know who to call and how to document things, so it takes only two or three hours to get a patient placed now," says Lenaghan. "This is a big problem in EDs right now, because we are seeing payers decreasing benefits to behavioral health and less inpatient health benefits. So there are more patients coming to the ED."

Use data to justify increase in physician time. "The VHA benchmarking data on patients per physician hour showed that the average of all the 81 hospitals involved is 2.13 visits per MD hour," says Ray Reidenbach, business manager of patient care services for DCH Regional Medical Center in Tuscaloosa, AL. "We knew we couldn’t afford to go to 2.13, but we wanted to make a significant improvement, so we created a goal of 3.5. Our starting point was 4.35, and we are now down to 3.05 visits per hour."

The benchmarking data convinced hospital administrators to renegotiate the ED contract for medical services, Reidenbach says. "Prior to the study, we didn’t know where we fit with other hospitals. We were pretty far out of line with the average on that particular measure, so this gave us a guide to work toward. We then calculated the number of additional physician hours we’d need to get to 3.5 visits."

Reschedule staff to match patient flow. "We charted patient visits in the ED by hour of day so our medical director could reschedule physicians to better align our coverage to match the patient flow for peak hours," says Reidenbach. "By doing that, more physician hours are used in direct patient care which improves patient flow. Peak hours are charted on an ongoing basis and reported in monthly meetings."

Improvements in efficiency were more closely linked to rescheduling for peak hours than overall patient volume, notes Reidenbach. "We suspected that our visits per MD hour data were correlated to patient volumes, but we found that they were not. A lot of it had to do with redoing the physician schedules," he says.

Additional staff hours may only be needed during peak hours, stresses Myers. "Maybe you don’t need extra FTEs during slow times, but you do need them during peak times such as summertime or viral seasons," she says. "Be creative in terms of how you staff your department, because you must be prepared for the unexpected," she says.

Use point of care testing. "We increased our use of i-stat point-of-care testing. For electrolytes, we started out at 42 minutes, with a goal of 26. We are now at less than 30," says Reidenbach. "We bought additional machines and trained the staff to use them. The lab did quality control to compare the lab sample and i-stat sample to make sure we were getting similar results. They were within a normal variance, so the lab was supportive."

Increase capacity of radiology. "We increased the capacity of radiology to service the ED by adding another x-ray room adjacent to the ED, upgrading the spiral CT scanner so it is one and one-half times the capacity we had before, and upgrading an MRI machine. We also increased the radiology staffing to handle those machines," says Reidenbach. "The radiology department had been manually keeping records of wait times and they were able to show significant reductions in delays for ED patients."

Bypass the ED for direct admits. "Physicians tend to send patients to the ED for direct admission even when it wasn’t necessary, so we internally worked out how we could bypass the ED for those kinds of cases," says Reidenbach. "We educated primary care physicians and their office managers, so patients are routed through outpatient registration area. When they arrive, their escort is there to take them to the unit."

When the physician first calls, the bed control office alerts the nursing unit so when patient arrives ancillary tests have already been ordered, Reidenbach explains. "Our baseline was 334 minutes for direct admits through the ED. For the ones that bypass, [we’re] looking at average of 15 minutes," he reports. "This was a way to provide an equal level of care without tying up the ED in volume."

A case manager for the ED. "Adding a case manager in the ED, as is traditionally done in ICU and med/surg, is a good way to ensure consistent care for patients," says Eva Morris, RN, unit manager for the ED at Lincoln General Hospital in Ruston, LA. "It can also prevent unnecessary visits to the ED that can back up patient flow. This reduces visits to the ED by clarifying instructions or explaining medication administration. Also, if a case manager knows a particular patient, [he or she] can help decide whether an ED visit is appropriate."

Link flow to satisfaction. "The first patient of every hour was our guinea pig patient which we used in our survey. Every single piece of the treatment process was broken down by time," says Morris. "Then, this same patient filled out a detailed satisfaction survey. So we not only saw how we were doing with times, but also got the patient’s opinion about how we did."

Streamline registration process. "By doing simultaneous triage and registration, we initiate treatment earlier to prevent delays," says Reidenbach. "It also allows the patient to realize the staff are caring for them immediately upon arrival. The second gain is that, when the patient is placed in a room 20 minutes after arrival, they may have x-rays already completed, so the physician can discuss findings and initiate treatment."

Track where patients are in the ED. "We developed a placement system for charts in the ED based upon where patients are with his or her treatment, so physicians and staff at first glance can tell what is going on with a patient in a particular room," says Alinder. "There are many automated systems out there to accomplish that, but they are extremely expensive, so we continue to do it manually."

In the central nurses station, four locations for charts indicate whether a patient is waiting to be seen, for lab and x-ray results, for admitting or consult physician, or for discharge. "We also have developed color coded clipboards to connotate the level of care the patient may require—red is critical, yellow is emergent, and green indicates non urgent. That allows the physicians, at first glance, to tell how many critical patients there are, so they can get a better grasp on their workload," says Alinder.

Registration staff report to ED. "Registration staff report to both the business office and the ED. That allows them to feel a part of the team, with an important role in the treatment process," says Reidenbach. "Their performance reviews are linked to their accuracy and timeliness of registration and their ability to work with patients. As a result, patient flow is impacted."

Use of patient flow algorithm. "We charted the entire process from the moment the patient arrives until they are discharged or admitted, with a detailed algorithm," says Reidenbach. (See algorithm inserted with this issue.)

Tracking delays in ancillary tests. "We worked with ancillary departments to document the time blood was drawn, when x-rays arrived, and when patients were brought back, on our nursing flow sheet," says Reidenbach. "That allows us to know what when we can expect the patient to return or lab results to be available."

Train ED nurses in triage. "We developed our own triage training tool, and also utilize components of the ENA triage training manuals. We outlined the roles and responsibility of triage and charge staff, and then have provided that education for staff nurses," says Reidenbach. "This way, if there is an influx of patients and a nurse needs assistance in triage, any staff nurse can help."

The triage training also helps when patients need to be retriaged. "We use different triage mechanisms throughout the care of any of our patients in the ED," Reidenbach explains. "If a patient suddenly becomes critically ill, any nurse can retriage that patient and determine the next level of care."

Abbreviate triage when physicians are available. "If there are only 2 or 3 patients and another patient comes to the ED, if you follow our normal triage practices, we would get the history and vital signs. But when there is a caregiver available, that process should be just to determine the level of care necessary. We do a briefer triage, have the patient registered and take them back to a room, instead of taking five or 10 minutes for triage and another two or three minutes for registration," Reidenbach explains.

Editor’s Note: For more information about the VHA National Benchmarking Consortia Study, entitled Emergency Services: Best Practices in Patient Flow Management, contact VHA Inc., 521 East Morehead Street, Suite 300, Charlotte, NC 28202. Telephone: (704) 378-2458. Fax: (704) 378-2415. E-mail: For a copy of the report on this project, please call VHA’s member support services at 1-800-VHA-PLUS. The fee for the report is $195.