Study offers solutions for bottlenecks: Treat and move patients in record time

Benchmark study of 100 EDs addresses your ED’s worst problems

Would you like to cut more than two hours from the time it takes to get a patient out of the ED and admitted upstairs? A national benchmarking study has discovered innovative ways to do just that, identifying best practices at more than 100 EDs.

The Clockwork ED Series on Eliminating Bottlenecks and Delays was developed by the Washington, DC-based Clinical Initiatives Center, a membership-based health care organization that performs strategic research for more than 1,500 hospitals. Three segments of a patient visit were identified: time to physician, time to ancillary services, and expediting admission. Best practices were identified for each. (See tips focusing on physician delays, p. 29.)

"This project is without a doubt the most exhaustive and insightful review of ED practice as a single body of work," according to Joseph Guarisco, MD, FACEP, chairman of the department of emergency medicine at Alton Ochsner Medical Foundation in New Orleans, which participated in the project.

Getting patients out of the ED is the single biggest bottleneck that ED managers face, says Gabor Kelen, MD, chair of the department of emergency medicine at The Johns Hopkins Hospital and professor at The Johns Hopkins University School of Medicine, both in Baltimore. "All the data shows you can spend all the time you want on the front end, but if you don’t fix the back end, it’s almost meaningless," he says. "All that will happen is you’ll delay by an hour or so when your ED becomes clogged."

The biggest obstacle to reducing delays in getting patients upstairs is the cultural divide between the ED and other hospital departments, Kelen says. "The vast majority of services are used to controlling their volume and workload. They see patients one at a time in serial mode and want to do the best they can for one patient before going on to the next."

The ED’s operations are very different, he emphasizes. "We have to work in parallel, caring for multiple patients simultaneously in different stages of work-up. We consider the total patient volume as one big organism and must provide the best possible care for that large organic system, and not necessarily for its individual parts."

Still, there are ways to get around that obstacle and bypass delays in the admitting process, urges Kelen. (See flowchart that identifies ED bottlenecks, enclosed in this issue.)

Here are some of the best practices identified by EDs that participated in the Clockwork ED Series (see tips on cutting delays for admitted patients, p. 27):

• Bed control bypass.

ED nurses fax or tube reports to inpatient nurses and send patients directly to inpatient beds. "This reduces the chance that the nurse will come up with an excuse not to take the patient," says Kyle Weston, a consultant for the Clinical Initiatives Center who worked with ED managers who participated in the project.

Common excuses given by floor nurses include shift changes, lunch breaks, or unmade beds. "Some of these excuses are definitely legitimate and they are not always stall tactics, but they still delay getting the patient upstairs," says Weston.

• Instant bed-status alert.

The floor nurse is removed from the communication process regarding bed status.

"Instead, housekeepers or transporters will flag the ED when the bed is ready to be cleaned and will automatically page staff so the next step is completed," says Weston. "As a result, the ED has more intelligence into what the status of the bed is, and the appropriate people are alerted when the bed is ready to receive the patient."

This eliminates communication delays by removing floor nurses from the process, so no data entry is needed, he says.

• Emergency physician admission authority.

This practice has reduced turnaround time for admissions in the ED at Alton Ochsner from 5.5 hours to 2.8 hours, reports Guarisco. "The emergency physician requests a bed as soon as the need for admission becomes evident. Not only is the bed requested, but also the patient admission process is initiated."

While the patient is being evaluated, the bed procurement and admission processes are taking place simultaneously, Guarisco says. "The consultants are notified once all of the critical information necessary to make management decisions is obtained. Consul tants are involved in the management of the patient early, once sufficient information is obtained which allows the consultant to initiate orders for inpatient management."

The former process in which the ED physician saw the patient, ordered the test, waited for the results, called the consultant, and then initiated the admit process was too time-consuming and cumbersome, he emphasizes.

• Zero tolerance for empty ED beds.

At Johns Hopkins, patients are always brought back when there is an empty ED bed, with empty beds hand-counted at four-hour intervals. "There used to be resistance from nurses to bring patients from the waiting room or from triage to an empty room, since they might not be able to get to them right away," notes Kelen.

It’s better to put patients in rooms even if you can’t treat them immediately, he says. "If they are in the waiting room, there is further delay. Also, if a patient crashes, they are better off in a treatment room than a waiting room."

Nurses were extremely resistant to this idea, so a new nurse manager was hired to help implement the program, he notes. "Eventually, they understand that this change has to occur, and it has reduced delays significantly."

Staff members are resistant to change as a rule, Kelen says. "People get into a certain mode, and it’s very difficult for them to adapt. So you literally have to make it somebody’s job and build in incentives to their job structure." The ED is working with hospital administration to find ways to reward nurses for reducing delays, he adds.

Data are collected on room availability and the number of patients waiting, and the data are shared with the charge nurses, he says.

• An admission facilitator.

This individual handles all the administrative work in admitting a patient, which includes dealing with the floor nurses; previously, those administrative aspects were completely in the hands of house staff, says Kelen. "So a house officer would phone another person upstairs and notify the medical shift coordinator and let central admitting know. Admitting would then notify the ED that the bed has been assigned. The whole process was extremely time-consuming."

Admission facilitators are extensions of the admitting office. "They don’t work directly for the ED; they work for central admitting," Kelen explains. "This is similar to the way you would put a satellite lab in the ED, which is run by the lab, but under our control."

The facilitator fills out a form that begins the tracking of the admissions process. (See copy of form, p. 28.) "They record some basic information, including the patient’s name and who the admitting attending is going to be," says Kelen. "At that point, the time starts ticking."

The following times are documented:

— the time the decision to admit was made;

— the time the facilitator was notified;

— when the medical shift coordinator was notified;

— when the patient arrived.

The facilitators also make sure all insurance information is verified and next of kin is recorded. "We can’t get a patient up to the floor until all that information is completed," Kelen notes.

A checklist is filled out with the steps the ED needs to complete, such as sending chest X-rays or labs, before the patient is sent upstairs. Then the facilitator makes sure the staff upstairs are notified in a timely manner, he says.

The time the bed is ready is recorded. "At that point, we only give them about 40 minutes before we send the patient up," says Kelen. Approximately three hours were saved since the facilitator was hired. (See chart, p. 29.)

• A place for patients.

EDs need to have their own "back-end safety valve," a place for patients other than the waiting room, he suggests. "This is a place completely under the ED’s control, such as an observation unit. This is the only solution in institutions where priorities of other services are not aligned with the ED."

• Transformation of the ED into an inpatient-style unit.

The most innovative approach is the creation of an ED-managed inpatient-style unit that transcends observation all the way to full admission, says Kelen. "The ED physician takes the role of the inpatient attending," he explains. "Thus, the ED is not held hostage to the vagaries and practice styles of physicians and services elsewhere in the hospital." The Johns Hopkins ED will be implementing that unit in July 2000, he reports.