Improving ED Throughput

Case Study

A 511 bed regional academic medical center requested a thorough

assessment and recommendations for improvement from HCT Consulting in
regards to their Emergency Department’s throughput times. This Level 1
Trauma Center is the 2nd largest Emergency Department in their state and
they average 8500 visits per month.

HCT assessed this hospital’s times by examining the three distinct phases of
ED throughput: intake, throughput and output. HCT collected data from each
of these phases, closely studied and observed processes, and conducted
interviews with leaders, physicians, staff and patients. Based on this
information, HCT made recommendation for improvement that had
significant impact with the hospitals throughput times.

During the intake phase, HCT analyzed the ED department’s registration,

triage and fast track processes. Much data was collected in this phase:
average visits by hour of arrival, distribution of cases by Emergency Service
Index (ESI), number of visits by hour based on the ESI, average check-in to
Triage time, and average Triage to room time. HCT made several
recommendations based on their assessment: implementation of a quick
registration process, relocation of triage, improvement in signage and the
addition of a volunteer greeter to direct flow in the waiting room.
Additionally, several changes to their fast track process were recommended,
such as: hours of operation, enhancements to office equipment and having a
MD/RN combo in triage during peak times to perform Medical Screening
Evaluations (MSE).
Much time was devoted to observing communication and teamwork during
the throughput process. Understanding the role of case management, as
well as the other members of the team was gained during this time. This
facility had initiated many processes during this phase and HCT determined
the effect that these multiple initiatives were having on the staff and their
throughput times. Of importance during this phase was the action of the
staff and the process they followed when they became over capacity. The
relevant data collected during this phase was average room to provider time
and average provider to bed request time. Recommendations to enhance
this phase included: implementation of a capacity alert policy, development
of a method to measure success on implemented initiatives, streamline the
number of initiatives being rolled out, a system to effectively evaluate
initiatives as they are implemented, and a communication plan to make
everyone aware of progress.

ED Output has several components. HCT investigated the multiple reasons

for delays in this phase of the process. The roles of Patient Flow Coordinator,
Bed Control and nursing in the ED and on the inpatient units were all closely
evaluated. Since the availability of beds in the inpatient units greatly
affected delay times, HCT analyzed the delays in discharge for inpatients.
The metrics measured during this phase included: average provider to bed
request time, average bed request time to discharge and average provider to
discharge. The evaluation of this phase resulted in several
recommendations: redesign of the roles for Patient Flow Coordinator,
Hospitalist, and ED Case Manager, enhancement to the bed control process,
establish parameters for Academic Medical staff for inpatient discharges,
update hallway bed policy, enhancement of processes that determine
isolation requirements, improvement to bed board meeting, new
housekeeping pager system, adjustments to housekeeping staffing, daily
huddles between unit based case managers and nursing, education for
nursing on DRGs, LOS and Case Management roles and responsibilities,
InterQual® education for case managers and creation of a Palliative Care
Team.

The hospital implemented many of HCT’s recommendations and quickly

experienced many positive results. Patient assigned bed times have
improved with 60% of patients being assigned a bed in 30 minutes and 90%
of patients being assigned a bed in one hour. Boarder hours have decreased
from 10.69 to 6 hours with a goal to move this to 4 hours. Left without being
seen (LWBS) decreased from 11.65 % to 7%. Many units have adopted the
process of discharge by appointment which is having an effect of patients
being discharged earlier in the day from inpatient units.

HCT’s thorough assessment of the phases that contribute to ED throughput

times and their recommendations led the way for this hospital’s
improvement. HCT has provided continued support to this hospital as they
persevere in improving their ED processes, thereby providing better quality
of care to their patients.