Project Profile: Hospital ED Patient Flow

Executive Summary – Patient Flow Improvement Cuts Length of Stay (LOS)

As a management consultant, I worked with a client hospital emergency department to reduce Average Length of Stay by 10%. Specific improvements implemented include patient arrival time and volume modeling, aligned clinical team scheduling, standardized nurse / doctor communication practices, and innovative charge-nurse-esque patient outflow coordinator.

As a management consultant I completed a wide range business improvement projects with world class companies in tons of industries. I have profiled a few of my projects here on RickMaher.info, but out of respect for my clients confidentiality, I have excluded their names and have changed some material facts and figures.

Situation

My client, was a health system that operated three hospitals each of which with one sizable main facility and numerous satellite facilities. This client was focusing on a growing trend in hospital operations – patient flow – or the optimization of patient movement through the various stages of care in a hospital in order to optimize the quality of care in tandem with hospital bed utilization. Under this focus, projects were conducted at each location, and scoped to include significant projects within many discrete departments at each location. This profile will highlight the work that I did in the adult emergency department (aka emergency room) of an 800 bed (large), university medical school, teaching hospital.

The emergency department was faced with growing demand due to community population growth and aging, and was struggling to maintain their high service level standards. In short, patients were experiencing longer wait times, and reporting reduced satisfaction in the quality of care and attention they received. As the only level I trauma center within reasonable commute, the department was also facing pressure from the state department of health to ensure constant available capacity in case of a sudden surge in trauma patients.

A capacity expansion project was being planned, but would not be ready for ~3years due to the need for a significant construction project to expand the physical space.

Task

In a management consulting role, I was brought in to identify and implement process and management improvements to increase the capacity of the emergency department within its current physical space and set-up. Further, the client insisted that patient care not only must be maintained, but indeed must be improved along with the throughput improvements. Finally, while the client and the university medical school generally worked well together, the doctors were not employees of the client and therefore were identified as a gray area in terms of in/out of scope. The core group of project stakeholders included hospital management and clinical support staff (e.g. nurses, techs, transporters, etc.).

Action

As with all of my projects, my first step was to get to know the key people, and develop a feel for the culture. The culture itself however, was absolutely unlike any other. If you’ve ever thought the chaos shown in emergency rooms TV must be dramatized, you’d be wrong. The level of activity and movement was every bit as fast and varied as I’d seen on TV, and I saw things that I will never forget – ranging from funny to scary and sad to joyous. Fairly quickly though, I realized that the level of activity was not at all chaos, most of the time it was just fast and varied. This was a key learning in getting to understand the culture and identifying opportunities to improve patient care.

Patient In-flow Patterns

In the process of getting to know the people in the department, I heard them say over and over, “you never know what is going to come through the door.” And while I came to understand their sentiment, and agree that the clinical details and demographics of patient was extremely varied, I looked to the data to uncover the real truth. In fact, as with most businesses, customer trends (in this case patient trends) are quite predictable. I was able to identify that patient arrival volumes and times were fairly predictable based on the time of day, the day of the week, and the week of the year. Further, while the clinical specifics of the patients were not very predictable, the acuity (the health severity and the amount of care resources required) of patients, by definition, was fairly predictable.

This was the first half of the story – by understanding when patients typically arrived, I was able to develop an improved staffing schedule to ensure that there was appropriate resources to address patients and prevent a significant backlog. We implemented this quickly, but saw almost no improvement.

Patient Outflow – The Real Root Cause

It became very clear that the inflow was only half of the equation, and that the outflow of patients from the emergency department was the real root cause of the long wait times. A common performance metric of hospitals and emergency departments is Length of Stay (LOS) or Average Length of Stay (ALOS). This metric is calculated by figuring the amount of time between when a patient first arrives, to when the patient departs. On aggregate, if 100 patients come in to the ED in a day, the ED Average Length of Stay for that day is the sum of each of the 100 individual Lengths of Stay divided by 100.

While the Length of Stay includes time that the patient spends sitting in the lobby waiting for care, the bulk of most patients’ LOS is accrued “in care,” the time from when they are brought to a bed from the waiting area until when they are moved out of the emergency department. Patients generally are moved out of the emergency department through two unique channels:

Discharged – patient care is complete and the patient leaves the hospital
Admitted – patient requires admission to hospital for more care, further diagnoses, further observation, etc.

In fact the mix between these two outflow channels was about 50%/50%. Recognizing that patients admitted to the hospital often faced delays due to a similar capacity constraint in appropriate hospital beds, I focused on identifying solutions that would expedite the progression of patients to be discharged. The first solution was create a standard procedure where the physician and nurse team assigned to each patient would discuss the likely outcome as early in care as possible: discharge or admit. By identifying patients in this manner, understanding that the disposition of the patient could change at any time, the team could track progress and eliminate idle time in any likely discharge patient’s process. For example, if a patient was identified as a likely discharge, and the doctor determined that the patient should be given a dose of medicine then observed for improvement, the administrative tasks related to that patient could be completed during the observation time such that as soon as the observation was complete, the patient could be quickly and safely discharged.

Care Team Communication – The Patient Flow Jackpot

This small change of forcing the doctor and nurse to talk directly to each other turned out to hit right on the real constraint in the process. While there was rarely a situation where the doctor and nurse were not communicating with each other, a surprising amount of the communication was indirect (e.g. notes in the patient chart) or left un-said, each side assuming the other was “on the same page.”

Next, communication delays were identified within the physician team. The physician teams, depending on time of day, were made up of 4-15 residents reporting in to 1-5 attendings. A phenomenon became apparent that residents were sometimes reactive or inactive in communicating up to the attending until the attending or a group of attendings called an update meeting. These update meetings would commonly go 3, 4, even 5 hours in between each, but within the 15 minute update meeting, there would be a batch of often 10+ patients that were suddenly cleared for admission or discharge.

To cut down on the physician batching I worked with the ED management to create an innovative nursing role. The position of charge nurse is common in hospitals and emergency departments, and in this busy ED, was fully occupied in managing the inflow of patients. Typically the charge nurse would work with the triage nurses to identify the patients waiting and their priority, then when a bed became available, the charge nurse would bring the patient to their bed, perform any minor immediate care tasks, and would assign a nurse to care for the patient and communicate the patient’s vital information to the nurse. We created a role that nearly mirrored the charge nurse, but was responsible for patient outflow. For example, if a care nurse was busy attending to patient A, but patient B appeared ready for discharge or admission, the outflow nurse, or Patient Flow Coordinator as we titled the role, would prod the physician to give next steps, or would assist the patient in preparing for discharge and exiting. The Patient Flow Coordinator also became an advocate for resident – attending conversations. Using tactics from gentle hinting to blunt commanding, the PFC recognized the importance of keeping a patient’s care progressing, and if a patient’s care was complete, expediting that patient’s discharge so that patients in the waiting room could receive care.

The Patient Flow Coordinator also filled a missing role in being the collaborator of all patient cases in the emergency department that were to be admitted to the hospital. Previously when two or more patients were admitted from the ED at about the same time, the first admission into the system received the first available appropriate bed. However the PFC was able to identify opportunities to increase quality of care by designating which admitted patients would be best served at the moment a bed became available.

Finally, I coached the Nurse Managers to create a regular routine of getting out of the office and administrative activities that tended to tie them down, and to work with the PFC and Charge Nurse to remove barriers to safe patient flow. Usually this meant that the Nurse Manager would identify any patient who had been in the ED for >6hrs and to convene a quick briefing on the patient with that patient’s care nurse, the resident, and the attending. In this meeting the Nurse Manager would identify the root cause of the delay and work with the care team to create a specific action plan to ensure that the patient received the appropriate care… Generally a patient in the ED >6hrs would receive better care if they were admitted to the hospital.

This active management by the Nurse Managers also kept them close in tune with any delays caused by hospital support services. For example, if the imaging department was on a backlog, the Nurse Manager could communicate that to the entire ED allowing the care teams to make clinical decisions as necessary.

Results

The Emergency Department Safe Patient Flow Project was a success. Operational improvements were measured as follows:

Adult ED Average Length of Stay decreased from 5:05 to 4:36
Average Pre-Care Wait Time was cut from 40 minutes to 25 minutes
Reduced Average Daily Elope Rate from 7% to 2%
Improved % Patients with LOS >6:00 from 45% to 27%

By reducing the strain in ED, the ED was able to accommodate patients to be admitted for a longer LOS when the hospital was at maximum capacity and unable to take in further patients from the ED.

The creation of the empowered Patient Flow Coordinator broke down the culture of doctors dictating patient care progression.

Nurse Managers performing regular and targeted Active Management rounds, prevented isolated variances from becoming crippling roadblocks for the entire ED.