The emergency department serves as the primary driver of admit volume in most hospitals, accounting for more than half of hospital admissions on average. If an ED fails to function efficiently — whether due to slow discharge processes, inefficient ED operations or ED staffing issues — some patients may leave without ever seeing a provider.
“If people are coming to the ED, they want to be seen, and if they can’t get in, [hospitals] lose revenue and potential admissions,” explains Jody Crane, MD, TeamHealth’s chief clinical officer of emergency medicine and co-author of The Definitive Guide to Emergency Department Operational Improvement. Comprising 20,000-plus clinicians, TeamHealth is a physician-led company offering staffing, administrative support and management services.
Patients entering a hospital via the ED tend to report lower Hospital Consumer Assessment of Healthcare Providers and Systems scores compared to patients who are directly admitted, Dr. Crane continues.
“Poor-performing EDs can really hinder ED revenue and inpatient revenue and utilization,” Dr. Crane warns. Poor patient experiences can translate into bad HCAHPS scores, which affect hospitals’ reimbursements in the value-based environment.
Patient flow is a major component of well-functioning EDs, and smooth patient hand-off processes can have a ripple effect across department operations hospital-wide. As the “front door” of the hospital, the ED is intertwined with the hospital’s clinical, operational and financial goals. Messy patient flow systems may negatively impact care, bottom lines, patient satisfaction scores, clinical quality and patient safety. Fortunately, there are several key steps hospital leaders can take to get their patient flow on the right track.
ED challenges — overcrowding, boarding and closed inpatient beds
The U.S. reports 141.4 million ED visits annually, according to the CDC/National Center for Health Statistics. A Press Ganey study of 1.5 million patients at 1,893 hospitals found patients who spent one hour to two hours in the ED reported an overall satisfaction rate of 89 percent. The satisfaction rate dropped to about 77 percent when patients spent six-plus hours in the ED.
“The take-home point is: If you’re efficient in the way you handle patients and you deliver reliable care, then patients are going to be almost uniformly satisfied,” Dr. Crane says. “The best way to please patients is to provide them with a reliable experience that is better than what they expected.”
Besides lowering patient satisfaction scores, inefficient patient flow in the ED can negatively influence operations across the hospital system. Consider an ED that is over capacity daily. In this scenario, let’s say a patient suffering from acute appendicitis walks through the door at 6 p.m. and is not seen until 3 a.m. The patient requires surgery at this point, but a surgeon is no longer onsite at such an early hour. Now, the hospital must call in staff to perform a surgery in the middle of the night. Ultimately, a weak patient flow system pushes volume into the overnight shift, when hospitals already have less staffing.
“If you’re not keeping up with your demands, that overnight hospitalist is going to be overwhelmed,” says Dr. Crane.
Additionally, Dr. Crane notes inefficiencies and constraints in other parts of the hospital can aggravate crowding in the ED and increase length of stay to roughly one day. This crowding may be due to closed inpatient beds. Strapped with cost constraints, hospitals are attempting to cut down on unnecessary spending, including closing inpatient beds not in use. Unfortunately, this has a ripple effect on ED patient flow.
“We’re encountering an unusual phenomenon of patients in the ED who are waiting to get upstairs, but there are closed beds upstairs,” explains Dr. Crane. While boarding in the ED may seem like the most appropriate solution in the short-term, it can also inadvertently lead to poor care quality, decreased patient safety, delayed care and low patient satisfaction, according to the American College of Emergency Physicians.
“It’s not that we’re running out of inpatient beds, but we’re running out of resources to care for patients on the inpatient side,” Dr. Crane says. “It’s a big dilemma.”
Don’t just ‘go with the flow’
How do ED leaders begin improving their patient flow systems? Improving patient flow within an ED requires trial and error and a deep-dive analysis. Dr. Crane suggests ED leaders first look at their metrics to pinpoint bottlenecks. Is the hold-up at the front door or is it a backend problem with transferring patients upstairs, for example?
Next, investigate your ED’s staffing efficiency to determine if the department has the appropriate mix of physicians and nurses at the appropriate times. Organizations don’t want to land too high or too low on national benchmarks for staffing productivity, as each extreme indicates either an excess or dearth of resources.
“We look at alignment of resources and make sure they’re paired up with demand coming through the door,” Dr. Crane says.
With a firm understanding of your ED’s problem areas, ED leaders can take action. Dr. Crane recommends mapping out an ED revamp in the following four steps.
- Build an improvement team. Identify every person who touches a patient and map the exact flow of the patient’s journey through the ED. This visual presentation will help uncover hurdles that need addressing.
- Conduct a streaming analysis. Historically, the focus of an ED has been on accelerating the “door-to-doctor” process. Now, there is a shift toward improving the “door-to-in-process,” which goes beyond door-to-doctor to include completion of testing and treatments during the encounter. To improve this time, organizations need to determine the acuity mix of their ED patients via a streaming analysis, in which organizations measure the number of low-acuity, mid-acuity and high-acuity patients coming through the door each day. “Try to understand, based on your specific volume and acuity, what the right care pathways are for those patients. Some EDs may need no pathways and some may need two or three,” Dr. Crane says.
- Align staff. Much like a streaming analysis, a staffing analysis forecasts patient demand for services every hour of the week, and even by season. Armed with this information, ED leaders can match staffing to expected demand to ensure coordination and optimization of staffing resources between physicians, advanced practice clinicians, and nurses. Physicians and nurses in particular compose two major resource groups in an ED, and hospital leaders are tasked with getting the mix right. When an ED is short a nurse, it doesn’t matter how many physicians are working, and vice versa — the patient will not move through the system efficiently. “Staffing is really important relative to flow,” says Dr. Crane. “The alignment through the week and the absolute numbers — you have to make sure you’re in a range.”
- Keep an eye on the backend. Within the ED, it’s imperative for physicians and nurses to practice handoffs. However, ensuring smooth patient flow on the backend may require restructuring on the inpatient side. “[Assess] flow management within the hospital, from speeding up discharges and really addressing the bed availability issue,” says Dr. Crane.
How to keep a finger on the pulse of your ED
Initiating change requires commitment, and leaders need to champion the new future. Dr. Crane refers to this process as “unfreezing” the ED, in which a team objectively analyzes the department’s current state and decides where the department needs to go based on metrics.
“Part of that change involves visualizing what the future state should look like,” Dr. Crane says. “We design a new system that could potentially work.”
Major behavioral change requires a gentle hand. Don’t jump in full force with the new system, but rather initiate rapid cycle testing. Try out a new patient flow process on a historically non-busy day. If it works well, try it on a busy day and then for a week. If it still operates smoothly, implement it permanently.
“[Rapid cycle testing] enables you to safely try a new process and objectively look and see if you’ve improved your metrics,” Dr. Crane says. “We engage folks by giving them a taste of the future.” He also encourages involving the C-suite by inviting executives to do a round in the ED and engage with the front- line staff.
Once a new system is in place, keep an eye on these seven “power metrics” to monitor patient flow:
- Door to Doc
- Left without being seen
- Discharge length of stay
- Admitted length of stay
- Boarding hours
- Provider productivity
- Patient experience
“When we’re monitoring, we track the most important metrics with a dashboard and compare them with CMS benchmarks,” says Dr. Crane.
How TeamHealth can help
Improving patient flow in the ED can have widespread, positive effects on operations hospital-wide. Hospital leaders considering addressing their patient flow concerns head on need not feel overwhelmed, however. With its roots in emergency medicine, TeamHealth has almost 40 years of experience offering support services, communication networks and educational resources for emergency medicine professionals.
TeamHealth’s thousands of emergency medicine providers continue to develop best practices to deliver the highest standards of evidence-based care. The company can help your hospital monitor and enhance patient flow and develop triage and staffing models to ensure a top-performing ED.
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