• Unclogging Patient Flow in the ED and Beyond

    Mar 01, 2012

    Breakthrough Practice Map

    With health reform measures promising to increase the ranks of the insured, hospitals and health systems are getting even more serious about improving patient throughput so they can absorb the extra volumes.

    Here is a sampling of breakthrough patient flow practices being adopted by progressive organizations in the emergency department (ED) and beyond. To view the infographic, click on the jpg images below. To learn more details about the specific practices highlighted, scroll down.  


    If you have trouble reading these jpg files, download a PDF of the infographic.  

    Details on ED Flow Innovations


    • Reduce unnecessary volumes
    • Avoid overcapacity/diversion

    Help patients find the least busy ED. Middlesex Hospital posts wait times for its three EDs that patients can access via smartphones and computers.

    In September of 2009, the central Connecticut hospital began posting the wait times of each ED (the hospital's ED and two satellite EDs) on its web site, according to a January/February 2011 case study in Urgent Matters E-Newsletter. Wait times are updated every five minutes. About a year into the effort, 3,000 people per week were accessing the wait times. More important, wait time across the three EDs began to level out. 

    Pilot frequent user programs. Spectrum Health identified patients who use the ED 10+ times a year-and launched a clinic just for them.

    Spectrum's new multispecialty center is a response to an issue identified by emergency and addiction medicine specialist R. Corey Waller, MD, MS, in 2008, according to a Spectrum press release. During that year, about 950 patients were identified as visiting Butterworth and Blodgett hospital EDs greater than 10 times. These patients were responsible for more than 20,000 total visits and $40 to $50 million in costs. 

    The central goal of the Center is to identify, accurately diagnose, and develop a care plan for each patient. When treatment is stable and the patient has successfully followed up with a primary care physician, the patient will be transferred into a primary care office. It is estimated that the program could save commercial insurers plus Medicare and Medicaid more than $15 million in Spectrum Health ED reimbursements during the first year of operation.

    Collaborate to eliminate diversions. After targeting zero diversions, Syracuse hospitals cut total hours on diversion by ~75 percent.

    "Diversion can be eliminated only when it's the focus of the entire hospital, not just the ER," said John McCabe, MD, CEO at Syracuse, N.Y.'s Upstate University Hospital in a May 2010 article in The Post-Standard

    Hospitals in California and Massachusetts are also reporting reduced diversions after regional or statewide decisions to eliminate ambulance diversions, according to a November 2010 article in Emergency Medicine News

    In addition, the California ED Diversion Project documented diversion declines of about 20 percent after collaborative efforts in California metropolitan areas that involved hospitals, local emergency medical services, and other stakeholders, according to a March 2011 study


    • Reduce wait times
    • Enhance patient experience

    Eliminate the waiting room. At Penn State Hershey Medical Center (PSU-HMC), patients are triaged in an ED greeting area, which only contains a few chairs.

    After a brief registration at Penn State Hershey Medical Center, the patient is triaged by a nurse, ED technician, and a physician/physician assistant, according to a January/February 2011 article in the Urgent Matters E-Newsletter. The provider conducts a medical evaluation and, as necessary, orders tests or sends the patient to an ED room for complex resuscitative care. While critical patients are sent immediately to a room, many patients can be treated and discharged without using a room. The left-without-being-seen rate fell from 5.7 percent to 0.4 percent, while volumes increased from 42,000 to 62,000.

    Swedish Medical Center in Issaquah, Wash. has also eliminated its ED waiting room, per an October 2011 article in Becker's Hospital Review. When an ED patient arrives, a greeter notifies the clinical team and brings the patient into a treatment room. Patient satisfaction is greater than 95 percent. 

    Pull till full. When an ED room is open, Christiana Care Health System uses direct bedding, bypassing triage and placing patients in open beds.

    The intervention was a major cultural shift for staff, says Heather Farley, MD, assistant chair, department of emergency medicine, in a September/October 2011 article in the Urgent Matters E-Newsletter. "Triage nurses realized that their workload was lessened, but core nurses were uncomfortable getting patients who had not had full assessments. Physicians were confronted with full chart racks showing how much work was yet to be done-which is not necessarily a bad thing." 

    Tell patients what to expect. Orlando Regional Medical Center increased patient satisfaction with a waiting room video on what occurs during an ED visit.

    Patient satisfaction was about 12 percent higher in patients who watched the video, according to a July 2008 study. The authors conclude: "Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population." 

    Start the patient's care. Thanks to standing orders for common complaints, University of Kansas Hospital nurses can arrange EKG and other tests while patient is in the waiting room.

    The ED staff worked with physicians to create standing orders for the 10 most common patient complaints, such as abdominal pain and extremity injuries, according to a  2009 article in The Business of Caring. These standing orders allow nurses to start a patient's care-for example, sending the patient for an X-ray or EKG and drawing blood-while the patient is in the waiting room. A small lab draw station was created near the waiting room to provide privacy.

    "The time that the patient was sitting there and doing nothing is now value-added time," says Selig. "This has reduced our left-without-being-seen rate because the patients perceive that they're getting their treatment started."

    Bonus point: Physicians appreciate having more information about the patient's condition when they arrive in the exam room because it allows their work to proceed more efficiently.


    • Employ team-based, rapid assessment
    • Segment patients for specialized care

    Triage as a team. Inova Fairfax Hospital's triage team includes an ED physician, nurse, scribe, emergency technician, and a registrar.

    The five member team works together on the ED patient's evaluation and treatment. "The scribe records everything the physician says and the technical assistant completes multiple tasks, such as order-entry. A registrar expedites care by registering patients into the Inova Fairfax Hospital computer system," according to a March/April 2011 case study in Urgent Matters E-Newsletter

    Patient throughput time for patients seen by the triage teams decreased by 64 percent. In addition, patient and staff satisfaction increased, and left-without-being-seen rates decreased.

    Segment patients by severity level. A triage nurse at Good Samaritan assesses the patient and triages them into three groups: emergent (higher acuity), urgent (complex, lower-acuity), and nonurgent (low-acuity).

    The ED at Good Samaritan Hospital in Suffern, N.Y., has 19 bays: 14 in the main ED and five for minor procedures. Patients who bring themselves to the ED are now met by a greeter/registrar and sign in at a quick registration kiosk. A triage nurse then assesses the patient and triages them into three groups:

    • Emergent (send to the main ED bays)
    • Fast track/urgent (treat in minor procedure bays and discharge or admit, as appropriate)
    • Super track/nonurgent (provide any needed tests or minor treatments, discharge from ED)

    Read the full October 2011 Leadership article: Going with the Flow: Three Strategies Help Improve Patient Throughput.

    Establish specialized units. St. Joseph's Regional Medical Center has a geriatric ED, and Bellevue Hospital Center established a step-down chest pain center.

    Establishing units for specific types of patients or expanding observation or step-down units can help free up critical ED beds and ensure patients get needed care. New York City's Bellevue Hospital Center established a six-bed chest pain center in 2010, according to an April 2011 report by the National Public Health and Hospital Institute. ED staff can now send chest pain patients-who do not appear to have a heart attack but should require monitoring-to a step-down area.

    St. Joseph Medical Center in Paterson, New York, has reduced hospital readmissions of geriatric patients by opening a geriatric ED. When they arrive at St. Joseph's ED, patients ages 65 or older are transferred to a separate 14-bed geriatric unit, unless they require immediate emergency assistance, according to a March/April 2011 article in Urgent Matters E-Newsletter

    A third example: Grady Health System established a seven-bed Care Management Unit in the ED for patients with diagnoses of asthma, chest pain, congestive heart failure, or hyperglycemia, according to a January/February 2011 case study.


    • Synchronize/standardize steps
    • Reduce handoffs/waste
    • Bring care closer to patient

    Assign dedicated teams to each track. At Thomas Jefferson University Hospital, separate ED teams manage emergent, urgent, and nonurgent patients.

    Each of the ED teams includes nurses, physicians, techs, and physician assistants, according to a June/July 2011 case study in the Urgent Matters E-Newsletter. "Teams are thinking critically about how they use their resources. For example, they are assessing whether it is necessary to continue taking vital signs on a patient every two hours if the patients are completely stable and in the process of getting admitted to another department where patients' vital signs will be monitored every four hours." 

    Redesign each track. Using Lean methods, teams at Christiana Care Health System streamlined all three tracks, reducing length of stay.

    The team assigned to tackle the nonurgent (or fast) ED track, reduced length of stay for these patients by 51 percent, according to a September/October 2011 case study in Urgent Matters E-Newsletter. Separate teams also used lean methods to reduce length of stay for emergent and urgent patients, by 36 percent and 20 percent respectively. 

    Christiana Care Health System used three common approaches to improve efficiency on each ED track:

    • Patient segmentation, or dividing patients by Emergency Severity Index group
    • Synchronous work, or accomplish more than one thing at a time
    • Standardized work, or reduce variability

    Provide point-of-care testing in ED. Massachusetts General Hospital created a satellite lab in the ED that offers a limited menu of rapid tests.

    The ED lab kiosk is managed and staffed by the hospital's central core laboratory, according to a September/October 2011 case study in the Urgent Matters E-Newsletter. A 2003 study found that the ED lab decreased test turnaround time by 87 percent, which correlated with a reduction in overall ED length of stay.


    • Commit to improve hospitalwide flow
    • Pull ED admissions (versus ED pushing admissions)
    • Establish surge capacity tactics

    Centralize bed management. The RN-staffed patient placement center at the University of Mississippi Medical Center coordinates all admissions.

    Akin to an air traffic control center, this unit combines all of the bed control functions, admitting nurse functions, and front-end utilization review nurse activities, as described in a June 2010 hfm case study. This level of centralization enables the patient placement center to maintain accountability over bed control, place patients in accordance with best-practice algorithms, and even cluster patients by attending physician to enable physicians to complete their rounds more efficiently.

    Good Samaritan Hospital, in Suffern, N.Y., also has an RN staffed patient flow center, according to a  October 2011 case study in the Leadership enewsletter. Directed by Kitty Welsh, RN, the Logistics Center manages bed availability, patient transport, patient discharges, and housekeeping from one centralized area. An electronic bed board is a major component of this central command center. Implemented in early 2011, the web-based bed board gives nursing and admissions staff a real-time snapshot of the status of beds across Good Samaritan. By looking at the bed board-which is viewable from any computer with Internet access and via a large monitor in the ED-staff can instantly obtain key bed information. As room information is updated, the changes are displayed in the "bed status" window.

    Schedule early discharges to free up beds. Kaiser Foundation Hospital aims for 11 a.m. discharges.

    After discovering that most admissions/discharges were occurring on the night shift, Kaiser Foundation Hospital set the goal of having 40 percent of discharges happen before 11 a.m., according to a case study from the California ED Diversion Project. "Discharge rounds now take place at 11:30 am, to begin the process of the following day's discharges. During these rounds, they identify which patients are likely to be discharged the following day, so that they can make sure that all necessary work is completed ahead of time, and a time can be scheduled for these patients to be discharged the following morning." 

    Adopt a boarder. When Stony Brook University Medical Center's ED reaches capacity, patients awaiting admission are given beds in acute care hallways.

    In the first year after the protocol was implemented, ED patient satisfaction increased from the bottom percentile to the 80th percentile, while inpatient satisfaction held steady, according to a case study in the March 2007 issue of The Business of Caring. The new approach has also impacted length of stay. A study conducted at Stony Brook found that the average length of stay is 0.8 days shorter when patients are moved to an inpatient hallway, compared with an ED hallway. A 2002 study by the Health Care Advisory Board found that reducing LOS by one day is equivalent to adding 49 new beds in a typical 300-bed hospital.


    • Avoid clogging ED with patients waiting to leave
    • Prevent unnecessary future ED visits

    Establish a discharge lounge. Bellevue Hospital Center's discharge center is open part-time five days week, currently processing 1,000 patients.

    "This gives ED staff an avenue for freeing up beds and sending patients to a more private area for step-down clinical care, as well as dispensation of discharge instructions, according to an April 2011 report by the National Public Health and Hospital Institute. The discharge coordinator also has full access to the team of 29 certified, in-house interpreters."

    Partner with health centers. A Maryland health center works with a local hospital to link eligible patients to a primary care provider at the center.

    Baltimore Medical System community health workers are at the ED from 8 a.m. to 11 p.m. weekdays and some weekend hours, according to a May 2011 U.S. Government Accountability Office report. Community health workers meet with eligible patients after triage by ED staff to discuss the benefits and services available at the health center. Community health workers schedule follow-up appointments for patients who would like to receive care at the health center. At their first health center appointments, patients are connected to primary care providers who, in coordination with case managers, oversee the patients' future needs.

    Navigate to primary care. ED navigators at Presbyterian Hospital set up appointments with primary care physicians for nonurgent patients.

    In July, the 453-bed hospital started the program aimed at reducing ED traffic by deferring such nonemergency cases like earaches and minor wounds to the hospital's primary care physicians, according to an October 2010 case study in HFMA's Healthcare Cost Containment newsletter. Currently, the hospital's ED gets about 180 visits a day; the goal is to reduce the number of ED visits by 10 to 15 percent, says Mark Stern, MD, medical director, Medical Management and Endcare Coordination, Presbyterian Healthcare Services, a network of eight hospitals in New Mexico.

    All patients are first triaged by a nurse to determine the required level of care. Cases like earaches, sore throats, and lower-acuity upper respiratory infections in patients older than two years old are sent to a clinician, such as a nurse practitioner, who performs a screening and obtains a medical history. Cases that are nonemergent or nonurgent are sent to customer service representatives, called navigators, who then schedule an appointment for the patient to see a primary care physician within 12 to 24 hours; uninsured patients are connected to other care resources within the community.

    More Breakthrough Flow Practices

    In addition to the tactics outlined above, many hospitals and health systems are reporting success with the following tactics.

    • Make patient throughput an organizationwide goal
    • Track and communicate performance on patient flow metrics, such as door-to-doctor times
    • Collect and trend data on ED volumes at various times and during various seasons-and staff to match demand
    • Consider radio frequency identification (RFID) or real-time location system (RTLS) technologies to help track patients, staff, and supplies/equipment
    • Add pharmacists to ED team to help with medication reconciliation and other issues
    • Test operating room flow tactics, such as block scheduling
    • Engage hospitalists in preventing hospital-acquired conditions and reducing length of stay
    • Hold daily multidisciplinary bed meetings
    • Establish a hospitalwide or multidisciplinary flow committee/team
    • Review housekeeping and transportation policies that can slow turnaround times