• 7 Tips for Improving Emergency Department Patient Flow

    Angie Esbenshade, Stephanie O’Bryon, and Wenzel Tirheimer Oct 19, 2015

    Florida Hospital Tampa increased overall ED patient satisfaction from the 6th to 80th percentile by using an immediate bedding and team triage patient flow system.

    Florida Hospital Tampa

    Florida Hospital Tampa team members screen a patient during team triage. (Photo credit: Florida Hospital Tampa)

    When Florida Hospital Tampa (FHT) in Tampa, Fla., moved into its new tertiary emergency department (ED) in November 2014, improving patient flow was a top priority. Volumes were increasing 38 percent annually despite a 21 percent staff turnover rate and employees ranked their ED in the lowest 25th percentile for employee engagement. Patients also ranked ED doctors in the bottom 9th percentile nationwide.

    Furthermore, FHT, part of the 41-hospital Adventist Health System, knew that its subpar performance could put both market share and payment at risk once it the Centers for Medicare and Medicaid Services (CMS) requires public reporting of ED patient satisfaction scores through the Emergency Department Patient Experiences with Care Survey (ED PECS), which is anticipated by January 2016.

    To better prepare for the financial impact that publicly reported data will bring and also improve the hospital’s reputation in the community, FHT introduced a flexible patient flow strategy—Doc1stER—to ensure patients were seen almost immediately by doctors. The strategy combines two flow tactics—immediate bedding and team triage—and flexes between them depending on the number of patient arrivals in the emergency department.

    Within two months of introducing Doc1stER, Florida Tampa Hospital was recognized as the most improved ED in the Adventist system.

    How It Works

    Immediate bedding bypasses the triage process and places patients in beds as soon as they arrive when beds are available. All patient input is done at the patient bedside as soon as patients have received an armband identifier in the same way it’s typically done for emergency medical services patients that arrive by ambulance.

    When there are no beds available, the ED shifts to team triage, where a nurse and a physician do an initial patient screening together in a triage room once the patient has received an identifier and a technician has performed a blood draw. The goal is a 90-second patient interaction. The physician moves between patient rooms as needed, triaging patients to a fast track care space, acute-care bed, or results-pending area, placing initial orders for tests and treatments.

    Florida Hospital Tampa ED Workflow
    Florida Hospital Tampa ED Workflow

    The results? One year after implementation, patients at FHT ranked doctors in the 85th percentile for satisfaction. Overall patient satisfaction for the ED has risen from the 6th to 80th percentile, even as ED volume grew by 30 percent and inpatient volume grew by 20 percent. Left without being seen (LWBS) patients also dropped dramatically for an annual return on investment of $400,000 (based on capturing approximately 1,000 additional patients at a cost of $400 per patient). 

    And finally, FHT also reduced door-to-provider time from 19 to 9 minutes, a key metric that is anticipated to be reported on the coming ED PECS survey (which will likely ask patients if they were seen by a provider within 30 minutes).

    7 Tips for Success

    Florida Hospital Tampa credits its success to the following actions:

    • Diagnose before you treat. By plotting six months of historical patient arrival data, FHT could anticipate when it would need to redeploy resources from immediate bedding to team triage to match physician and nurse staffing. They asked: When do patients typically arrive? When do things wind down?
    • Explain the “why.” Physicians were on board quickly once FHT’s CEO Brian Adams connected the new process with better clinical outcomes for patients. Likewise, nurses, emergency medical technicians, and administrative staff agreed that front-loading resources made sense once leaders explained the goal was to expedite patients to eliminate unsafe treatment delays.
    • Ensure strong support from administration, physicians, and ancillary staff. Nurses can’t do it alone. FHT leaders recognized the ED sets the tone for the rest of the patient experience with 70 percent of inpatients arriving via the ED. At FHT, nurses and physicians round together on patients, which creates alignment and engagement among team members. Lab and radiology staff also understand the new process and work diligently to move patients through efficiently to meet goals.
    • Hold planning sessions to avoid delays. FHT included everyone who would participate in the new triage process to make sure they were informed about expectations. For example, lab testing would be delayed if radiology also lost time trying to locate patients. Likewise, patient access staff would be delayed in completing full registrations if they weren’t sure where to find emergent patients who didn’t go through the usual admitting process.
    • Test change along the way. To help FHT staff prepare and become accustomed to the process changes, the hospital tested the new process on days that weren’t busy or during single shifts for 30 to 60 days before launch. Throughout the pilot, FHT staff reflected on what worked well, barriers that needed to be addressed, and opportunities for improvement. For example, if a physician needed to request more tests after the patient was triaged, it added time to the patient’s stay. As a result, FHT staff clarified when this type of action is appropriate.
    • Deliver unwavering consistency and repetition. First, front-line leaders and nurses at FHT helped design new work flow processes. Then they practiced using them. They recognized that change is hard: Just as your brain needs time to adjust moving a trash can in your office, so too does it take time to hardwire a new behavior. Every new ED hire participates in a simulated training for constant revalidation to ensure training sticks.
    • Step up communication. FHT leaders rounded on clinicians and employees daily to collect feedback and make changes on how the process is working. They asked: What’s working well? What are your observations about the process? They also used a quick huddle at shift changes so everyone had a shared understanding of real-time flow performance compared to goals and the number of patients who are leaving without being seen.

    The ED Transformation

    As healthcare continues to transform itself, EDs are transforming too. A smooth workflow in the ED sets the tone for the rest of the patient experience as more than two-thirds of inpatients arrive via the ED. With tracking of ED patient satisfaction by CMS expected in early 2016, hospitals and health systems that build strong support from administration, physicians, and ancillary staff for efficient and patient-friendly EDs are likely to experience strong patient loyalty and a positive impact on the bottom line.

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    Angie Esbenshade, RN, MSN, is an emergency department special coach, Studer Group, Pensacola, Fla.

    Stephanie O’Bryon, MSN, RN-BC, is administrative director, emergency department operations and patient services, Florida Hospital Tampa. Stephanie.O’Bryon@ahss.org

    Wenzel Tirheimer, MD, is an emergency department doctor, Florida Hospital Tampa.

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