Drawing on more than 15 years of experience as an emergency physician and medical director, Dr. Kenneth Heinrich, a regional director and medical director of Emergency Department consulting services for ECI Healthcare, a division of Schumacher Clinical Partners, identifies in this series the ED practices ripest for efficiency gains.
This article, Part Two of a three-part series, describes some of the primary drags on in-room efficiency in the emergency department (ED) and lays out the general rules of thumb and specific measures EDs can take to avoid them. Part One focused on the arrivals process. Part Three will focus on patient disposition. Although each of these articles details changes that can improve workflow and patient satisfaction, EDs need to address all three parts of the patient's journey to achieve real volume gains. As any patient who's been admitted promptly only to be marooned in a room will tell you, bottlenecks in one area can always derail progress in another.
Drag 1: Lab testing and radiology
Perhaps because of their ubiquity and utility, lab testing and radiology are typically the two biggest culprits of slow-down in the in-room patient work-up. Radiology-related delays occur mostly when the ED physician must wait for imaging to be completed before he or she can prescribe an appropriate treatment. CT scans and ultrasounds are the more frequent cause of delays because those, by and large, must wait to for interpretation by a radiologist. Patient flow hinges on the radiologist's availability and workload in those instances, in addition to timeliness of study completion.
Because most emergency departments have a limited amount of space in which to see patients, tying up beds with patients waiting for testing isn't simply an efficiency issue. It also can be dangerous, relegating incoming patients—some whom may be in dire need of emergency care—to the waiting room.
Efficiency trick: Evaluate and adjust; repeat
The way to speed up these processes is the way to speed up any workflow issue: evaluate and adjust, evaluate and adjust.
All hospitals should measure lab turnaround times and radiology turnaround times, focusing especially on the most common lab and radiology tests performed in the emergency department. Importantly, it's not just measuring turnaround that's necessary, but measuring turnaround time as it is experienced by the patient. Just as with the arrival process, the various steps of lab test ordering, confirmation, and verification may seem brief from the provider's perspective, but it adds up for the patient on the other side.
A patient who waits an hour for a test result would likely be irritated to hear the lab tout a turnaround time of 20 minutes—even if, from the time the sample was recorded to the time the test is completed, only 20 minutes have passed.
The ideal way to evaluate these processes, not surprisingly, is to track times automatically. Both the lab and the radiology department should be hooked into the same EHR as the emergency department, so that the clock starts the second the order is entered from the ED. That leg of the relay clock should stop when the result is in the computer, ready for viewing. Understanding which of these different components is behind the delay is crucial for identifying perennial bottlenecks or persistent issues.
Medical directors should seek out reporting not only on the average or median times but also on the outliers. With an overall turnaround time goal of 45 minutes for a particular lab, and an average of about 40 minutes, things aren't necessarily okay. It may be that the average is 40 minutes, but that the range is from 25 minutes to an hour and a half. If there are a significant number of times where an ED is waiting an hour and a half for lab results, the impact to emergency department flow is immense. Once those red flags are identified, the appropriate changes can be made: staffing may need to be adjusted, or the ED may need more help drawing labs at certain times of the day. Although the appropriate tweak would depend on the particular circumstances of the ED, some of the solutions I have suggested over the years include having lab techs help out during certain hours; reducing some nursing hours to allow more nursing assistants to accomplish more of the necessary draws; shifting some nurse and tech hours from low-volume hours (typically morning) to better serve busier hours (typically evening). At the least, medical directors need to know how often the hospital exceeds its goal turnaround times or thresholds.
Drag 2: Physician and advanced practice provider (APP) workflow
Part Three of this series will zero in on ways to improve the patient disposition process after a decision has been made to "dispo." But one of the main delays for in-room efficiency can be traced to the time before that decision is issued. There are very few EDs where you won't find patients occupying rooms unnecessarily, waiting for disposition.
Part of the issue is intrinsic to emergency medicine today, where the emphasis is on getting a provider to patients quickly. That emphasis echoes the ED physician's guiding directive to "stabilize and treat."
In my experience, however, emergency medicine needs to acknowledge a second, counterintuitive axiom: It is generally faster and more efficient to disposition existing patients before picking up new patients.
Efficiency trick: "Disposition first"
When Dr. Jeffrey A. Schwartz, chief medical officer at ECI Healthcare, was my regional director, he insisted on a short and sweet version of that axiom: "dispo first." With the obvious caveats about emergent patients, both workflow and bed space in the ED are more efficient when physicians work on getting stable patients out of the ED before they move to new patients. Physicians who accept this axiom can look to various strategies to help accomplish this goal.
Teamwork approach: Look to nurses to act on their knowledge and prompt physicians toward dispo. Nurses often have the best awareness of where patients are in the overall flow, especially in terms of whose results are back and awaiting physician review. A good ED nurse will prompt the physician toward disposition: "It looks like everything is back—are we ready to dispo this patient?" While some physicians may get a little bit frustrated by that prompt because they feel that it's added pressure on them, the nurse is really doing what's right for the patient. It's undeniable that physicians can get bogged down in the details of their many patients; EDs should capitalize on any type of support that both moves patients along and clears up personal bandwidth for the physician.
Individual suggestion: Following the philosophy laid out by Atul Gawande in his 2009 The Checklist Manifesto, physicians can keep a checklist, or "scorecard," of where their patients are in the process. One version could have check boxes for everything the physician is waiting on, whether that's labs, X-ray, CT, or discussions with the admitting physician. Every time something comes back or gets done, the physician should check it off. The physician can review the list constantly in order to self-prompt his or her way to faster dispositions.
Drag 3: Systemic workflow issues
Perhaps the ED team is not working as fast as the flow of information permits: an order is in, but the patient is waiting for a sample to be taken. Or results are back, but physicians aren't reviewing them. Or a patient is ready for disposition, but the order isn't there.
Issues like these, coupled with a renewed emphasis on disposition, can be addressed at an administrative level with the addition of a position dedicated to patient flow. Considering the financial pressures on today's hospitals, it's a difficult sell to get a CFO to approve a new hire for the ED. But if bottlenecks are threatening ED efficiency, with certain effects on patient satisfaction and possible impacts on the quality or speed of care, an added position—or at least, the added concept of patient flow coordination—could be cost-effective.
Efficiency trick: Add an Air Traffic Controller
Right now we act as our own air traffic controllers. A charge nurse is supposed to fill this need, but charge nurses in the typical ED are, in my experience, swamped. With a dedicated patient flow coordinator, though, busy EDs are better able to pinpoint and eliminate unnecessary delays. Whether it's an empowered APP and nurse team, an individual checklist, or a new position entirely, today's ED must find ways to be more aware of traffic flow, the status of test results, when reassessments are needed, and who is ready for disposition.
Conclusion
As discussed above, encouraging an orientation toward "dispo first" is one of the fundamental ways to improve efficiency in the ED. The last part of this series explains how to capitalize on that focus during the actual disposition, and how to ensure that the strides made in these earlier stages are realized when the patient leaves the ED.
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