The first two parts of this Clinical Efficiency Tricks series laid out the systemic and individual changes that can improve emergency department (ED) patient flow during the arrivaland in-room processes.
This article concludes the series by focusing on the two drivers of efficiency for the disposition of ED patients.
The first driver is the ED's orientation or culture. Begin to evaluate that orientation by considering questions like these: Is there the same urgency around disposition as there is around intake? Is the discharging physician helping to get the patient out of the ED, and are all of the necessary resources in place to conclude that visit? Think prescriptions, instructions, and even an escort—all of these elements need to be priorities for any ED interested in efficient patient flow from beginning to end.
The second driver is much simpler: Are hospital beds available when you need them?
1. Create a Culture of Urgency
Traditionally, ED physicians would see patients and then decide when those patients were ready to be discharged. They would fill out discharge instructions and prescriptions, put it on the chart, and walk away. After that, the nurse took over—talking with the patient, ensuring that he or she understood the instructions and next steps, and contacting the ED physician only if there were any remaining questions. At some point after the physician's discharge decision and according to the nurse's timetable, the patient would actually leave the ED.
The gaps in this process—the time from physician to nurse, nurse to patient, and then patient to door—are too unpredictable for an efficiency-oriented ED. Most obviously, these time lags can delay room openings for incoming patients. Less obvious is their impact on the patient being discharged: delays late in the visit can sour a patient on the entire experience, coloring his or her memory of the process even if the arrival and in-room phases went without a hitch. The ED just missed out on its final opportunity to make a good impression.
The "trick" here is to loosen up roles and get people to rally around disposition as they did around arrival. Nurses and providers should be equally, and cooperatively, engaged in the discharge process and should have the flexibility to function as a team.
As an example, at one of our hospitals we created a page for patient discharges using Vocera, a secure wireless communication system. After I saw a patient and was ready for that patient to be discharged, I would simply announce into my communication badge, "Discharge, room 18." That meant everybody operating Vocera in the ED knew that there was a patient in room 18 whose workup was complete—and anyone who was free would check in with the primary nurse and show up to help discharge if necessary.
There are some EDs where the nurse is not the only one discharging patients: in many of the simpler cases, a provider can complete the entire discharge. Even in this case, it's important to check in with the nurse to make sure nothing else is needed (repeat vital signs, for instance) prior to discharge. When people in the ED think of themselves as part of a team, rather than as distinct and hierarchical positions, the disposition process can be as nimble as the arrival process.
2. Inpatient Collaboration
Where many hospitals struggle is after the decision is made to admit the patient. Too often, patients are left waiting in the ED for yet another evaluation or because an inpatient bed isn't ready for them. The trick in the former scenario is to have fostered a true partnership between the ED and physician leaders from the hospital side. Hospitalists and the ED need to work together to ensure most hospitalist evaluations and full-admission orders are performed on the floor, where the patient is most comfortable. The prevalence of EHRs makes it easier to enter "bridge orders," or transition orders (including bed requests), from anywhere. Of course, there will still be times when the admission is in question, and we need our colleagues to come to the ED. In these cases, there should be a reasonable time expectation for that work to be completed. We also like to have a shared focus for what testing is necessary in the emergency department: only that which will impact the patient's disposition.
One solution to the unnecessary bed-not-ready delay is to create a "bed czar," someone responsible for finding and assigning open beds quickly. That should be the only—or at the very least, the main—responsibility of the bed czar, who is tasked with staying ahead of the needs of the ED, not reacting to them. The ultimate goal here is to prevent last minute scurrying to find a bed, have housekeeping clean it, or to find a nurse who can take the patient to it.
Instead, the bed czar estimates how many beds will be needed each day based on prior averages, and can get a sense of open beds when starting his/her shift. By staying in close contact with the ED, this person can keep an ongoing list of probable admissions and approximate timing of those admissions. This list makes it possible to identify open floor beds in advance, ensure they're clean, and give the nurse a heads-up. The goal is to have the call from the ED answered promptly and knowledgeably: "Your patient can go to 302, and Nurse Jones will take care of her."
Transitions Make the Process Work
One of the most crucial efficiency tricks mentioned above: collaboration between hospitalists and emergency physicians. My hospitalist colleagues and I have spent a lot of time understanding each other's perspectives and strategizing how to best address a patient's needs, whether in the ED, observation unit, or inpatient unit. For instance, Dr. Kenneth R. Epstein and I published this article on how to navigate common conflicts between hospitalists and ED physicians, and how to achieve efficient, quality care for patients during such transitions.
Identifying responsibilities is a critical step. Once emergency physicians and hospitalists agree that a patient is to be admitted, there's not much additional work to be done in the ED; it can all happen on the floor. In those cases, the best thing for patients is to get them to an inpatient bed as quickly as possible. Waiting in the emergency department is frustrating for the patients waiting, of course, but having those beds occupied is also delaying emergency care for patients in the ED waiting room. If hospitalists engage with the ED to accelerate those transitions, the entire process leaps forward: initial orders come faster, beds are put to use, and all patients get the care they need more quickly.
To this end, ED physicians and hospitalists together must develop standard protocols and approaches to hospitals admissions from the emergency department. Like any efficiency effort, you need both individual buy-in and systemic change to make lasting, sustainable improvement.
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