Many hospitals are struggling to address crowded and inefficient emergency departments. As the ED is the "front door" to the hospital for many patients, it is essential that hospitals have efficient, safe EDs.
The Reading Hospital and Medical Center in West Reading, Pa., is the highest volume single-site ED in Pennsylvania, with more than 130,000 visits a year. The six-year-old facility was built to accommodate roughly 280 people a day, but sees close to 400 people. ED volume has increased 30 percent over five years, and is continuing to increase; last year, the hospital predicted a 3 percent increase in volume but saw an actual increase of more than 6 percent. To manage increasing volume with limited space, the ED designed a new process for delivering care. Charles Barbera, MD, chairman of emergency medicine, explains how the new system improved patient flow and efficiency.
Developing new ED processes
The overarching goal of the ED model was getting people to the most appropriate level of care as fast as possible. Other goals included addressing the physical and emotional needs of the patient and the family, improving throughput and maintaining high patient satisfaction.
To meet these goals, the ED team first developed protocols for the 20 most common complaints of patients visiting the ED. These protocols allow ED clinicians and staff to begin evaluating and treating patients with those 20 most common conditions as soon as they enter.
For example, the ED worked with the departments of obstetrics and psychiatry to develop protocols for pregnant patients and patients with behavioral issues presenting to the ED. Under the new process, pregnant patients entering the ED are moved to the obstetrics department as quickly as possible. A similar process exists for psychiatry patients. Transferring patients to the appropriate department quickly enables the ED to get patients to the right level of care and enables the ED to treat more patients.
The ED also created patient-focused treatment areas designed for different types of patients. The ED has a pediatric area with pediatric nurses, a fast track area for people with non-emergent needs and pods that the ED can open or close depending on patient volume. For example, Dr. Barbera says typically no beds in the flex unit are needed at 7 a.m., but by noon, all 24 beds in the unit may be full. The different patient-focused treatment areas within the ED help the team reach the goal of getting patients to the most appropriate level of care as quickly as possible.
Immediate bedding
To speed processes on the front end, the ED instituted immediate bedding, a practice in which ED patients are immediately taken to a room. Patients are then triaged and evaluated by a physician and case manager. In the past, patients would be seen by a nurse, wait for a room to open and then get evaluated.
Taking patients to rooms first speeds the evaluation and treatment process, which improves patient flow. The ED at Reading Hospital and Medical Center reduced its median time to physician from more than 40 minutes to fewer than 20 minutes over a period of four months.
The ED also began point-of-care testing, in which clinicians and staff conduct lab and other tests at the patient's bed to cut down time. A study in Annals of Emergency Medicine found point-of-care testing reduced ED length of stay by 22 minutes compared with central laboratory testing at a large, academic, urban medical center.
Working as a team
A core part of the ED process redesign was establishing teams of physicians and nurses to work together to deliver care efficiently and safely. At the beginning of every shift, ED team members would hold a "shift huddle," an opportunity for outgoing staff to update people coming on shift about patients' conditions.
The ED team also works with providers in other departments to facilitate safe patient transitions. For example, the ED and intensive care unit established a process where ED patients can be evaluated for admission on the floor instead of in the ED, which frees up space for incoming patients.
Tracking progress
To determine progress in patient flow, the ED tracks multiple metrics, including length of stay, time from arrival to provider, time from arrival to admission and time from arrival to discharge, among others. Dr. Barbera and other leaders review operational data monthly and length of stay, daily census and patient satisfaction data weekly.
Culture change
Shifting to the new ED process was a significant culture change for physicians, nurses and staff, according to Dr. Barbera. "It was hard to transition. Some people didn't survive it; some retired," he says. He had one-on-one meetings with physicians and physician assistants to explain why the ED needed to change its processes and what the goals of the new model were. The ED also held townhall meetings to explain the change to everyone.
Continuous improvement
While the ED has improved patient flow and throughput, the team is continuing to work on optimizing efficiency and delivering quality care. The hospital is planning to add roughly 30 beds to the ED in an upcoming expansion, which will create more capacity. However, the expansion does not mean the ED can revert back to old ways. "As we build more rooms, we're cognizant of the fact that we still cannot be a holding tank for inpatients. Inpatients need to go to the inpatient room, and we need to serve our function in treating emergencies," Dr. Barbera says.
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The Reading Hospital and Medical Center in West Reading, Pa., is the highest volume single-site ED in Pennsylvania, with more than 130,000 visits a year. The six-year-old facility was built to accommodate roughly 280 people a day, but sees close to 400 people. ED volume has increased 30 percent over five years, and is continuing to increase; last year, the hospital predicted a 3 percent increase in volume but saw an actual increase of more than 6 percent. To manage increasing volume with limited space, the ED designed a new process for delivering care. Charles Barbera, MD, chairman of emergency medicine, explains how the new system improved patient flow and efficiency. Developing new ED processes
The overarching goal of the ED model was getting people to the most appropriate level of care as fast as possible. Other goals included addressing the physical and emotional needs of the patient and the family, improving throughput and maintaining high patient satisfaction.
To meet these goals, the ED team first developed protocols for the 20 most common complaints of patients visiting the ED. These protocols allow ED clinicians and staff to begin evaluating and treating patients with those 20 most common conditions as soon as they enter.
For example, the ED worked with the departments of obstetrics and psychiatry to develop protocols for pregnant patients and patients with behavioral issues presenting to the ED. Under the new process, pregnant patients entering the ED are moved to the obstetrics department as quickly as possible. A similar process exists for psychiatry patients. Transferring patients to the appropriate department quickly enables the ED to get patients to the right level of care and enables the ED to treat more patients.
The ED also created patient-focused treatment areas designed for different types of patients. The ED has a pediatric area with pediatric nurses, a fast track area for people with non-emergent needs and pods that the ED can open or close depending on patient volume. For example, Dr. Barbera says typically no beds in the flex unit are needed at 7 a.m., but by noon, all 24 beds in the unit may be full. The different patient-focused treatment areas within the ED help the team reach the goal of getting patients to the most appropriate level of care as quickly as possible.
Immediate bedding
To speed processes on the front end, the ED instituted immediate bedding, a practice in which ED patients are immediately taken to a room. Patients are then triaged and evaluated by a physician and case manager. In the past, patients would be seen by a nurse, wait for a room to open and then get evaluated.
Taking patients to rooms first speeds the evaluation and treatment process, which improves patient flow. The ED at Reading Hospital and Medical Center reduced its median time to physician from more than 40 minutes to fewer than 20 minutes over a period of four months.
The ED also began point-of-care testing, in which clinicians and staff conduct lab and other tests at the patient's bed to cut down time. A study in Annals of Emergency Medicine found point-of-care testing reduced ED length of stay by 22 minutes compared with central laboratory testing at a large, academic, urban medical center.
Working as a team
A core part of the ED process redesign was establishing teams of physicians and nurses to work together to deliver care efficiently and safely. At the beginning of every shift, ED team members would hold a "shift huddle," an opportunity for outgoing staff to update people coming on shift about patients' conditions.
The ED team also works with providers in other departments to facilitate safe patient transitions. For example, the ED and intensive care unit established a process where ED patients can be evaluated for admission on the floor instead of in the ED, which frees up space for incoming patients.
Tracking progress
To determine progress in patient flow, the ED tracks multiple metrics, including length of stay, time from arrival to provider, time from arrival to admission and time from arrival to discharge, among others. Dr. Barbera and other leaders review operational data monthly and length of stay, daily census and patient satisfaction data weekly.
Culture change
Shifting to the new ED process was a significant culture change for physicians, nurses and staff, according to Dr. Barbera. "It was hard to transition. Some people didn't survive it; some retired," he says. He had one-on-one meetings with physicians and physician assistants to explain why the ED needed to change its processes and what the goals of the new model were. The ED also held townhall meetings to explain the change to everyone.
Continuous improvement
While the ED has improved patient flow and throughput, the team is continuing to work on optimizing efficiency and delivering quality care. The hospital is planning to add roughly 30 beds to the ED in an upcoming expansion, which will create more capacity. However, the expansion does not mean the ED can revert back to old ways. "As we build more rooms, we're cognizant of the fact that we still cannot be a holding tank for inpatients. Inpatients need to go to the inpatient room, and we need to serve our function in treating emergencies," Dr. Barbera says.
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