Lakeland (Fla.) Regional Medical Center is home to the state's busiest single-site emergency department. It had roughly 170,000 ED visits in 2012 and is on track to have more than 180,000 ED visits this fiscal year. Despite this increase in volume, the ED has decreased its wait time, length of stay and rate of patients leaving without being treated. These changes are the result of an ED redesign that began in 2011, driven by the hospital's executive leadership.
Before
Before the redesign, LRMC's ED had a longstanding practice of segregating adult patients by levels of clinical acuity into either a critical care or intermediate care area. This separation of beds according to patient acuity led to poor utilization of beds, according to Maureen Leckie, ED director at LRMC. For example, a patient who met the criteria for the intermediate care section who did not require emergent treatment may have had to wait for a bed if the intermediate care section was full although beds may have been available in the designated critical care area.
In addition, the fact that the ED was the busiest single-site ED in the state deterred some nurses from applying, concerned an overcrowded environment with patients in halls waiting for beds would be too difficult to work in, which left many vacancies, according to Ms. Leckie.
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• ED volume increased 16.5 percent from January 2011 to January 2013. 1: CMS' Hospital Compare database as of June 2012 |
After
The redesigned ED care model has grouped rooms into nine pods or areas: one pod for triage, six that serve adults, one that serves children and one for minor non-urgent conditions. An RN serves as a "bed traffic controller" for the triage pod, assigning triaged patients to one of the pods on a rotational basis so no one pod becomes overwhelmed by receiving multiple new patients at once. Each of the adult and pediatric pods contains 12 beds, including two designated for critical care patients. One physician, one nurse supervisor and four RNs provide direct patient care on each of these pods. The nurse supervisor's role is to provide clinical expertise and monitor patient flow. This supportive design for nurses and efficient flow has led to a waiting list for nurses wishing to join the ED team, Ms. Leckie says. In addition, assigning only one physician per pod drives accountability because each physician is responsible for his or her pod and meeting the pod's goals, she says.
• One triage pod. When patients arrive, they are immediately seen by a nurse for a quick triage and are assigned to a pod based on their age (child or adult) and the current utilization of each pod. Immediate bed placement keeps the lobby empty most of the time, helping create an efficient and welcoming environment. "It's a benefit to patients because when they arrive for medical care, the last thing they need to see is a chaotic environment," Ms. Leckie says.
• One pediatric pod. The ED has a pod entirely devoted to pediatric patients, who are triaged and cared for by pediatric ED nurses and a dedicated ED physician.
• Six adult pods. Each adult pod has universal bedding, which allows all acuity levels to be assigned to the pods. However, when one pod receives a patient in need of immediate emergency care, the pod is bypassed and put on hold for 20 minutes; no new patients are assigned to the pod so that the nurse and physician have sufficient time to attend to the patient's immediate needs.
• One fast-track pod. The fast-track pod is available for patients with minor conditions who can be assessed and treated quickly. It includes treatment rooms as well as recliner chairs for low-acuity, mobile patients.
Optimizing an ED for patient flow
Here are four important factors of LRMC's ED transformation:
1. Vision. In 2011, LRMC's CEO made improving ED patient flow a core strategic goal. This leadership from the top of the organization rallied physicians and staff around a common vision of increasing quality of care.
2. Collaboration. Because the ED relies on multiple hospital departments to deliver care — radiology, surgery, pharmacy, etc. — an ED redesign requires changes not only in the ED, but also in these interconnected departments. LRMC created a team with representatives from the ED, the radiology department, the laboratory, the pharmacy, the respiratory department, transportation and the patient placement department. The team met weekly to develop goal-driven processes. The team still meets to review data and ensure the ED maintains or improves its patient flow.
Collaborating with physician leadership was also integral to the ED redesign's success, according to Ms. Leckie. ED physicians and nurses brainstorm and share strategies for making their workflow more efficient during monthly meetings. Shared decision-making between nursing leaders and physician leaders created a culture of open communication and a healthy work environment, she says.
3. Data analysis. Collecting and analyzing data is one of the driving forces behind the ED's improvement. The redesign team receives daily and weekly summaries of detailed data from the hospital's strategic analyst team. For example, the EHR captures physicians' timing for evaluating and treating patients, admission practices, pharmacy practices and test utilization, among other measures. Physicians and nurses have dashboards where their individual data and data for their peers are compared, which motivates improvement, Ms. Leckie says.
4. Simulation. One unique tool LRMC used to improve patient flow was a simulation model developed by an industrial engineer. The model uses existing data to predict outcomes, such as wait times, under various situations, such as different staffing levels and patient volumes. These predictions help ED staff be proactive instead of reactive. For instance, predictions from the tool led ED leaders to expand pod hours, flex nursing hours and add additional radiologist coverage to decrease turnaround times for reading radiology studies.
Vision, leadership, teamwork, constant monitoring of data and predictive analysis have all been critical to LRMC's ED redesign. Ms. Leckie says these strategies can be adapted to improve other hospitals' EDs. "If you have a vision — if you can truly see it — you can make it happen," she says.
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