Improving Patient Flow and Reducing Emergency Department Crowding (Text Version)

On September 27, 2010, Megan McHugh, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (656 KB).  

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Slide 1

Improving Patient Flow and Reducing Emergency Department Crowding

An Evaluation of Interventions at Six Hospitals

AHRQ Annual Meeting
September 27, 2010

Megan McHugh, HRET
Kevin Van Dyke, HRET
Julie Yonek, Northwestern University
Embry Howell, Urban Institute
Fiona Adams, Urban Institute

Note: on bottom of every slide is the logo for HRET: Health Research & Educational Trust.

Slide 2

The Problem

• Half of hospitals report operating at or above capacity (AHA 2007).
• A minority of hospitals meet recommended wait times for all ED patients (Horwitz et. al. 2009).
• Approximately 500,000 ambulances are diverted each year (Burt et. al. 2006).
• On a "typical" Monday, 73% of EDs are boarding two or more admitted patients (Schneider et. al. 2003).

Slide 3

The Consequences

• Increased door-to-needle times for patients with suspected acute myocardial infarction (Schull et. al. 2004)
• Lower likelihood of patients with community-acquired pneumonia to receive timely antibiotic therapy (Fee et. al. 2007, Pines et. al. 2007)
• Poor pain management (Hwang et. al. 2008)
• Increased mortality (Richardson et. al. 2006, Sprivulis et. al. 2006)
• Lower patient and staff satisfaction (Boudreaux et. al. 2004, Richards et. al. 2000)

Slide 4

Research Questions

1. What factors facilitated or hindered the implementation of strategies?
2. What resources were used to implement the strategies, and what was the associated cost?
3. What changes in patient flow occurred after the implementation of the strategies?

Slide 5

Urgent Matters Learning Network (UMLN)
 

Map of the Eastern United States showing the locations of the following hospitals:

• St. Francis Hospital
• Westmoreland Hospital
• Stony Brook University Medical Center
• Good Samaritan Hospital
• Thomas Jefferson University
• Hahnemann University Hospital

Slide 6

UMLN Hospital Requirements

• Form a multi-disciplinary, hospital-wide team.
• Select and implement improvement strategies.
• Complete an implementation plan and monthly progress reports.
• Participate in UMLN meetings.
• Participate in the evaluation of the strategies.

Slide 7

UMLN Framework

An image showing the UMLN Framework is shown. 

Slide 8

UMLN Interventions

• Protocols for specialty consultations
• Standardized registration and triage
• Mid-Track
• ED/Inpatient department communication tool
• ESI Five-level triage
• Immediate bedding
• Fast track improvement (2 hospitals)

Slide 9

Methods—Data & Analysis

• Two rounds of interviews (129 total)
  • Recorded, transcribed, uploaded to Atlas
  • Grounded theory approach
  • "Ingredient" approach

• Patient-level data:
  • Pre-Implementation (Dec 08-Feb 09)
  • Post-Implementation (Dec 09-Feb 10)
  • Dependent variables: ED LOS, LWBS
  • Independent variables: Date/time of visit, age, gender, triage level, lab, x-ray, disposition, occupancy rate

Slide 10

Common Facilitators/Barriers to Implementation

• Facilitators:
  • Participation in UMLN.
  • Executive support/availability of resources.
  • Strategic selection of planning team.

• Barriers:
  • Staff resistance.
  • Organizational culture.
  • Lack of staff resources.

Slide 11

Implementation Expenses

Strategy	Description of Expense	Total Expense
Fast track improvement (1)	Construction project 3 Nurse practitioners	$490,000
Mid-Track	Construction project GYN stretcher EM physician	$320,683
Registration & triage	Computers on wheels Triage training	$32,850
ED/Inpatient Communication	Fax machine	$200

No new resources were acquired for the following strategies:
Fast track improvement (2), Protocols for specialty consults, ESI Five-level triage, Immediate bedding

Slide 12

Hours Spent Planning and Implementing

Position	Hours
ED nurses	963
ED charge nurses/Nurse educators	680
ED technicians	352
Physician specialists	315
Process/quality improvement leaders	280
ED administrative directors	271
ED nurse managers	238
Registration managers	108

Slide 13

Hours Spent Planning and Implementing
 

Strategy	Total Hours
Immediate bedding	40
Mid-Track	65
Fast track improvement (1)	160
ED/Inpatient communication tool	239
Protocols for specialty consultations	256
Fast track improvement (2)	371
Standardized registration & triage	857
ESI Five-Level triage	1,017

Slide 14

Hours Spent Planning and Implementing

Position	Hours
ED physicians	107
Inpatient unit floor managers	100
ED department chairs/physician directors	87
Hospital c-suite	59
ED nurse practitioner/physicians assistants	49
Hospital director-level	32
Data/IT analysts	13
ED clerks	5

Slide 15

Change in ED Length of Stay

LOS in Minutes
Regression-Adjusted Mean ED Length of Stay,
Pre and Post Implementation

Image: The slide presents a bar chart titled, “Regression-Adjusted Mean ED Length of Stay, Pre and Post Implementation.” The chart shows three hospitals—defined by their interventions—along the horizontal axis and length of stay in minutes along the vertical axis. Each hospital has two bars. The first represents the average, regression-adjusted length of stay for patients who made a visit to the ED before the intervention was implemented. The second represents the average, regression-adjusted length of stay for patients who made an ED visit after the intervention was implemented.

Registration and Triage: 207 minutes pre-implementation, 194 minutes post-implementation

ESI, Open Bed, Fast Track Improvement: 481 minutes pre-implementation, 440 minutes post-implementation

Mid-Track: 335 minutes pre-implementation, 327 minutes post-implementation

Notes: The interventions displayed above were associated with a significant reduction in ED LOS at the p<.05 level. Data are shown for all ED patients, except Mid-Track, which includes data for ESI III s only. All other interventions were not found to be significantly associated with a reduced ED LOS.

Slide 16

Lessons for Other Hospitals

• Leverage factors that facilitate implementation.
• Develop a plan to address challenges early.
• Recognize that some strategies require significant financial and/or time investment.
• Recognize the important roles played by non-MDs and RNs (e.g., registrars, clerks, techs).
• The effort may result in statistically significant and meaningful improvements in patient flow.

Slide 17

http://www.urgentmatters.org

Megan McHugh, PhD
Director, Research
Health Research & Educational Trust
American Hospital Association
mmchugh@aha.org