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

Slide presentation from the AHRQ 2010 conference.

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


Slide 1

Improving Patient Flow and Reducing Emergency Department Crowding

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

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

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

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)

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

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

UMLN Framework

An image showing the UMLN Framework is shown. 

Slide 8

UMLN Interventions

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 and Analysis

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

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

Implementation Expenses

StrategyDescription of ExpenseTotal Expense
Fast track improvement (1)Construction project
3 Nurse practitioners
$490,000
Mid-TrackConstruction project
GYN stretcher
EM physician
$320,683
Registration & triageComputers on wheels
Triage training
$32,850
ED/Inpatient CommunicationFax 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

Hours Spent Planning and Implementing

PositionHours
ED nurses963
ED charge nurses/Nurse educators680
ED technicians352
Physician specialists315
Process/quality improvement leaders280
ED administrative directors271
ED nurse managers238
Registration managers108

Slide 13

Hours Spent Planning and Implementing

Hours Spent Planning and Implementing
 

StrategyTotal Hours
Immediate bedding40
Mid-Track65
Fast track improvement (1)160
ED/Inpatient communication tool239
Protocols for specialty consultations256
Fast track improvement (2)371
Standardized registration & triage857
ESI Five-Level triage1,017

Slide 14

Hours Spent Planning and Implementing

Hours Spent Planning and Implementing

PositionHours
ED physicians107
Inpatient unit floor managers100
ED department chairs/physician directors87
Hospital c-suite59
ED nurse practitioner/physicians assistants49
Hospital director-level32
Data/IT analysts13
ED clerks5

Slide 15

Change in ED Length of Stay

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

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

For More Information

http://www.urgentmatters.org

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

Current as of December 2010
Internet Citation: Improving Patient Flow and Reducing Emergency Department Crowding (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/mchugh/index.html