How to Get a Handle on ED Overcrowding

A projected increase in emergency department volume within the next three years means hospitals need to get to work now to implement better patient flow schemes. The need is urgent because how patients move through the ED has significant financial implications throughout the rest of the hospital.

This article appears in the May issue of HealthLeaders magazine.

These days, hospitals are trying to make things quick, quicker, and quickest for beleaguered emergency departments and their patients, who often face delays in treatment after they enter the hospital's automated doors. By establishing streamlined throughput systems, hospitals hope to prevent frustrated patients from walking out, bolting without getting care.

Leaders are improving triage areas, redesigning facilities, rotating physician staff, separating patients for urgent or nonurgent care, and implementing improved technology for greater efficiencies to eke out cost savings.

These multipronged approaches are born from hospital leaders' awareness that quality of care is affected when ED patients are placed in holding patterns, or boarded. Overcrowding contributes to poor care, frustrated patients, increased costs, potential harm, and stress for both patients and staff.

And the worst may be yet to come: Healthcare leaders overwhelmingly expect an increase in ED volume within the next three years—with 36% forecasting a major increase and 50% a minor increase, according to the May HealthLeaders Media Intelligence Report.

Overcoming delays is important for hospitals because patient satisfaction also can be impacted, which carries monetary consequences when poor scores are reported to the federal government.

But when patients, information, and materials flow efficiently through the ED, all aspects of care there can improve significantly. Hospitals are working to implement various flow schemes—such as split flow, bed counting, and fast tracking—all in an effort to move patients more efficiently through the ED. They are also improving workflow management and using technology programs to reduce extensive
patient waits.

At Pittsburgh-based UPMC, a 20-plus hospital system, when nursing staff and physicians meet every morning, part of their focus is on the ED, a big-picture view looking at big-screen projections showing the expected daily census, how many discharges, and how many patients they can add to each unit in each hospital.

"We predict the demand for the day," says Deborah Kaczynski, MS, who is senior administrative director for UPMC Mercy, which has 462 licensed beds, and works for the UPMC system's patient flow initiatives. She also is a faculty member for the Institute for Healthcare Improvement, an independent nonprofit organization based in Cambridge, Mass.

Kathleen Mikos, chief nursing officer and vice president for patient care services for the 275-staffed-bed Ingalls Memorial Hospital in Harvey, Ill., attends meetings with the organizationwide steering committee to focus on patient flow. She and her staff examine the ED demands, monitoring its impact on the rest of the hospital. Mikos oversees patient flow of the ED, which includes a fast-track component for patients with less serious conditions.

Mikos and Kaczynski are emphatic that improvements to the ED patient flow can only be mastered by addressing the needs of other hospital units—from surgery to housekeeping—that are impacted by what happens in the emergency department.

"You are never going to make headway toward improving the ED unless you realize it's a system issue," Mikos says. "We don't want long wait times, so we have to be in a constant state
of readiness."

Achieving that state of readiness often comes at a price: many failed attempts, Kaczynski says.

"We had tried many of the traditional approaches in the past to improve patient flow and were very frustrated. Nothing was working," Kaczynski recalls. "Ultimately, we learned that you couldn't attack patient flow in a silo, as a single entity. You had to find a certain platform that would manage flow at the entire hospital level."

Improving ED patient flow has significant financial implications through the rest of the hospital, says Andy Daniels. He is chief operating officer of Avita Health System, which runs Bucyrus and Galion community hospitals, each with 25 staffed beds, in Ohio.

"The ED is the gateway for 70% to 80% of the admissions into our facilities," says Daniels. "As a team, the ED is a critical component of the inpatient program. An ED department with a good flow is essential to a successful inpatient program, period."

"Healthcare facilities should be paying close attention," Daniels adds. "The trains need to run efficiently, effectively, and be considerate of the patient experience. Without that in your ED department, you're sunk."

Many hospitals have used technological changes to improve ED throughput. The 509-bed Albert Einstein Medical Center in Philadelphia uses a workflow management tracking tool to keep pace with ED flow. For an urban facility, the benefit of such a system was important to reduce waiting times and improve movement of patients through the ED, says Carl Chudnofsky, MD, chairman of the department of emergency medicine at Albert Einstein Medical Center.

"We put in automatic tracking with different types of tracking hardware," says Chudnofsky. Despite successes, the process isn't always smooth. Over time, the hospital has had to overcome technical challenges, such as the fact that tracking and electronic medical record software were not "talking to each other." The facility shut down the tracking for a while to fix that issue, he says.

The 371-bed George Washington University Medical Center in Washington, D.C., also uses a computer-based fast-track system. While technological systems are important, proper coordination and communication among physicians, nurses, and other staff is essential to improve ED patient flow, says Robert Shesser, MD, chief of emergency medicine at GWU Medical Center. "We've managed to make improvements by making little changes and measuring the effect of those changes," Shesser says.

Coordinating care may be the most important element, says Daniels of Avita Health System. "We are doing fast-track and process reengineering and doing the triage up front, a combination of things. We're working on improving with quick registration and bedside registration." Although the hospital has electronic medical records, the ED "is still paper-based, and we're still able to accomplish improvements," he says.

Team coordination is extremely important to improve ED operations, according to Daniels. "It takes a strong ED leader, a good working relationship with your ED physician group, and a willingness on the part of the support departments like lab and x-ray to play along. Improving ED flow is a team sport," he notes.

Success key No. 1: The process
When the 374-staffed-bed St. Mary Medical Center in Langhorne, Pa., began looking into process improvements for its hospital several years ago, leadership believed it had no choice. The throughput in the ED was sluggish. An ED designed for 50,000 visits a year was hosting nearly 70,000 patients. Perhaps predictably, patient satisfaction was low.

"For many years, the ED carried a significant portion of the hospital burden, and volumes were steadily increasing," says Gary Zimmer, MD, chairman of the department of emergency medicine at St. Mary Medical Center and senior vice president for TeamHealth, a Knoxville, Tenn.–based company that provides hospital-based services including ED management.

It was "part demographics, partly an aging population around the hospital," Zimmer adds.

The hospital made two changes—one in brick and mortar, the other in clinical processes. Both were lengthy, tedious, and, ultimately, worthwhile, he says. With the ED nearly 50% over capacity, in 2011 the hospital began adding 18 new beds in the emergency department as part of a $22 million expansion scheduled for completion the first quarter of this year, for an overall 70-bed treatment area, including 11 pediatric beds.

In the meantime, St. Mary initiated a split-flow model designed to have patients seen by a provider as quickly as possible. Under this model, patients are seen first by a nurse as soon as they enter the ED, says Sharon Brown, vice president of patient care and chief nursing officer. "Nurses are specially trained [that] when the patient comes in through the door, the assessment process begins. We figure out what's going on and how we can meet the needs of a patient in an efficient manner."

The nurse then makes an initial evaluation and directs patients to the appropriate specialized unit, whether that is prompt, urgent, or rapid assessment care, or pediatric care. Prompt care is for minor injuries, such as a sprained ankle. Urgent care is for severe illnesses that could result in hospital admission. Rapid assessment is what the hospital calls a "resource-intensive process" in which studies and tests are done, and then a patient is moved to a private area for treatment decisions.

Patients also are moving quicker through the ED, says Zimmer. Since 2005, the door-to-doc time decreased from about 45–50 minutes to 20–25 minutes in 2013, he says. In the meantime, he says "length of stay dropped 40 minutes" from 344 minutes to 304 minutes, based on Hospital Compare data.

According to Hospital Compare, the average time a patient spent in the ED before they were seen by a healthcare professional at St. Mary was 28 minutes in 2012, while the state average was 31 minutes and the national average was 30 minutes.

Just getting to the point of initiating the split-flow model was complicated, Zimmer says.

The hospital embarked on a six-month plan that focused on workflow process redesign, which involved 30 employees, including staff interacting with the ED, lab, floor nurses, physician assistants, and leadership, Zimmer adds.

St. Mary initiated the changes after reviews by hospital leadership and staff. It was an exhausting and
sometimes aggravating cultural shift, he says. In a two-day Lean workflow analysis, hospital officials whittled down what had been a lengthy process—68 steps from when a patient arrived until care was completed—to about 48 steps, he says.

"During those two days, we retooled people's jobs," Zimmer adds. "Some people were unhappy, but we listened to their concerns. There were some sleepless nights. But the process wasn't designed in a vacuum; it involved staff, and that was the key. There was an attitude, 'We can do this,' and we all pushed each other. We also had many site visits in ancillary departments that were impacted."

Zimmer says the hospital worked to "adopt a really different way of thinking. We really hardwired the process and didn't allow people to deviate from it." Eventually, the champions of change—including nurses and physicians who were "process owners of the change"—narrowed down the pool of ideas to those that could be implemented, he says.

"The basic concept of sorting out the middle-acuity patients was the key to our success," Zimmer says. "We committed ourselves to continue to evolve the process."

Success key No. 2: Bed control
Keeping tabs on hospital bed usage—how many patients are on the floor, who is ready to be discharged, what kind of patients are arriving—helps hospital personnel efficiently process patients from the ED to other areas of the healthcare facility.

Several years ago, Ingalls Memorial Hospital "didn't have a strong process in place for bed control," says Mikos, the CNO who oversees the ED and projects designed to increase hospital efficiencies. "It might have taken three hours to find a bed."

Implementing an electronic bed request system has significantly improved the hospital's ability to coordinate care for patients, especially those transferred as inpatients from the ED. A computer system monitors the beds and determines which ones are open, filled, or need to be cleaned. "Having an electronic bed management system has drastically improved the hospital's ability to find a range of beds and coordinate care," Mikos says.

Bed control. Central transportation. Housekeeping. "It all ties together; all three are important," she says.

The hospital receives about 49,000 visits a year to its 26-bed ED, an increase of 7,000 from five years ago. During that period, the hospital reduced its ED length of stay from 335 minutes to about 200 minutes. Mikos attributes the results to what she termed improved efficiencies in the hospital's ED throughput, especially its bed request or "tele-tracking" system.

With the bed request model, Mikos identifies another benefit: It reduces the need to build more bed space for the ED.

For many hospitals, "I think the instinct is you need more beds," she says, "but that's not the case to improve patient flow in the emergency departments."

To improve bed control, Kaczynski, the patient flow coordinator at UPMC, also keeps her eye on the numbers. The hospitalwide bed meeting is attended by the chief nursing officer, medical director of care management, nursing and clinical leaders, and directors of ancillary support departments. In a presentation before the Institute for Healthcare Improvement, Kaczynski said the "ED and inpatient must partner for success."

Using a real-time demand/capacity management program, the staff works to predict capacity each day. It begins with a "unit-based huddle" where nurses evaluate who will be discharged, what rooms are available, and who might be admitted. It is determined whether procedures such as MRIs are needed and if transportation must be arranged.

By 8:30 each morning, they evaluate capacity and whether demand could exceed that. If so, transfers may need to be arranged or special units may be contacted for extra bed capacity. Then evaluations are made during a "housewide bed meeting" attended by nurses representing each unit who review data on a large screen.

In addition, while many hospitals attempt to have discharges by noon, Kaczynski does not subscribe to that philosophy. "We want to make sure we have a bed when we need a bed, whether it's 10 a.m. or 5 p.m."

Started at its Shadyside campus, a 512-licensed-bed tertiary care hospital, the real-time demand/capacity management program has been replicated on other campuses.

Carrying out the patient flow philosophy ensured successful reductions in the hospital's ED length of stay, Kaczynski says.

Rick Wadas, MD, chief of community emergency medicine for UPMC, says six years ago, the Shadyside campus, which sees a high-acuity population, had ED lengths of stay that hovered "in the 400-minute" range. By 2013, the ED length of stay generally decreased "down to 230 or 240 minutes," he adds. Wadas says a key reason for the improvement was the real-time demand/capacity management program. "That's why there was a lot of success," Wadas says. "We also have gotten buy-in from the entire hospital knowing that this is not just an emergency department problem, but one involving the whole facility."

Success key No. 3: Physicians First
While having patients wait in the ED is aggravating to just about everyone involved, the 340-bed Roseville (Calif.) Kaiser Permanente Hospital decided to take a bold step to improve patient flow: It got rid of the waiting areas and began a Physicians First program.

Within the past year, the hospital increased the size of its ED, a 60-bed unit equipped for 70,000 patients annually. "Instead of having patients in a waiting room, we put them into the ED itself," says Pankaj Patel, MD, an emergency medicine specialist. "We didn't need a large waiting room."

If patients have to wait, they do so in an ED bed or sitting area within the department, where there are increased diagnostic tools and emergency cardiac catheterization equipment readily available, he says. The increased size has not only led to improved and swift care, but has given a psychological lift to patients who usually wait long periods for ED beds.

"With this new system, the physician is right there and will determine if you should be taken care of," Patel says. "When a patient comes in, instead of being in a waiting area, a nurse or physician will see him in the ED itself, as the Physicians First name implies," he adds. "We've eliminated our triage area in the front where most of the patients would be and instead added rooms," Patel says. "It makes it a much more efficient process."

The overall door-to-doc waiting time has been reduced to 5–15 minutes as opposed to the 45 minutes it was previously, he says. The hospital ensures that three physicians are "up front in the ED and try to assess the patient within 5 minutes of arrival," he adds. At that point, the ED uses a triage system, depending on the care that a patient needs. "If you stubbed your toe, we give you a treatment and discharge you from the front [of the ED]," he says. "If you have chest pain, we can get an EKG or lab workup, so we can get that process started up front right away, as well."

Success key No. 4: Patient satisfaction
One of the major goals for hospitals working to improve the patient flow is to achieve patient satisfaction. It's no easy task. The ED is often a chaotic place, with disruptions and people suffering from various degrees of illness or injury. Waiting times might prompt patients to leave before being seen because they perceive that the hospital is taking too long.

"We live in the real world," says Zimmer of St. Mary. "Some patients are upset with us." While the Centers for Medicare & Medicaid Services has not released national statistics about how many patients leave hospitals without being seen, an Annals of Emergency Medicine study published in 2011 found a median percentage of 2.6%, based on 9 million ED visits to California hospitals. However, the range varied widely from lower than 1% to 20.3%.

Of the hospitals profiled in this story, rates for patients leaving without being seen ranged from 0%–2%.

Wadas says the organization's hospitals "have rates of 0% to 0.1%, depending on the month; it's actually that low. If you think about it, if that number is high, you are not meeting people's needs and so you are not providing service. That was a big goal of ours to make sure that number was low. That number is partially dependent on the rest of the process. If all your beds are clogged up and people are there for hours and hours, you can't get people in the waiting room into beds, get them seen and taken care of."

Ingalls' rate for patients leaving without being seen is 2%, but was high as 10% a few years ago, says Mikos.

Paul Zielske, director of patient care and emergency and surgical services for Ingalls, attributes the reductions to "the changes that we've put in place, and shows what can happen with an effort: You can decrease those times."

At the same time, he notes, the hospital's ED volume increased from 42,000 to 49,000, but efficiency enabled the hospital to "have better responsiveness."

When patients leave without being seen, they are, in their own way, expressing deep dissatisfaction with a hospital. By decreasing the number of those patients who leave, satisfaction scores can improve, Zimmer of St. Mary says.

At St. Mary, patient satisfaction registered 95th percentile in 2012, after the hospital expanded its ED and made split-flow changes. Zimmer says that was an improvement over several years and that patient satisfaction with the entire hospital is linked to improvements in the ED.

Patients spread the word when there are long wait times. They even compare notes: "How long did it take for a physician to see you?" Zimmer says. "If you have a poorly run ED, it's very difficult to have inpatient satisfaction. From a business perspective, Medicare dollars are at risk based on HCAHPS scores. If you have ED docs that do not do well, you have a direct risk of losing Medicare dollars because of poor outcomes," he explains.

At George Washington University Hospital, 2% of nearly 38,000 people were reported to have left without being seen. Several years ago, that rate was at least 5%, says Shesser, chairman of GWU Hospital's ED.

"Over the years, we've managed to decrease our 'left without being seen' rate and improve throughput by making little changes and measuring the effect of those changes," Shesser says. "We are certainly paying closer attention to that in the new world of pay-for-value."

At Avita Health System's small Bucyrus and Galion community hospitals, both had to deal with high rates of patients leaving without being seen, at 3% several years ago. "We focused our interdepartmental groups on reducing time lags," says Daniels. As a result, the health system has reduced the 'left without being seen' rate to 0.41% at Bucyrus and to 0.18% at Galion as of January 2013.

"The biggest problem that remains to be overcome is always maintaining the success that you already have," Daniels says. "The more successful we become in our community and as word spreads, we will be the ED of choice. As our volume grows, it will be important that we do not slip and that we continue to meet customer expectations for service."

Reprint HLR0513-7

This article appears in the May issue of HealthLeaders magazine.