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How to Get a Handle on ED Overcrowding

Joe Cantlupe, for HealthLeaders Media, May 30, 2013

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.

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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."

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