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Split ED Flow, Watch Your Bottom Line Grow

 |  By kminich-pourshadi@healthleadersmedia.com  
   April 02, 2012

Financial leaders, pay heed to your emergency department. EDs are rife with process inefficiency and the patient satisfaction and financial prognoses aren't good. Yet it's possible to improve care and cut costs.

First I'll share a personal story of a recent trip to a Boston-area emergency department with my 15-month-old son. It was a bad experience, but a good example of why so many hospitals are losing money in their EDs.

When my husband and I arrived at the ED with our hysterical baby, no one looked up or offered direction in the waiting room. I went to the nearest desk to ask for assistance and was pointed to another desk. That receptionist pointed to a sign-in sheet and asked what was wrong with my son.

After I explained that he had a fever of 102 degrees and hadn't been able to hold anything down for hours, she said, "Okay," then directed me to see the woman next to her about payment.

Over the next two hours, we were seen by two nurses and a doctor, each of whom asked the same questions and checked the same vital signs. The ED on weekday night wasn't very busy, yet two hours passed before a treatment suggestion was made&mdash:an eternity for parents with a sick and screaming child.

Once medication was given to stop the vomiting, we stayed in the room with our son for another hour and half before a nurse said we could go home. In total, we spent over three and a half hours in the ED, and our son spent more than 90 minutes in a bed. In hindsight I wondered why the first nurse couldn't have made the same diagnosis as the physician. Had I gone to a pediatrician's office, the same diagnosis plus a trip to the pharmacy to get the medication would've taken an hour.

As a CFO, do you see any flaws with this scenario? Is it reminiscent of patient visits to your hospital's or health system's ED?

As a consumer, I'm angry about having to wait so long to get my child some relief. My experience at this ED has soured me on the rest of the hospital. If this is how inefficiently the organization runs an essential area like the ED, what's the rest of the place like? The organization hasn't lost one patient, but three—me, my husband, and my son.

My experience didn't have to be this way. There are tools available to help healthcare institutions improve their patient flow while reducing costs.

In 2005, the Agency for Healthcare Research and Quality awarded more than $9 million for 17 new grants under its Partnerships in Implementing Patient Safety program. One grant winner was "Improving Patient Flow in the Emergency Department," led in part by Twila Burdick, vice president of organizational performance at Banner Health in Phoenix. The project analyzed a patient flow process called Door to Doc, which reduces the time that ED patients wait to be seen by a physician by moving them through two different intake processes.

Under the government grant, Burdick's team created a free toolkit to allow hospitals and health systems to replicate the program. It contains resources for implementing operational changes including the Door to Doc split flow process, interactive spreadsheets that use queuing for patient flow, multidisciplinary training aids and methods, a plan for managing implementation, and project management tools.

 

Teri Johnson-Kelley, MSN, RN, CEN, the director of nursing for the ED at Banner Estrella Medical Center in Phoenix, used the Door to Doc process in her department. Banner Estrella's 34-bed ED saw 92,400 patients in 2011, though it was designed to handle 74,000 patients when it opened in 2004. Johnson-Kelley recounts that within two weeks of opening, ED volume hit 50% over the anticipated census.

Yet there was no money to expand the department or staff. "Unfortunately the other side of the house was empty," she says. "We didn't have a lot of surgeries yet or other things in the community that usually feed a hospital&mdash:the ED was the front door."

With an overabundance of patients, wait times grew long; Johnson-Kelley says it sometimes took 6-8 hours for patients to be seen, which led to staff concerns about patient safety. The hospital leadership soon decided it had to get creative about how it saw patients. Banner Estrella partnered with Arizona State University's College of Engineering to find ways to maximize throughput. The result was the split flow model.

How does it work? Say Patient X presents at the ED with belly pain she's had for three weeks. The first stop is a quick look, where a registered nurse assesses the patient's condition and assigns an Emergency Severity Index number to route the patient through the ED.

If the vital signs are stable (an ESI of 3–5) then the patient sees a physician and RN together for assessment and testing. Patients don't return to the waiting room to await test results; instead they go to a continuing care area so an RN can monitor their vital signs and reaction to medication. The patient receives a pamphlet explaining the process, and care providers must check off each step in the patient's pamphlet.

"The idea is the patients who are less sick move through the process quickly," Johnson-Kelley says. "These patients only use 12 of our beds in the ED. However, there are small wait areas for the other steps in the process."

Contrast the process for patients with an ESI of 1–2 (critical care). If Patient Y comes in with chest pains, he bypasses the intake process and an ER technician performs an EKG and works to differentiate the type of chest pain.

"The beauty of this is we decrease the risk for the acute care patient in getting them from lobby to bed," Johnson-Kelley says.

But even acute care patients don't "own" their beds, she explains. If the patient stabilizes, he is moved to continuing care so the bed can be used by the next acute care patient.

"We have 34 beds. If we stayed with the old process, I'd have one bed per patient and that doesn't work when you need to see 94,000 patients a year. We were able to increase our productivity, decrease our risk, and decrease our costs," she says. "Plus everyone was happier: the patients, the physicians, and the nurses."

Banner Estrella has come a long way from the 6-8–hour wait times in 2004. Now on the ED's worst day, the average wait time is 36 minutes. Overall patient satisfaction scores for the ED average 86%. And the department has won national awards for quality care for three years in a row.

Plus, the split flow model has a quick financial ROI. "Initially, doing this required a few more resources for redesign and staff, because we had to create separate areas for intake, quick look, and continuing care. But we gained better throughput, patient satisfaction and safety," Johnson-Kelley says. "This gave us the ability to bed acute care patients immediately and that far exceeds any amount we spent.,"

Editor's note: For more on the split flow model, check out the HealthLeaders Media webcast Lower Costs, Better Productivity in Your Emergency Department, in which Johnson-Kelley and other ED innovators will answer subscriber questions on how to turn around ED operations.

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Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
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