"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."