Adopt This 5-Part Process to Reduce ER Length of Stay

Establishing a 'fast track' for low-acuity patients improves efficiency in emergency departments.

Creating a "fast track" process in an emergency department that separates patients with high- and low-acuity conditions significantly reduces length of stay, recent research shows.

Excessive length of stay in emergency departments contributes to ER overcrowding, patients leaving without being seen, and decreased patient satisfaction.

Establishing a fast track capability for patients with low-acuity conditions improves ER efficiency, researchers wrote recently in the Journal of the American Medical Association.

"After the initiation of the Fast Track process in December 2015, and without making any other changes to ED workflow or staffing, there was a 25% decrease in the length of stay of patients with low-acuity conditions (from 190 minutes to <150 minutes) and the rate of patients leaving without being seen decreased from 8% to 4% in just five months. At the same time, patients with moderate- and high-acuity conditions who were discharged had reduced length of stay in the ED and stable or reduced rates of leaving without being seen."

The Fast Track process has five elements:

1. Workflow: The Fast Track care pathway for low-acuity patients features a standardized workflow to manage patients, including specific roles and actions for each staff member such as rooming patients and delivering discharge instructions. Separating low-acuity patients and creating a standardized workflow helps ER staff to estimate the resources needed to meet patient demand.

2. Process management: Standardized staffing processes include a daily team huddle at the beginning of each shift to set expectations such as assigning medical assistants to specific procedures for wound care preparation and nurse practitioner approaches to charting and discharge practices. Department leaders coach standard processes for rooming, documentation, procedures, and discharges.

3. Data drivers: Daily data reports are generated and shared with frontline and executive staff to enable adjustments to new processes.

4. Dedicated work space: Positioning the Fast Track team in a separate area of the emergency department increases the capacity to manage more complex patients in other parts of the ED.

5. Enlisting leaders: Engaging hospital leadership such as the CEO, chief medical officer, and chief quality officer in daily data-driven huddles, weekly planning sessions, and quarterly workshops boosts the ED improvement initiative.

Determining acuity levels
 

In establishing the Fast Track model, the initiative team took three approaches to determine low-acuity conditions, the lead author of the JAMA article, Mary Mercer, MD, MPH, told HealthLeaders.

• Safety parameters were set, including strict exclusion of patients with abnormal vital signs.
   
• The Emergency Severity Index (ESI) nursing triage tool was used to determine which patients would be most likely to be discharged and would be most likely to need the lowest level of resources and tests. This set of patients have low admission rates.
   
• The Fast Track triage process also involves identifying patients who are ESI outliers. For example, patients with chest pain, headache, and abdominal pain, even if initially triaged as an ESI 4 or ESI 5 level, often had much longer lengths of stay than other patients with that triage level because of the risk of a serious condition such as a heart attack or surgical condition.

"We used both aggregate data and direct observation to determine types of patient visits that would be amenable to being safely and efficiently seen in Fast Track," said Mercer, an associate clinical professor in UCSF's Department of Emergency Medicine and EMS base hospital medical director at Zuckerberg San Francisco General Hospital.

Keys to Fast Track success
 

There are three crucial components to achieving Fast Track success, Mercer said. "What we were trying to highlight in this manuscript were the ingredients needed for implementing sustainable change in a way that used the critical elements of an organizations' culture to align improvement work with the organization's strategic objectives."

• Executive leadership: The Fast Track initiative was the first of several improvement efforts to launch a lean management system at Zuckerberg San Francisco General Hospital. The executive team's commitment to embarking on the lean system and seeking to better understand and support frontline initiatives was apparent from the beginning and throughout the process.
   
• Interdisciplinary approach: People of all relevant disciplines in the ED from physicians, nurses, nurse practitioners, clerks, and medical assistants were involved in the design, testing, implementation, and monitoring of the new program. Each staff member's job had to be easy to execute repeatedly and consistently. Interdisciplinary team members helped to coach their peers in an ongoing fashion to ensure consistency of the process.
   
• Daily data reporting and department-wide huddle: Sharing information in real-time is critically important to monitor the performance of Fast Track, elicit ideas for improvement, and update how the executive team and other staff members are supporting the initiative.