Addressing Emergency Department Inefficiencies to Enhance Patient Flow

A high-performing ED is critical to a hospital's operational, clinical and financial goals, explains Jody Crane, M.D., M.B.A, TeamHealth's chief clinical officer of emergency medicine and co-author of The Definitive Guide to Emergency Department Operational Improvement.

JC: Poor-performing EDs can hinder revenue, patient satisfaction and utilization. Patient flow is a major component of well-functioning EDs, and smooth patient hand-off processes can have a ripple effect across department operations hospital-wide. As the “front door” of the hospital, the ED is intertwined with the hospital's clinical, operational and financial goals. Messy patient flow systems may negatively impact care, bottom lines, patient satisfaction scores, clinical quality and patient safety.

JC: Inefficient patient flow in the ED can negatively influence operations across the hospital system. Consider an ED that is over capacity daily. Let's say a patient suffering from acute appendicitis walks through the door at 6 p.m. and is not seen until 3 a.m. The patient requires surgery at this point, but a surgeon is no longer onsite at such an early hour. Now, the hospital must call in staff to perform a surgery in the middle of the night. Ultimately, a weak patient flow system pushes volume into the overnight shift, when hospitals already have less staffing. It you're not keeping up with your demands, that overnight hospitalist is going to be overwhelmed. Additionally, inefficiencies and constraints in other parts of the hospital can aggravate crowding in the ED and increase length of stay to roughly one day.

JC: First, identify every person who touches a patient and map the exact flow of the patient's journey through the ED. Next, conduct a streaming analysis. Today, there is a shift toward improving “door-to-in-process,” which goes beyond door-to-doctor to include completion of testing and treatments during the encounter. To improve this time, organizations need to determine the acuity mix of their ED patients via a streaming analysis. Third, align your staff. A staffing analysis forecasts patient demand for services every hour of the week. Armed with this information, ED leaders can match staffing to expected demand to ensure coordination and optimization of staffing resources between physicians, advanced practice clinicians, and nurses. Lastly, keep an eye on the backend. Within the ED, it's imperative for physicians and nurses to practice handoffs, though ensuring smooth patient flow on the backend may require restructuring on the inpatient side.

JC: Initiating change requires commitment, and leaders need to champion the new future. We refer to this process as “unfreezing” the ED, in which a team objectively analyzes the department's current state and decides where the department needs to go, based on metrics. Don't jump in full force with the new system, but rather initiate rapid cycle testing. Try out a new patient flow process on a historically non-busy day. If it works well, try it on a busy day and then for a week. If it still operates smoothly, implement it permanently. Lastly, rapid cycle testing enables you to safely try a new process and objectively look and see if you've improved your metrics.

JC: Improving patient flow in the ED can have widespread, positive effects on operations hospital-wide. Hospital leaders considering addressing their patient flow concerns need not feel overwhelmed, however. With our roots in emergency medicine, TeamHealth has almost 40 years of experience offering support services, communication networks and educational resources for emergency medicine professionals. TeamHealth's emergency medicine clinicians continuously develop best practices to deliver the highest standards of evidence-based care. We can help your hospital monitor and enhance patient flow and develop triage and staffing models to ensure a top-performing ED.

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