SummaryTo improve emergency department patient satisfaction and throughput (the time from emergency department arrival to inpatient admission or emergency department discharge), St. Francis Medical Center in Los Angeles implemented a bundle of interrelated strategies that included changes to the emergency department to facilitate faster service and the redesign of processes and policies to free up inpatient capacity. Since implementing the improvements, the emergency department has experienced a 5.5-percent increase in patient volume, a 1-hour decline in average time waiting for an inpatient bed, a 24-percent increase in patient satisfaction, and a 23-percent drop in the number of patients who left the emergency department without being seen.Moderate: The evidence consists primarily of before and after comparisons of key statistics related to the ED and inpatient admission process. The evidence is relatively recent because many of these strategies were implemented in August 2006 and continue to undergo modifications.
Developing OrganizationsSt. Francis Medical Center
Date First Implemented2006
Problem AddressedLike many urban hospitals around the country, St. Francis Medical Center routinely experiences overcrowded conditions in its emergency department (ED), with patients being forced to wait a long time for both ED care and for inpatient beds to become available.
- National overcrowding: The number of patients visiting EDs in the United States has increased by 90.3 million between 1993 and 2003. During this same period, the number of EDs has fallen by 425.1 The combination of increased demand and tighter supply has led to longer waiting and transport times, which have damaged the quality of care rendered by many EDs, especially those in urban areas.
Overcrowding at St. Francis: The St. Francis ED was experiencing overcrowding, resulting in long wait times, increased ambulance diversions, increased patient holding times, inconsistencies in boarding and care, patients leaving the hospital without being seen, poor patient satisfaction, and declining ED staff morale.
Staffing issues, triage bottlenecks, breakdowns in communication, uncontrollable fluctuations in demand related to trauma visits, and the inability to obtain an inpatient bed were all compounding ED overcrowding at St. Francis. More than 37 percent of inpatient admissions come from the ED, but ED patients cannot be transferred to inpatient units when beds are not available. St. Francis often had up to 15 patients who were awaiting admission in beds stationed in hallways outside the ED; the wait typically lasted more than 5 hours. These patients, known as "boarding patients," have limited privacy, receive less timely services, and do not have the benefit of expertise and equipment specifically tailored to their condition, as they would as an inpatient.1
Description of the Innovative ActivityThe medical center implemented a comprehensive bundle of strategies designed to streamline the ED intake process, increase available inpatient beds, reduce ED overcrowding, and reorganize ED staffing. The initiatives, which are described below, included changes to the ED itself as well as changes in policies and processes within the inpatient facility.
Front-End ED Improvements
Programs to Reduce Inpatient/Admitting Bottlenecks
- Fast-track area for less severe patients: Approximately 29 to 41 percent of the 170 patients seen daily in the ED have less severe injuries (e.g., sprains) or lack medical insurance and a primary care physician and thus come to the ED for primary care treatment. To better serve these patients, St. Francis created a five-bed, "fast-track" area staffed by a physician assistant located one floor below the main ED. When ED patients arrive, a triage nurse evaluates them and determines which patients to send to the fast-track area, where they are seen quickly by the physician assistant who is qualified to treat relatively minor conditions. The fast-track area is open from 10 a.m. to 2 a.m., when demand is greatest.
- ED remodeling: The center spent more than $1 million on ED remodeling, including creating the fast-track area, reconfiguring the waiting room, developing a dedicated area for triage and rapid medical evaluation, and adding 11 beds (for a total of 34). The creation of the fast-track intake service opened up space to facilitate this remodeling.
- Staffing enhancements: St. Francis implemented several initiatives designed to bolster staffing in the ED, including the addition of resources dedicated to facilitating the redirection of inpatient admissions from the ED.
- Nursing students: The specialty nurse (registered nurse or RN) training program provides students with specialized nursing education in emergency medicine.
- Patient-flow nurse: This new position tracks all ED patients to identify those who need to be admitted, and then works with physicians, inpatient nurses, housekeeping, and transport to facilitate inpatient discharges to make room for ED boarding patients. One of the tools used by the patient-flow nurse is Code Purple, a process that brings together a team of key nursing and ancillary staff when significant bottlenecks occur in the ED. The patient-flow nurse assumes a leadership role, spearheading the team's evaluation of the needs of boarding patients and the available bed supply. Action steps are instituted, which can include seeking appropriate discharges, transferring existing inpatients to a lower level of care unit, and ensuring that the discharge lounge (see below) is fully utilized.
- Lobby coordinator: This individual, available during shifts when volume is highest, is responsible for enhancing customer service in the ED waiting area by communicating with, and serving as a liaison between ED staff and patients/families.
- Inpatient staging unit: The inpatient staging unit relocates admitted ED patients who are awaiting a bed assignment (boarding patients) out of the ED to a distinct holding unit staffed by an RN and/or certified nurse assistant as needed. The inpatient staging unit is a five-bed unit typically staffed from 7 a.m. to 7 p.m. daily to meet the California nurse–staffing ratio for a medical–surgical unit. When needed, however, the inpatient staging unit provides 24-hour service. This unit allows the hospital to provide an inpatient standard of care to patients while they await formal admission. Inpatient staging unit staff can also perform administrative intake tasks that facilitate patient transfer to inpatient units (a task that wins favor among inpatient nurses who frequently have to perform these duties). The unit also helps to increase available capacity in the ED, thus allowing it to operate more efficiently.
- Mobile admit program: The success of the inpatient staging unit resulted in a need to develop alternative processes to care for boarded patients when the inpatient staging unit was full. In those instances, the mobile admit program goes into effect to ensure that boarded patients receive a single standard of care, regardless of their physical location. Under this initiative, an inpatient staging unit nurse [telemetry and intensive care unit (ICU) or ICU-trained] is dispatched to the ED to assume responsibility for ED boarding patients. The mobile admit program nurse is responsible for completing the inpatient admitting process (initial assessment), notifying the assigned attending physician of the location of the patient, and initiating admission orders. Once an inpatient bed or an inpatient staging unit bed becomes available, the patient is transferred. The mobile admit program nurse is especially important for the growing number of patients being seen in the ED who require admission to the ICU (this increase is due in part to the closing of nearby EDs), as the nurse can provide ICU-quality care to these patients.
- Expansion and reconfiguration of bed capacity: The supply of licensed beds does not always match demand. To provide greater flexibility, St. Francis expanded its telemetry bed capacity by establishing 10 additional swing beds (that were wired for telemetry) on an existing medical–surgical unit and providing telemetry training to additional staff. In addition, internal analysis found that the hospital had a surplus of perinatal versus medical–surgical beds. To provide greater flexibility, the hospital relicensed 12 perinatal beds to medical–surgical beds but retained the ability to "swing" those beds back to perinatal status as needed. This change in bed licensure provided the hospital with additional flexibility to meet fluctuations in medical–surgical needs.
- Policy to discharge inpatients by noon: Discharge delays have been a major contributor to the inpatient throughput bottleneck. St. Francis adopted a "discharge-by-noon" target that was communicated to all levels of the organization. The hospital’s chief operating officer meets with high-volume physicians regularly to review their patient discharge data and keep awareness of the throughput goals high, especially among those with a tendency for late-in-the-day discharges.
- Explicit goal to fill inpatient beds within 90 minutes of patient discharge: St. Francis has recently begun to track how much time lapses between when a physician writes a discharge order to when the bed is occupied by a new patient. The hospital hopes to reduce this time to 90 minutes.
- Discharge staging lounge: Periodically, patient and family circumstances hinder timely discharges. St. Francis created a lounge, staffed by RNs or certified nurse assistants, that provides a safe, comfortable place for discharged patients who are awaiting transportation. After initially putting the lounge in an out-of-the-way location (the basement), the hospital moved it to the middle of the medical–surgical floor to remind providers of this resource. After some initial reluctance by nurses, utilization has steadily increased. The hospital still struggles, however, to staff the discharge lounge.
Since the implementation of these strategies, St. Francis Medical Center's ED has faced additional throughput challenges. The closure of local hospitals and the discontinuation of key health care services, including King-Harbor Hospital's ED in August 2007, has led to continued increases in demand. St. Francis Medical Center will continue to track performance indicators for the ED initiatives presented here, and based on the resulting data, will further advance collaboration and innovation in the development of new strategies that respond to the changing needs of the community.
The medical center added a new initiative to their overall patient flow program to address overcrowding. They developed and instituted a full capacity plan that allows for different levels of response depending on the level of overcrowding in the ED and input units. The plan uses a nationally recognized quantitative measurement tool that provides different levels of overcrowding and calls for specific actions to occur at each level. The quantitative tool used is known as the National Emergency Department Overcrowding Scale (NEDOCS), developed by the University of New Mexico.
References/Related ArticlesRubino L, Stahl L, Chan M. Innovative approach to the aims for improvement: emergency department patient throughput in an impacted urban setting. J Ambul Care Manage. 2007;30(4):327–37. [PubMed] Available at: http://www.ambulatorycaremanagement.com/pt/re/jacm/abstract.00004479-200710000-00008.htm;jsessionid=HQWQ5mhgnzJjlGM1kSQ1VSlQrmhmRj9lKLYTzCNJys4yHMyTGCLT!65375592!181195628!8091!-1
The national report card on the state of emergency medicine. American College of Emergency Physicians, 2009. Available at: http://www.emreportcard.org/uploadedFiles/ACEP-ReportCard-10-22-08.pdf.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .)
Asaro PV, Lewis LM, Boxerman SB. The impact of input and output factors on emergency department throughput. Acad Emerg Med. 2007;14(3):235-42. [PubMed]
Abaris Group. California Emergency Department Diversion Project (Report 1). Oakland, CA: California Healthcare Foundation; 2007. p. 1-16. Available at:http://caeddiversionproject.com/uploads/CAEDDiversionProjectReportOne3-21-07.pdf
Contact the InnovatorLarry Stahl
Vice President of Ambulatory/Support Services
St. Francis Medical Center
3630 E. Imperial Hwy.
Lynwood, CA 90262
Phone: (310) 900-7315
FAX: (310) 635-4497
Innovator DisclosuresMr. Stahl has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsSt. Francis' redesign and staffing strategies have increased the number of ED patients treated, improved patient satisfaction, and reduced waiting times for inpatient admissions and the number of patients who leave the ED without being seen.
Moderate: The evidence consists primarily of before and after comparisons of key statistics related to the ED and inpatient admission process. The evidence is relatively recent because many of these strategies were implemented in August 2006 and continue to undergo modifications.
- Increased ED volume: Since the implementation of the program, ED patient volume has increased by 5.5 percent. Although several different programs have contributed to this success, the innovator believes that the creation of the fast-track area is the primary reason for the increase.
Fewer patients leaving without being seen: The "left-without-being-seen rate" at St. Francis' ED has fallen 23 percent since the program's inception, with only 3 percent of patients leaving without being evaluated by a provider. This figure is well below the roughly 9-percent average of other urban EDs. The use of physician assistants and the lobby coordinator program are credited with being major contributors to this decrease. Going forward, the hospital hopes to increase the number of ED patients treated by physician assistants to 60 to 75 a day.
Enhanced patient satisfaction: Patient satisfaction in the ED improved 24 percent, owing in large part to the lobby coordinator program.
Reduced waiting time for inpatient admission: The average amount of time that a "boarded" ED patient waited for an inpatient admission fell from 5.4 to 4.5 hours between August 2006 and March 2007, owing in large part to the development of the inpatient staging unit.
Limited success in achieving discharges by noon: Data from high-volume physicians have demonstrated limited improvement in the ability to discharge patients by noon, owing in part to the failure to change physician behavior (e.g., making rounds earlier in the day, giving discharge orders by phone when possible). To address this issue, St. Francis is currently moving to the use of hospitalists, who will be under contract to treat all admitted patients. St. Francis' leaders hope that this strategy will help them to achieve consistent discharge times and regimens and therefore meet the noon deadline.
Context of the InnovationLocated in Los Angeles County, St. Francis Medical Center is the largest hospital in the Daughters of Charity Health System. One of the busiest private hospital EDs in southern California, St. Francis treats approximately 60,000 ED visitors, and its level II trauma service provides care to more than 1,470 patients each year. The hospital as a whole provides medical care to 1 million residents who face significant poverty, high unemployment, educational deficiencies, high teenage pregnancy rates, and a lack of health insurance coverage. In fact, Los Angeles County has one of the highest proportions of uninsured individuals in the country, including a large undocumented population that places additional pressure on county EDs. About 2.25 million Los Angeles County residents lack health insurance, and the uninsured have been documented to wait longer before seeking treatment, thus requiring more extensive and expensive care. Facing overcrowding, long patient waiting and holding times, increased ambulance diversions, patients leaving without being seen, and low patient satisfaction and staff morale, the hospital's governing board made improving ED services and inpatient bed flow and capacity one of the organization's top strategic priorities. In late 2005, the center's administrative and medical staff leadership created a Throughput Committee charged with developing and implementing initiatives to reduce boarding time.
Planning and Development ProcessKey steps in the planning and development process are outlined below:
- Formation of committee: The Throughput Committee is made up of nursing, physician, and administrative champions. The committee, which meets every 2 weeks, was originally charged with developing a hospital-wide approach to improve patient throughput across the spectrum of care. Areas considered by the committee included the redesigning of ED space, changing physician behaviors and inpatient discharge practices, and reconfiguring ED staffing and the ED patient admission and evaluation process. The team was also charged with developing and monitoring key indicators to measure the success of the new initiatives and with keeping the hospital’s top management team and governing board updated regularly.
- Periodic monitoring and reporting: Each quarter, a strategic plan update is presented to the medical center's board of directors. In addition, patient throughput and other key clinical quality and performance metrics are reported on a monthly basis to the Department of Emergency Medicine, the Medical Executive Committee, and the Quality and Patient Safety Committee. Data in these reports include:
Total length of stay for ED patients discharged to home
Total length of stay for admitted ED patients
Average time patients are held awaiting admission
Patients who left the ED without being seen
Average number of ED patients seen daily
Resources Used and Skills Needed
- Staffing: The hospital hired a physician assistant, additional triage nurses, and a patient-flow nurse. In addition, designated leaders and champions from nursing, the medical staff, administration, and the ED were involved in the development and implementation of the programs.
- Outside consultant: Architectural redesign of the ED facilities was performed by an external consultant.
- One-time remodeling costs: The hospital spent $200,000 on development of the fast-track unit and $875,000 for the waiting room remodeling, development of areas for triage and rapid medical evaluation, and the addition of 11 more beds.
Funding SourcesSt. Francis Medical Center
The hospital funded the physical renovations and the hiring of new staff, as the institution's leaders have made throughput improvements a major hospital priority.
Tools and Other ResourcesSt. Francis Medical Center's Web site. Available at: http://www.stfrancismedicalcenter.org:80/Pages/default.aspx
Getting Started with This Innovation
- Make ED improvements and innovations an institutional priority, empower managers to make changes, and encourage them to use a multipronged approach that addresses both the ED and inpatient arenas simultaneously.
- Ensure that patient records can be shared across the hospital. At St. Francis, the electronic medical record is critical to this task.
- Examine the data related to the patient flow experience and bottlenecks in the hospital, including both the inpatient and ED arenas. Armed with that data, stakeholders can identify what areas need improvement and then measure any efficiencies gained through the improvements.
- Find other hospitals of similar size and patient base to see how they have improved ED efficiencies.
- Coordinate with emergency management services to see whether improvements can be made in the processes and policies related to transporting patients to the facility via ambulance.
Sustaining This Innovation
Designate a committee to oversee the program. The committee should include a team of individuals who meet regularly to craft improvements, monitor success, and develop progress reports for institutional leadership.
Designate an institutional leader, such as the chief operating officer, to meet with physicians regularly to review their discharge data and keep them aware of throughput goals. At St. Francis, these meetings have made physicians more cognizant of the spillover effect of prolonged inpatient length of stay on ED overcrowding.
Consider using statistically valid sampling to monitor key indicators. St. Francis, for example, uses statistically valid sampling to estimate how many physicians discharge patients by noon and how long it takes nurses to get patients out of their beds after the discharge papers have been signed. The hospital lacks the capacity to track these indicators hospital-wide.
Be prepared for continuing challenges due to the dynamic health care market environment. For example, St. Francis Medical Center has been affected by closure of the nearby county hospital that had previously provided ED services. Since then, St. Francis has noted a 10- to 13-percent increase in ambulance traffic with an overall increase in ED volume of 14 to 15 percent. The higher acuity of receiving and walk-in patients has had a direct impact on telemetry and ICU beds; the inability to reduce this volume has affected various components of recent throughput efforts, most notably higher acuity, resulting in a longer length of stay for this population of patients. In the early months of 2008, Saint Francis Medical Center's acute care beds have been at nearly 100 percent capacity.
Additional Considerations and Lessons
- Although the patient-flow nurse has been instrumental in improving throughput, there was some initial resistance to the idea from inpatient floor nurses who were reluctant to accept new admissions. Originally meant to be a combination of bed czar, ED manager, case manager, and inpatient discharge manager, the patient-flow nurse position is currently being reevaluated to determine how best to bring together these disparate elements into one job. The current thinking is that the position will be redefined as a discharge nurse manager who helps floor nurses to become more efficient during the discharge process.
Use By Other Organizations
- St. Francis has joined with 10 other hospitals in Los Angeles, Ventura, and San Bernardino counties in a regional ED Diversion Project. The collaboration involves physician champions who meet regularly to share data and success stories.
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 31, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.