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Service Delivery Innovation Profile

Comprehensive Bundle of Strategies Improves Emergency Department Turnaround Time, Reduces Boarding Time and Patients Leaving Without Being Treated


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Snapshot

Summary

Lakeland Regional Medical Center implemented a comprehensive bundle of strategies to improve emergency department throughput, including reorganizing space into pods, making staffing changes to facilitate patient flow, requiring emergency medical service personnel to provide advance notice of ambulance arrivals so that a bed can be preassigned, and having a multidisciplinary team develop and use care plans for nonemergent patients who repeatedly present with chronic pain issues. Together, these initiatives significantly improved patient turnaround time (in part by reducing visits from nonemergent patients with chronic pain), which in turn has led to fewer patients leaving before being treated and fewer patients boarding in the emergency department while awaiting an inpatient bed assignment.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including patient turnaround time, the percentage of patients leaving without treatment, and the number of patients boarding in the ED awaiting bed assignment.
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Developing Organizations

Lakeland Regional Medical Center
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Date First Implemented

2011
January

Problem Addressed

Many emergency departments (EDs) in urban areas routinely experience overcrowded conditions, resulting in long waits for patients, ambulance diversions, patient boarding in hallways, and patients leaving without being treated.
  • A common problem: Between 1996 and 2006, the annual number of ED visits in the United States increased by roughly 32 percent, from 90.3 million to 119.2 million. During this time, the number of U.S. hospitals operating EDs declined, dropping from 5,000 in 1991 to fewer than 4,000 in 2006.1 As a result, ED overcrowding has become quite common,1 with 90 percent of large hospitals (300 or more beds) that operate EDs reporting consistently functioning at or above capacity.2
  • Driven by multiple factors: Multiple factors account for ED overcrowding in urban areas, including inefficient patient flow, patients coming to the ED with conditions that are not emergencies, and uncontrollable fluctuations in demand related to trauma visits.
  • Leading to long turnaround time, related problems: Patients often wait a long time before being treated and discharged from the ED. A Press Ganey research study found that in 2009, patients admitted to hospitals waited an average of 6 hours in an emergency room, while almost 400,000 patients waited 24 hours or more.3 Between 2003 and 2009, the mean wait time in U.S. EDs increased by 25 percent; longer wait times occurred in EDs in urban areas and in EDs with greater annual visit volume.4 Before implementation of this program at Lakeland Regional Medical Center, ED patients routinely waited 4 to 5 hours (and sometimes up to 10 hours) before being treated and discharged. Together, ED overcrowding and associated long wait times can cause other related problems as well, including "boarding" of patients in hallways, diversion of ambulances to other facilities, patients leaving the ED before being treated, and patients generally being dissatisfied with ED services. For example, before implementation of this program, the long wait times at Lakeland led 4 percent of ED patients to leave without seeing a doctor.

What They Did

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Description of the Innovative Activity

Lakeland Regional Medical Center implemented a comprehensive bundle of strategies to improve ED throughput, including reorganizing space into pods, making staffing changes to facilitate patient flow, requiring emergency medical service (EMS) personnel to provide advanced notice of ambulance arrivals so that a bed can be preassigned, and having a multidisciplinary team develop and use care plans for nonemergent patients who repeatedly present with chronic pain issues. Key strategies include the following:
  • Reorganizing space into pods: Previously, the Lakeland Regional ED had two designated patient care areas: one for critical care patients and a second for noncritical patients. As part of this improvement strategy, the ED staff decided to no longer divide patients by acuity according to these designated areas and instead grouped rooms into nine pods: one for triage, six that serve adults, one that serves children, and one for "fast-track" patients.
    • Triage pod: A nurse supervisor and three registered nurses (RNs) (increasing to five RNs as arrival patterns peak) staff the triage pod, assessing patients as they come to the ED and assigning them to other pods as appropriate. Because beds are not earmarked for specific types of patients as was done previously, the triage nurse supervisor can assign patients to maximize use of available capacity.
    • Adult and pediatric pods: Each of the 6 adult and pediatric pods has 12 beds, including 2 designated for critical care patients. One physician and four RNs provide direct patient care on each of these pods (although only four of them are staffed between 1:00 a.m. and 8:00 a.m.). A nurse supervisor monitors and manages patient flow for these pods during regular work hours (see sub-bullet under Staffing for more details).
    • Fast-track pod: Staffed by a physician, nurse supervisor, and four RNs, the fast-track pod includes five recliner chairs for low-acuity, mobile patients. The fast-track pod serves as an efficient place to serve patients who do not require a bed, allowing clinicians to quickly treat and discharge patients with relatively minor conditions.
  • Staffing to facilitate patient flow: The following staffing-related strategies were put in place to facilitate patient throughput:
    • Bed traffic controller: An RN serves as a "bed traffic controller" for the triage pod, assigning patients to the adult pods. The RN rotates patient assignments to the adult pods so that clinicians do not become overwhelmed with multiple patients at once. When the RN assigns a critical care patient to a pod, she will delay new assignments to that pod for 20 minutes so that the staff has sufficient time to attend to the patient's immediate needs.
    • Nurse supervisor to monitor, manage patient flow: Each adult and pediatric pod has a nurse supervisor who monitors patient flow and identifies and addresses any delays in care. For example, the nurse supervisor may follow up on a diagnostic test that has not been performed or on results that have not been received, remind the physician that laboratory test results have arrived, resolve difficulties in reaching a consulting physician, move a teenager from the pediatric pod to an adult pod if the pediatric pod is full, and prompt physician decisions related to hospital admission or ED discharge.
    • Throughput coordinator during off-hours: Because pods do not have nurse managers present regularly during off-hours and weekends, an RN throughput coordinator assumes responsibility for monitoring and addressing workflow issues and delays across all pods at night and on weekends.
    • Assessment-Care-Treatment (ACT) Team: When pods are at full capacity, the bed traffic controller can activate a small group of nurses for the triage pod, known as the ACT team. Led by the triage nurse supervisor on the shift, this team implements protocols approved by ED physicians to initiate laboratory testing and other needed services. The goal is to begin care before bed assignment, thereby reducing delays. The ACT team is typically activated when a patient has waited for 15 or 20 minutes after triage for a bed assignment.
  • Prenotification from EMS personnel: EMS personnel notify the bed traffic controller about all patients coming to the ED by ambulance, providing information about their medical history, condition, and severity of illness. The bed traffic controller uses this information to assign these patients to pods before their arrival. After arriving at the ED, EMS personnel view a tracking board at the EMS entrance to learn the patient's bed assignment and then deliver the patient directly to that bed.
  • Care plan for frequent visitors with chronic pain: A multidisciplinary pain management team (including a palliative care pharmacist, pain management pharmacist, hospitalist, the ED medical director, and the ED manager) develops individualized care plans for patients with chronic pain who frequently visit the ED. The care plan is initially developed when an ED physician notifies the team about a patient who has presented with chronic pain issues multiple times over the past 3 months. The team meets periodically to review the records of referred patients and develop individualized care plans, including a strategy for managing medications. This plan becomes part of the electronic medical record. If the patient comes to the ED again complaining of chronic pain, the triage nurse receives an electronic alert that a medical management plan for chronic pain has been developed for this patient and reminds the ED physicians that a care plan is present. The ED physician then assesses the patient and discusses the plan, self-management strategies, and care settings that can be used in the future instead of the ED.

Context of the Innovation

An 851-bed not-for-profit community medical center, Lakeland Regional Medical Center is the only hospital in the city of Lakeland, FL. The facility offers a comprehensive set of primary and specialty medical services to Polk County residents, including a 105-bed ED that handled approximately 172,000 visits in 2012. The ED is responsible for more than 70 percent of inpatient admissions to the hospital. The impetus for this program came from ED staff, who over time had pursued some process improvement initiatives that resulted in small improvements to patient flow and throughput. In 2010, the hospital’s new chief executive officer (a biomedical engineer) decided that a significant overhaul of ED workflow and processes was needed to achieve meaningful improvement, and she and the hospital board of directors made improving ED efficiency the organization's number-one priority for 2011.

Did It Work?

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Results

Together, the bundle of strategies has led to significantly shorter waits and faster turnaround time, which in turn has led to fewer patients leaving before being treated and fewer ED boarders.
  • Faster service: The average patient is seen by a doctor within 19 minutes of arrival at the ED and is treated and discharged in slightly more than 2 hours, significantly below the 4 to 5 hours required before implementation of this program. As of February 2013, the vast majority (approximately 80 percent) of patients are treated and discharged in fewer than 3 hours; before the program began, it took twice that long to treat most patients.
  • Fewer leaving without treatment: Before implementation of this program, roughly 4 percent of patients left without being treated; by 2012, that figure had dropped dramatically, to 0.3 percent.
  • Fewer ED boarders: The number of ED boarders declined from 1,837 in January 2010 to 195 in January 2013; this decline was associated with decline in the number of boarding hours from 11,420 in January 2010 to 585 in January 2013.
  • Fewer nonemergent visits for chronic pain: An evaluation involving a small sample of patients revealed that ED visits dropped roughly in one-half for patients with chronic pain who had a care plan in place.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including patient turnaround time, the percentage of patients leaving without treatment, and the number of patients boarding in the ED awaiting bed assignment.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Assembling multidisciplinary planning team: The associate vice president for the ED and the ED director assembled a multidisciplinary team of ED staff (physicians, nurses, technicians, and administrative staff) and representatives from all other service areas involved in emergency care, including radiology, laboratory, pharmacy, and patient transport.
  • Implementing quality improvement process: Through biweekly meetings over a 12-month period, the team used Toyota's Lean methodology to evaluate every step involved in current ED workflows and processes to identify inefficiencies and delays. The team then developed strategies to address these problems and implemented rapid change cycles to test these proposals. The team also reviewed historic patient arrival patterns and changed staffing levels and patient flows in response to them.
  • Meeting with physicians and nurses: The team met with physicians and nurses on an ongoing basis to communicate the need for rethinking ED workflow and processes, emphasize senior leadership support of these changes, and solicit suggestions for process improvements.
  • Training staff: Various ED staff trained nurses on how to work effectively in pods; nurses working as bed traffic controllers and throughput coordinators also received training. ED staff worked with EMS personnel to implement the prearrival notification process.
  • Designing and executing public relations campaign: The medical center’s marketing department designed and implemented a public relations campaign that used various media to publicize the improvements at the ED and share data on their impact.

Resources Used and Skills Needed

  • Staffing: Overall, the process improvements required a moderate increase in nurse staffing.
  • Costs: Data on development and operating costs for this initiative are not available. The largest upfront expenditures consisted of planning and executing the care process redesign, hiring additional nursing staff, and executing the public relations campaign.
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Funding Sources

Lakeland Regional Medical Center
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Adoption Considerations

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Getting Started with This Innovation

  • Ensure senior management support: Lakeland Regional had full strategic and financial support for ED process improvements from its chief executive officer and board. Process improvement would not have been possible without this support.
  • Do not accept size and limited inpatient capacity as excuses for poor efficiency: Hospital administrators, clinicians, and patients may come to accept ED overcrowding as a natural consequence of being a large facility with limited inpatient bed capacity. To change this mindset, emphasize to all stakeholders that ED efficiency can and should be achieved regardless of hospital or ED size and that process improvement can be achieved in the ED even if inpatient units are experiencing backlogs.
  • Emphasize purpose of process changes to clinicians: When meeting with physicians and nurses, emphasize how implementing process changes will support better quality care and service. Elicit and act on suggestions or input provided during these sessions.
  • Delineate clear performance measures: Set performance measures tied to patient care improvements and emphasize to clinicians that these indicators are being set up to gauge progress, not to evaluate their personal performance.
  • Carefully examine existing patient flow: Program developers should map each step of the current workflow in detail to identify opportunities for improvement.
  • Do not wait for “perfect” data: Do not wait for excessive amounts of data to justify a proposed strategy. A new idea should be tested once a reasonable amount of evidence exists that it may be beneficial.
  • Set up one-physician pods: Assigning multiple physicians to the same pod can create confusion that contributes to delays. In contrast, assigning one physician to each pod creates clear accountability for performance.
  • Spread critical care beds across pods: Most EDs using a pod system designate one for critical care. Based on the experience at Lakeland Regional, the better approach is to disperse critical care patients across pods. At Lakeland, this strategy led to improvements in patient flow and staff workflow and to reductions in length of stay.

Sustaining This Innovation

  • Review performance data on ongoing basis: Monitor performance metrics (such as patient turnaround time) on a daily, weekly, monthly, and annual basis to ensure that the new processes continue to be efficient and effective, and that performance does not slip over time.
  • Use past successes to spur additional improvement: Clinicians will remain supportive of the program as long as they regularly see evidence of its success. To that end, regularly share data and anecdotal feedback from patients and clinicians with ED physicians and staff.

More Information

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Contact the Innovator

Maureen Leckie, RN, BSN
Director of Emergency Services
Lakeland Regional Medical Center
1324 Lakeland Hills Boulevard
Lakeland, FL 33805
(863) 284-1787
E-mail: maureen.leckie@lrmc.com

Innovator Disclosures

Ms. Leckie reported having no financial interests or business/professional affiliations relevant to the work described in the profile.

Footnotes

1 DeLia D, Cantor JC. Emergency department utilization and capacity. The Robert Wood Johnson Foundation Synthesis Project, Issue 17. July 2009. Available at: http://www.rwjf.org/pr/product.jsp?id=45929.
2 Burley G, Bendyk H, Welchel C. Managing the storm: an emergency department capacity strategy. J Healthc Qual. 2007;29(1):19-28. [PubMed]
3 Rice S. Don't die waiting in the ER. CNN.com [Web site]. January 13, 2011. Available at: http://www.cnn.com/2011/HEALTH/01/13/emergency.room.ep/index.html.
4 Hing E, Bhuiya F. Wait time for treatment in hospital emergency departments: 2009. National Center for Health Statistics Data Brief No. 102. Atlanta (GA): Centers for Disease Control and Prevention. 2012 Aug. Available at: http://www.cdc.gov/nchs/data/databriefs/db102.htm.
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Original publication: June 05, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.