How Fast Are We? Throughput Times for Admissions From the Emergency Department

1. How Fast Are We?Throughput Times for Admissions From the Emergency Department Brian Hom; Deborah Porter RN, NM; Kathleen Chambers RN, MSN, CPN; Laura Gaertner RN, BSN

2. Background • Overcrowding and slow patient throughput is a major problem in hospitals throughput the U.S. • There is a dramatic rise in E.D. wait times and diversions in the U.S. • Over the past two decades, the number of emergency rooms have decreased while the number of patient visits have increased by 35 percent. • Capacity issues usually arise in areas of the hospital where demand fluctuates i.e. Emergency Room • In 2008, the Center of Disease Control reported the average time that patients wait to see a doctor in hospital ERs grew from 38 min. to 1 hr. between 1996 and 2006. • Emergency department visits in the U.S. increased from 90 million to 119 million from 1996 to 2006.

4. Effects • Overcrowding and slow patient throughput compromises patient safety, reduces hospital revenues, and affects staff and patient satisfaction. • The quality of patient care is jeopardized because the amount of patients outweighs the availability of resources. • The level of stress for the staff increases • Prolonged pain and suffering by patients • Long patient wait times • Increased transport times for ambulance patients • Inconvenience and dissatisfaction for patients and their families

5. Indicators of Overcrowding • The number of hours a hospital is on diversion status • The number and length of time patients are on hold in the emergency room after being admitted • The proportion of patients that leave the emergency room before having a medical evaluation since they are tired of waiting

6. Hypothesis If data is collected about the average time taken between key steps in the patient throughput process (arrival, disposition, bed ready, report, and transfer) in the adult emergency room, then a baseline will be developed that can lead to future research on possible improvements to the patient throughput process and the staff can focus on improving the specific areas that may slow down patient throughput down.

7. Methodology • Retrospective study conducted on the throughput times for normal adult admissions (no cardiac arrest or stroke) in the emergency department of Fairview Hospital. • The charts of over 300 patients were examined using EPIC • Ten charts were taken each day from June 12, 2011 to July 4, 2011 • The patients were chosen randomly based on when they were admitted • Day shift: 7 am to 3 pm • Evening shift: 3 pm to 11 pm • Night shift: 11pm to 7 am • The arrival time, disposition time, assignment/ bed ready time, report time, and the time the patient went up to the floor were recorded

8. The amount of time in minutes was determined for each of the key points in the throughput process • The average time was determined for each checkpoint for each shift in each day • Staff from various departments were asked about their opinions as to what slows down patient throughput

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14. Results • The data can act as a starting point for further research regarding patient throughput • All the steps of the throughput process affect the times but no one step is responsible • The throughput times for the evening are often longer due to a greater influx of patients in the evening • According to the data, the time between when the patient arrives in the emergency department and when they are admitted to the hospital is typically the longest

15. Factors That Affect Throughput • Each department has their own factors that may contribute to overcrowding and slow patient throughput • According to a 2003 report on ED overcrowding by the US General Accounting Office: “the factor most commonly associated with crowding was the inability to transfer emergency patients to inpatient beds once a decision had been made to admit them as hospital patients rather than to treat and release them” • These patients are known as boarding patients-they still require care and take up space, equipment, and staff time so other emergency patients cannot be treated

16. Co-pay is collected from patients after they are ready to be discharged • The IV contrast fluid that is required for certain tests takes hours to circulate the body • Not enough staff on duty • Beds are not cleaned in a timely manner for the next patient • Limited number of beds that have telemetry • Discharge of inpatient beds not occurring in timely fashion • ER holding admissions until later due to other priorities • Immense paperwork requires time to fill out completely • Charting slows nurses down • Doctor does not make rounds in a timely manner • Ride is late to pick up patient • Explaining what medication to take and how to take it for inpatients • ED patients tend to be older and have more complex conditions- requires more tests • Takes time to receive results from tests • Standard for admittance is changing • ED patients compete for available beds with scheduled admissions (ex. Surgery Patients) See next slide.

18. Suggestions to Improve Throughput • Actions to address the throughput usually involve increasing capacity or efficiency • Build larger ED • Focus on increasing speed of registration and triage • Improve efficiency outside of ED • Encourage staff to discharge patients by noon • Set up a “dock and triage” system where a physician is stationed in the triage and admits only the patients that need it while quickly treating those with less severe conditions • Assign an area specifically for inpatients beds ready to be discharged because patients who are ready to be discharged often wait for hours just for their doctors to make their rounds. This occupies inpatient beds that need to be used.

19. Recommendations • In future studies, test several ideas on throughput improvement and see if they improve efficiency • Use a larger data set to obtain more accurate results • Make comparisons to other area hospitals

20. Conclusion • The purpose of this study is to develop a base that can be used for further research in the improvement of patient throughput • Improving patient throughput or flow will improve patient care and satisfaction • This data will help the hospital and staff gain insight as to what can be done to improve patient throughput • Many factors that affect patient throughput are out of the hospital and staff’s control (i.e. IV contrast fluid requires several hours before certain tests can be done) • Improving patient throughput is important because it directly affects patient care, hospital revenues, and overall satisfaction of the patients and staff • A hospital functions as one team and all the departments need to work together in order to resolve the patient throughput issue

21. Works Cited “Emergency Department Crowding-Patient Flow/‌Throughput.” Emergency Nurses Association. N.p., 2011. Web. 22 June 2011. <http://www.ena.org/‌IQSIP/‌ENAStrategicPriorities/‌Crowding-Patient%20Flow/‌Pages/‌Default.aspx>. Handel, Daniel A, MD, et al. “Emergency Department Throughput, Crowding, amd Financial Outcomes For Hospitals .” Wiley Online Library. N.p., 2011. Web. 19 July 2011. <http://onlinelibrary.wiley.com/‌doi/‌10.1111/‌j.1553-2712.2010.00814.x/‌full>. Joelving, Frederick. “ER crowding tied to higher death rates.” Reuters. N.p., 13 June 2011. Web. 28 June 2011. <http://www.reuters.com/‌article/‌2011/‌06/‌13/‌us-er-crowding-idUSTRE75C0Q220110613>. “Patient Throughput.” Hospitals in Pursuit of Excellence. N.p., 2010. Web. 22 June 2011. <http://www.hpoe.org/‌topic-areas/‌patient-throughput.shtml>. Smith, Ben. “Hospital Overcrowding.” Cartoon. CAMfitti carTOONS. N.p., 2011. Web. 21 July 2011. <http://camffiti.blogspot.com/‌2010/‌02/‌will-this-solve-hospital-overcrowding.html>.

22. Thank You! Mentors: Deborah Porter RN, NM; Kathleen Chambers RN, MSN, CPN; Laura Gaertner RN, BSN Fairview Hospital and the Emergency Department Office of Civic Education Initiatives Summer Internship Program