115 Improving Emergency Department Efficiency: Decreasing Wait Times by Redistribution of Physician Staffing

Abstract

Delays before receiving care in the emergency department (ED) can reduce the quality of care and increase risks and discomfort for patients with varying degrees of illnesses or injuries. The length of time patients wait to see a provider in the ED is also an important driver of patient satisfaction. We have an internal goal of performing a comprehensive (Full) exam on 90% of triage Emergency Severity Index (ESI) level 3 (urgent) patients within 120 minutes of arrival. We focused on this group because it represents both the largest volume of patients as well as having the greatest opportunity for improvement. We wanted to decrease wait time without using any additional physician or ancillary resources. Of the several hypothesized ways to reduce the wait time, we assessed the flow pattern in our ED and changed staffing patterns using staggered, overlapping shifts. Our goal was to reduce door to comprehensive provider exam time in ESI Level 3 patients. We performed a quasi-experimental, before and after study of patients from the ED of a large, urban, university-affiliated hospital. All patients who presented to the ED who were triaged to an ESI level 3 obtained from the departmental throughput report were included. The prior staffing pattern was of physician coverage of 12-hour shifts from 08:00-20:00 and 20:00-08:00, with some 11:00-23:00 hour coverage. We implemented multiple overlapping attending and resident physician shifts over 5 days on the weekdays to better align coverage with patient volume. ED throughput was evaluated from January 2018 through February 2019 after implementing the new staffing patterns in October 2018; encompassing times prior to, partial, and complete implementation. The throughput data was reviewed for total patients registered by triage, percentage of patients receiving full practitioner exam in less than 120 minutes from arrival, and median time in minutes to full exam. In the analyses pre- and post-intervention, continuous variables were assessed using Student t-test, while categorical data were assessed using chi-squares distribution. Prior to implementation of our overlapping physician scheduling intervention median Door-To-Full Exam was 84 minutes. Post implementation there was an immediate and sustained, in addition to statistically significant, reduction in our median Door-To-Full Exam. In Jan & Feb 2019 the median Door-To-Full was 52 minutes, which is a 62% decrease in median Door-To-Full Exam from the same period in 2018. Pre-intervention our percentage of level 3’s being seen under 120 min was 64%, and after intervention implementation was 82% representing a 18% increase of level 3’s being seen in goal time of under 120 minutes.Tabled 1JAN 18FEB 18MAR 18APR 18MAY 18JUN 18JUL 18AUG 18SEP 18OCT 18NOV 18DEC 18JAN 19FEB 19P-VALUETotal Volume Adult7,4596,6646,9156,8227,3386,9567,2187,2336,8667,0636,4726,7637,2046,5680.16Level 3 by Triage6,3705,9875,6875,6386,2395,6385,4455,5725,5045,8365,4235,9825,9295,5150.66Level 3 Percentage of Total Volume85%90%82%83%85%81%75%77%80%83%84%88%82%84%0.22Door To Full Exam (Triage Level 3)--Median Minutes91877284736889847665494952520.00Door To Full Exam (Triage Level 3)--Average Minutes10211196103968711210610188666967700.00Full Exam < 120 min (Triage Level 3) Percentage60%61%68%64%67%72%61%63%64%73%83%82%84%81%0.00 Open table in a new tab Without increasing attending and resident physician or ancillary staff hours, or redesign of physical space we were able to dramatically increase the number of ESI category 3 patients seen in less than 120 minutes. Patient volume data-driven redistribution of physician staffing led to marked improvement in emergency department efficiency.