Emergency Department Patient Flow Research Articles

Analysis of factors influencing length of stay in the Emergency Department in public hospital, Yogyakarta, Indonesia

BackgroundsThe increasing demand for emergency care may cause prolonged Emergency Department length of stay that has an impact on quality of care. In Indonesia, factors influencing Emergency Department length of stay are difficult to determine. The purpose of the study was to identify factors that contributed to length of stay at tertiary hospital Yogyakarta, Indonesia. MethodsA descriptive study was conducted with a cross-sectional, retrospective design. Participants (n=139) were patients aged 18 years or over who presented to Emergency Department at tertiary hospital, over seven consecutive days. Data were gathered by reviewing patients’ notes using modified data collection tool and by measuring the average time in each stage of Emergency Department patient journey. Mann–Whitney and Kruskal–Wallis tests were utilised to analyse data. ResultsThe median Emergency Department length of stay was 330min. The acuity level, specialist consultation and need for admission were associated with increased Emergency Department length of stay (p<0.05). Laboratory turn around time (median 58min) and waiting for bed availability (median 167min) contributed to prolonged length of stay, for discharged and admitted patients, respectively. ConclusionsThis study assists in understanding factors that most significantly influence Emergency Department length of stay in an Indonesian hospital and will inform policy makers in development of strategic plans to improve Emergency Department patient flow.

The Effect of Emergency Department Expansion on Emergency Department Patient Flow

Introduction:Overcrowding in the emergency department (ED) has been a global problem for a long time, but it is still not resolved.Aim:To determine if an ED expansion would be effective in resolving overcrowding.Methods:This was a retrospective study comparing two 10-month periods before (September 2015 to June 2016) and after (September 2017 to June 2018) the ED expansion in an urban tertiary hospital. The existing ED consisted of 45 beds in the adult area and eight beds in the pediatric area. After the construction, the number of beds was not increased, but a fast track area was newly established in the adult area, and a 25-bed ward for emergency hospitalized patients was opened.Results:The number of patients visiting the ED increased from 77,078 to 87,927. The proportion of patients who returned home without treatment significantly decreased from 11.5% to 0.9% (p&lt;0.001). The number of adult patients increased from 40,814 to 60,720, but the number of patients who could be treated on the bed decreased (22,166 (54.3%) vs. 17,776 (29.3%), p&lt;0.001). The number of pediatric patients was similar in both periods. Median ED length of stay (LOS) of total patients increased from 193.0 min to 205.8 min (p&lt;0.001). Of the 18,900 hospitalized patients during post-period, 1,255 (6.64%) were admitted to the emergency ward, and the boarding (from admission decision to hospitalization) time of the admitted patients decreased from 239.2 min in the pre-period to 190.9 min in the post-period by 38.3 min. However, more time was required for admission decision in the post-period (216.8 vs. 253.3, p&lt;0.001).Discussion:The ED expansion allowed more patients to be treated, and the emergency ward reduced boarding times of admitted patients. However, due to the increase in the number of patients, the time required for medical treatment increased.

Emergency department personnel's individual preferences should not be neglected when an IT-technology is to be introduced

There is an increasing demand and importance for quick clinical assessment of patients by experienced front-line physician, and for efficient patientflow in emergency department without delay. That requires application of new technologies, including IT-solutions. From the other side, healthpersonnel, as a human factor applying technology, should accept it and not be neglected. Purpose: preliminary qualitative assessment of physicians' individual preferences related to introduction of conceptual tablet-device based documentation technology in emergency department.&#x0D; We used ”Presurvey” solution developed for the emergency department in order to speed-up documentation process by front-line physicians, which is mobile device based web-app system allowing data input via button selection and visualising standardised autotext (front-line doctor's clinical assessment note) based on the ABCDE clinical algorithm. Author had participated in the concept development. ”Presurvey” was used at Emergency department, Regional Hospital Horsens, during 100-days period, from October 2017, working days, between 7.30-18.00. Mini-iPad was used as mobile device. “Presurvey” was introduced to doctors individually. 9 experienced emergency doctors were invited, they were completely free to apply the concept or not on a case to case basis. There was gathered feedback and undertaken audit.&#x0D; ”Presurvey” was applied by 8 (89%) doctors in 528 patient-cases (12,5%) out of 4.215 admitted patients of medical and surgical profiles. 1 (11%) physician wouldn't use ”Presurvey”, 3 (33%) doctors have tried, but preferred the conventional documentation way. 5 (55%) users, including author, had positive attitude. 4 (44%) of them (without author) were active users, based on criteria of repeated use of ”Presurvey”. Audit revealed personal preferences, mostly addressed to autotext. The concept was evaluated as making sense by 7 (78%) doctors, however there was different level of unsatisfaction related to the text formulations. 4 (50%) participating doctors accepted autotext concept with minor adjustments, while the other 50% would prefer flexibility of ”alive” language as communication tool for documentation.&#x0D; Small-population observational study demonstrates that for implementation of a new IT-based technology related to the medical documentation in emergency department it is important to consider as choice flexibility for specialists as their individual variables and preferences, which should be carefully studied when introduced bigger scale solutions.

Pediatric Trauma Experience After Transition to a Freestanding Children's Hospital.

Transition of pediatrics services to freestanding children's hospitals is a common trend over the past 3 decades, yet there is no published information on the effect of these moves on the pediatric emergency department (ED). We looked at the effect on trauma volume and severity presenting to the ED after transitioning to a freestanding children's hospital at a location previously without dedicated pediatrics services. We analyzed data using a retrospective chart review of pediatric trauma visits (age, <15 years) from our pediatric trauma registry. Data analyzed included trauma volume per year, injury severity score, method of trauma, and method of arrival to hospital. Patients were differentiated into groups based on premove years (2008-2010) and postmove years (2012-2014). A total of 833 trauma patients were admitted to the ED between 2008 and 2014. Trauma volume per year almost doubled in years after the move. Difference in injury severity score and methods of trauma were not statistically significant. In postmove years, there was an increase in emergency medical service and private vehicle visits. New characteristics and location of the freestanding children's hospital may suggest that easy access to the new location, parental preferences for specialized pediatrics services, and emergency medical service preferences may have positively impacted trauma volume without affecting the severity of trauma seen in our department. This study provides a unique single-center experience in understanding ED patient flow after a major department transition.

The impact of medical specialist staffing on emergency department patient flow and satisfaction.

The aim of this study was to describe the impact of additional medical specialists, non-emergency physicians (non-EPs), performing direct supervision or a combination of direct and indirect supervision at an EP-led emergency department (ED), on patient flow and satisfaction. An observational, cross-sectional, three-part study was carried out including staff surveys (n=379), a before and after 16-week data collection using data of visits during the peak hours (n=5270), and patient questionnaires during 1 week before the pilot and during week 5 of the pilot. Content analysis and descriptive statistics were used for analyses. The value of being present at the ED was acknowledged by medical specialists in 49% of their surveys and 35% of the EPs' and ED nurses' surveys, especially during busy shifts. Radiologists were most often (67.3%) convinced of their value of being on-site, which was agreed upon by the ED professionals. Perceived improved quality of care, shortening of length of stay, and enhanced peer consultation were mentioned most often.During the pilot period, length of stay of boarded patients decreased from 197 min (interquartile range: 121 min) to 181 min (interquartile range: 113 min, P=0.006), and patient recommendation scores increased from -15 to +20. Although limited by the mix of direct and indirect supervision, our results suggest a positive impact of additional medical specialists during busy shifts. Throughput of admitted patients and patient satisfaction improved during the pilot period. Whether these findings differ between direct supervision and combination of direct and indirect supervision by the medical specialists requires further investigation.

Coaching for Chaos: A Qualitative Study of Instructional Methods for Multipatient Management in the Emergency Department.

Busy environments, like the emergency department (ED), require teachers to develop instructional strategies for coaching trainees to function within these same environments. Few studies have documented the strategies used by emergency physician (EP)-teachers within these busy, chaotic environments, instead emphasizing teaching in more predictable environments such as the outpatient clinic, hospital wards, or operating room. The authors sought to discover what strategies EP-teachers were using and what trainees recalled experiencing when learning to handle these unpredictable, overcrowded, complex, multipatient environments. An interpretive description study was conducted at multiple teaching hospitals affiliated with McMaster University from July 2014 to May 2015. Participants (10 EP-teachers and 10 junior residents) were asked to recall teaching strategies related to handling ED patient flow. Participants were asked to describe techniques that they used, observed, or experienced as trainees. Two independent coders read through interview transcripts, analyzing these documents inductively and iteratively. Two main types of strategies to teach ED management were discovered: 1) workplace-based methods, including both observation and insitu instruction; and 2) principle-based advice. The most often described techniques were workplace-based methods, which included a variety of insitu techniques ranging from conversations to managerial coaching (e.g., collaborative problem-solving of real-life administrative dilemmas). A mix of strategies are used to teach and coach trainees to handle multipatient environments. Further research is required to determine how to optimize the use of these techniques and innovate new strategies to support the learning of these crucial skills.

A Descriptive Time Inventory of Emergency Department Nursing Workflows

Background: Previous emergency department (ED) process improvement efforts used probabilistic analytical or simulated models without considering the impact of specific tasks on ED patient flow and resource needs. We focus on the tasks and workflows that comprise nursing activity in an urban academic ED and level I trauma center receiving over 80,000 annual visits. &#x0D; Experimental Design: Using a time/motion observational methodology, we create a minute-by-minute time inventory account of nursing tasks and workflows as observed through the activities of 35 nurses over 124.5 hours, representative of 24/7 patient care in 7 ED care areas. “Tasks” were defined as discrete, measurable, and consequential step(s) to accomplish a clinically meaningful goal (“workflow”). The task with highest cognitive demand for each minute of observation was recorded. We also tracked 12 discrete highest-acuity (“shock”) events and catalogued second-by-second observational accounts of each nurse diverted. &#x0D; Results: Our data demonstrate significant variation in tasks based on time of day. We observed substantial operational load moving patients between care areas, with intake and discharge comprising 25% of nurse workflows. Downtime averaged 32%, with variation depending on care area. Downtime was highest (47%) with passive video monitoring of psychiatric care and lowest (22%) in high-turnover intake areas. Highest-acuity patient-care events result in significant and variable nurse diversion from other tasks averaging 1:03:29 in combined nursing effort. &#x0D; Conclusion and Potential Impact: Movement of patients between care areas represents significant operational load. Interruptions and task preparation accounted for a surprising portion of activity. Highest-acuity patient care events result in substantial and variable diversion of nurse care.

Characterizing the Long-term Care and Community-dwelling Elderly Patients' Use of the Emergency Department.

IntroductionElderly patients, particularly those in long-term care (LTC), are a growing proportion of patients who present to the emergency department (ED). This population is medically complex, with high burdens on ED resources and patient flow. This study sought to characterize how elderly LTC and community-dwelling (CD) patients use ED services. Materials and methodsThis was a retrospective cohort study that assessed approximately 200 senior (age>65) ED visits. These patients were either residing in LTC facilities or they were CD. All participants lived in the same, medium-sized Canadian city. Data indicating demographic information, acuity of presentation, and administrative parameters (such as disposition status or length of stay) were collected and analyzed.ResultsA few statistically significant differences between the populations were noted. This included mean age, which was 82.6 years in the LTC population and 77.3 for the CD group (p<0.001). There were 27 repeat visits among patients in the LTC group, compared to six from the CD patients (p<0.001). In the LTC population, 75 patients required transport from emergency medical services (EMS) compared to 41 from the control group (p<0.001).ConclusionLTC patients re-present to the ED and use EMS services more frequently than their CD counterparts. This difference indicates potential areas to target for future quality improvement work to help enhance care to this vulnerable population.

Improving Health Care Management Through Persistent Homology of Time-Varying Variability of Emergency Department Patient Flow.

Excessive admissions at the emergency department (ED) is a phenomenon very closely linked to the propagation of viruses. It is a cause of overcrowding for EDs and a public health problem. The aim of this work is to give EDs' leaders more time for decision making during this period. Based on the admissions time series associated with specific clinical diagnoses, we will first perform a detrended fluctuation analysis to obtain the corresponding variability time series. Next, we will embed this time series on a manifold to obtain a point cloud representation and use topological data analysis through persistent homology technic to propose two early real-time indicators. One is the early indicator of abnormal arrivals at the ED whereas the second gives the information on the time index of the maximum number of arrivals. The performance of the detectors is parameter dependent and it can evolve each year. That is why we also propose to solve a biobjective optimization problem to track the variations of this parameter.

Improving Low-acuity Patient Flow in a Pediatric Emergency Department: A System Redesign.

Children's National Health Systems pediatric emergency department (ED), is a level 1 trauma center in Washington, DC, which treats over 90 000 patients annually. Approximately 50% of arriving patients are triaged as low acuity, Emergency Severity Index level 4 or 5. With limited space and resources, these patients are treated inefficiently, with average delays from arrival to provider time of 1.3 hours and length of stays (LOS) close to 2.5 hours. In July 2016, Children's National Health Systems ED initiated a focused approach to improve both patient flow and experience for these low-acuity patients. We assembled a multidisciplinary ED-based task force. The quality improvement initiative began in January 2017 and consisted of 4 steps: (1) front-end space redesign; (2) implementation of a new front-end patient triage and assessment process; (3) increased doctor and nurse staffing; and (4) dissemination of data updates to reinforce awareness and adherence to workflow. Our process outcomes were arrival-to-provider time and LOS for low-acuity patients. Our balancing measures were the rate of return to the ED within 72 hours and arrival to provider times for high-acuity patients. We used statistical process control methodology to measure the effects of our interventions over time. We performed a secondary analysis to measure the response of wait times to total daily volume comparing preintervention to postintervention. We decreased the LOS by 11 minutes (9%) and arrival to MD times 21 minutes (35%) for the same period 1 year apart.

62 Patient Flow Improvements in a Rural Critical Access Hospital Reduces the Number of Patients Who Leave Without Being Seen

Making the case for investments to improve emergency department (ED) throughput and outcome measures can be difficult due to financial considerations as well as institutional history and culture. Our goal was to show that significant return on investment (ROI) exists for rural Critical Access Hospitals (CAH) to improve ED patient flow by reducing the number of patients who leave without being seen (LWOBs). We analyzed the impact on the number of LWOBS after the transition from a traditional nurse triage model to a direct to room parallel process patient flow strategy in a rural CAH ED in Minnesota. Prospective observational design. Setting: Rural CAH ED with average annual volume of 10,000-11,000 visits. Population: Consecutive ED patients in the year prior to transitioning to enhanced front end patient flow, 4/1/2015 to 3/31/2016, and the year post implementation, 4/1/16 to 3/31/17. Protocol: In April of 2016, the new processes consisted of changing from a traditional ED triage model to a direct-to-room placement model with parallel processes. The transition to the new processes included the addition of a second registrar to perform bedside registration. From the electronic medical record, we computed the percentage of LWOBS pre and post implementation and calculated the difference along with the 95% confidence interval. There were 21,875 patients in the database over the 2 years. The percentage of LWOBS in the first year was 3.4% and the second post implementation year was 0.1%. The difference was 3.3% (95% CI 2.9%-3.7%). This represents 368 more patients seen in the post implementation year compared to the year prior. The implementation of enhanced front end patient care processes, including investment in an additional registrar, yielded many more patients being seen who previously were LWOBs in a low volume rural CAH. This resulted in significant financial ROI as well as more timely and likely better care.

Interventions to improve patient flow in emergency departments: an umbrella review

ObjectivesPatient flow and crowding are two major issues in ED service improvement. A substantial amount of literature exists on the interventions to improve patient flow and crowding, making it difficult...

Using Nurse Practitioners to Optimize Patient Flow in a Pediatric Emergency Department.

Using nurse practitioners (NPs) in pediatric emergency departments (PEDs) is commonplace in the United States, yet little is known on the impact of NPs on patient flow measures in these environments. This study quantifies the impact of NPs on 2 common measures of patient flow. We conducted a retrospective cohort study using administrative data from an academic tertiary care PED. Mean shift length of stay (LOS) and the daily proportion of patients leaving without being seen (LWBS) by a clinician were compared between shifts with and without NPs on duty, matched for external variables affecting the level of activity in the department. Multivariate regression analyses were also conducted to further adjust for covariates such as the total number of PED care providers, patient acuity distribution, and total volume seen in the ED. Despite a slightly reduced total number of providers present on shifts with NPs on duty, a modest but statistically significant reduction in mean shift LOS (-19.11 minutes [95% confidence interval (CI), -31.01 to -7.22]) and daily proportion of LWBS (-1.11% [95% CI, -1.97% to -0.26%]) was observed for shifts with NPs compared with shifts without NPs on duty. Regression analyses showed that incremental NPs on shift were associated with a decreased LOS (-18.76 minutes [95% CI, -24.51 to -13.02]) as well as a reduced odds of LWBS (odds ratio, 0.56; 95% CI, 0.37-0.87). Nurse practitioners have a modest impact on patient flow measures in a PED and are a valuable resource to optimize patient flow.

Thematic Issues in Analysis and Visualization of Emergency Department Patient Flow

Emergency Department (ED) congestion is a significant problem affecting clinical outcomes, patient satisfaction and hospital costs. Identifying and resolving bottlenecks in the flow of patients from the ED to eventual admission or discharge has the potential to reduce wait times, improve care for individual patients, and increase the volume of patients treated at the hospital over time. Our objective was to review methods commonly used to measure, analyze, and visualize patient flow, characterize drawbacks to these methods, and identify areas in which analysis and visualization can be improved to make bottlenecks easier to identify and resolve. Sixty-five articles obtained from PubMed and Google Scholar searches were reviewed to identify: (1) variables used to measure ED throughput; (2) downstream effects of ED congestion; (3) factors contributing to ED congestion; (4) techniques used to predict or respond to ED congestion; and (5) tools used to visualize data on ED throughput. Hospital resource availability, patient demographics, and environmental factors have all been used to predict contributors to ED congestion. Unfortunately, the hospital practices most critical to ED congestion are unlikely to change as they involve increasing the number of beds and providers or modifying protocols with EMS, insurance, and other care facilities. Therefore, interventions addressing optimization of ED resource allocation and visualization of ED data are the best avenue to yield more efficient ED operation.

P112: FLO on flow: front line ownership of emergency department, hospital, and health system patient flow a novel approach to ED overcrowding (Part 1)

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).

P073: The GridlockED board game: using serious games for medical education

Introduction: The management of patient flow in the emergency department (ED) is crucial for the practice of emergency medicine (EM). However, this skill is difficult to teach didactically and is learned implicitly in the latter half of residency training. To help expedite the learning process, we developed the GridlockED board game as an educational tool to simulate ED patient flow. By having junior medical trainees play this game, we believe that they will develop a greater understanding of patient flow and resource management in the ED. Additionally, since GridlockED is a cooperative game, players may also benefit by improving their communication and teamwork skills. Methods: GridlockED was developed over twenty months of iterative gameplay and review. Feedback from attending emergency physicians, residents, and medical students was integrated into the game through a Plan-Do-Study-Act (PDSA) model. Emergency medicine nurses, physicians and residents at McMaster University were recruited to play GridlockED. Each player completed a pre-survey to collect demographic data and to assess their prior experience with playing board games. All play sessions were recorded for data collection purposes. Following each game session, a member of the research team conducted an exit interview with the players to gather information about their play experience and the educational value of the game. A post-survey was also sent to each participant for further feedback. Results: Eighteen gameplay sessions were conducted from June to August 2017. A total of thirty-two participants played the game (13 emergency physicians, 15 residents, and four nurses). Overall responses to the post-gameplay survey showed that players endorsed GridlockED as a useful potential teaching tool (75%, n=24/32) and the majority felt that it had the potential to improve patient flow in the ED (56%, n=18/32). Most participants found that the game was easy to play (91%, n=27/29), and that the instructions were clear (87.5%, n=28/32). Respondents also felt that the game reflected real life scenarios (56%, n=18) and that cases reflected the types of patients that they saw in the ED (78%, n=25). Conclusion: Our results have shown an overall positive response to GridlockED, with most participants supporting it as both an engaging board game and potential teaching tool. We believe that future studies with larger sample sizes and medical students will further validate the use of serious games in medical education.

Improvement of emergency department patient flow using lean thinking.

To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time. A prospective interventional study. An ED of a tertiary care hospital. Triage acuity level-3 patients. To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff. Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation. Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%). Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.

Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

BackgroundEmergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. Materials and methodsA retrospective, 1-year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non-trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non-urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. ResultPatients discharged from ED had 0.4h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83–0.96) compared with the merged model. ConclusionThe separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

Split Flow Model of Care: A Solution for Emergency Department Patient Flow

Emergency Departments (EDs) across the United States struggle to deliver efficient care in a timely manner. Factors such as increasing patient volumes, a reduction in the number of EDs, and higher inpatient census appear to be creating EDs that are overcrowded (American College of Emergency Physicians [ACEP], 2016; American Hospital Association [AHA], 2017). The consequences of overcrowded EDs combined with extended wait times create a significant quality and safety issue for EDs (Newell et al., 2011; Pines, 2006; Richardson, 2006; Sun et al., 2013). The purpose of this quantitative non-experimental before and after study utilizing retrospective data was to determine if the implementation of a Split Flow Model of Care for ambulatory ED arrivals would impact the median length of stay (MLOS) for discharged patients and the left without being seen (LWBS) rate. Data was collected from two separate six-month time frames before and after the implementation of the Split Flow Model of Care. A Kruskal-Wallis Test failed to demonstrate statistical significance between the MLOS for discharged patients and the LWBS rate before and after the Split Flow Model of Care was implemented. However, the study demonstrated clinical significance when the LWBS rate decreased 61 percent between the two time periods. This decrease occurred despite an increase in patient acuity and an increase in ED patient boarding during the six months following the implementation. This study outcome offers other nursing leaders, healthcare organizations, and emergency departments the opportunity to learn new strategies to impact LWBS rates despite overcrowding challenges in emergency departments.

The impact of the improvement in internal medicine consultation process on ED length of stay

IntroductionAlthough consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy. MethodThis study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine. ResultsEmergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar. ConclusionThe improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.