Emergency Department Patient Flow Research Articles

Enhancing patient flow in emergency department (ED) using lean strategies–an integrated voice of customer and voice of process perspective

PurposeThe purpose of this paper is to systematically investigate the patient flow and waiting time problems in hospital emergency departments (EDs) from an integrated voice of customer (VOC) and voice of process (VOP) perspective and to propose a new lean framework for ED process.Design/methodology/approachA survey was conducted to better understand patients' perceptions of ED services, lean tools such as process mapping and A3 problem-solving sheets were used to identify hidden process wastes and root-cause analysis was performed to determine the reasons of long waiting time in ED.FindingsThe results indicate that long waiting times in ED are major concerns for patients and affect the quality of ED services. It was revealed that limited bed capacity, unavailability of necessary staff, layout of ED, lack of understanding among patients about the nature of emergency services are main causes of delay. Addressing these issues using lean tools, integrated with the VOC and VOP perspectives can lead to improved patient flow, higher patient satisfaction and improvement in ED capacity. A future value stream map is proposed to streamline the ED activities and minimize waiting times.Research limitations/implicationsThe research involves a relatively small sample from a single case study. The proposed approach will enable the ED administrators to avoid the ED overcrowding and streamline the entire ED process.Originality/valueThis research identified ED quality issues from the integration of VOC and VOP perspective and suggested appropriate lean tools to overcome these problems. This process improvement approach will enable the ED administrators to improve productivity and performance of hospitals.

Patient flow from emergency department to inpatient psychiatric unit - a narrative review.

To review the literature on common issues impacting psychiatric patient flow in emergency departments (EDs) and to explore evidence-based solutions proposed to improve patient flow. The review was divided into three parts and a broad array of keywords were chosen to achieve greater depth in the review. Administrative data and organisational publications were included along with peer-reviewed articles in various databases. Psychiatric patients have increased ED length of stay (EDLOS) and the proportion of psychiatric presentations in ED has increased significantly.1 Several factors contributed to increased EDLOS. Introduction of psychiatric short stay units,2 improving patient flow3 and appropriate increase in beds were identified as some of the possible solutions to improve patient flow. Psychiatric patient flow in ED is a complex issue and needs a coordinated approach to improve access. Future studies should focus on understanding the effectiveness of some of the proposed strategies.

Acute care for renal colic in Canadian healthcare - a commentary on emergency department patient flow metrics and treatment options.

Acute care for renal colic in Canadian healthcare - a commentary on emergency department patient flow metrics and treatment options.

Interprofessional barriers in patient flow management: an interview study of the views of emergency department staff involved in patient admissions

ABSTRACT Patient flow in emergency departments (EDs) is notoriously difficult to manage efficiently. While much of the attention has focused on the procedures, protocols and pathways in which patients receive their first hours of care, less attention has been paid to the relational factors that make it happen. Our study is the first, to our knowledge, to consider the role of interprofessional barriers, defined as suboptimal ways of working, as perceived by ED staff in patient flow management. Drawing on 19 interviews with hospital staff in an acute tertiary trauma center hospital in England, we established three flow-related types of interprofessional barriers: ED teamwork barriers, performance-driven coordination barriers, and referral-related collaborative barriers. Knotworking was recognized as a form of interactions and asset to teamworking, coordination, and collaboration. Identifying processes such as chasing, escalating, and advocating enabled our investigation to highlight a very complex set of interprofessional interactions, and signpost what the suboptimal practices of flow management are. Our analysis holds promise for hospitals beyond the National Health Service in England.

Impact of the COVID-19 Epidemic on the Routine Emergency Services in a Tertiary Hospital, China: A Retrospective Cohort Study

Background: The sudden outbreak of COVID-19 epidemic in China has caused tremendous challenges on the Chineses medical system. The Chinese government and hospitals have taken robust measures to curb the spread of the deadly virus. Its impact on the routine medical services was ignored and nil-discussed. Objective: To identify the impact of the novel coronavirus epidemic on emergency department (ED) patient flow and safety, and the performance of the routine ED service. Methods: This retrospective observational cohort study was undertaken in a tertiary public teaching hospital ED in Chengdu, China. ED data of patients were routinely collected to compare demographic, clinical characteristics, and outcomes around the Chinese New Year Eve in 2019 and 2020. Data were analyzed with the Chi-square statistical test. Results: Over the study periods, there were 31,855 and 25,244 patients presented to the ED in 2019 and 2020 respectively. During the epidemic period in 2020, the daily number of average ED visits was lower than that in 2019 (430±134.9 v.s. 572±38.6, p=0.00), with fewer triage 1&2 cases (145±33.3 v.s.178±15.0, p=0.00). Nevertheless, the mortality increased slightly during the epidemic period in 2020 (0.2% vs. 0.1%, p=0.009), with higher Apache II scores (28 vs.19, p= 0.022) and shorter ED elapsed time ( 0.2 vs. 1.4 days, p=0.016) among these death cases. Conclusions: The COVID-19 epidemic had an evident impact on the patient’s behavioral patterns and routine emergency services, which caused higher ED mortality. Hospitals should make an effort to balance the supply and demand for medical resources. Funding Statement: Scientific and technological project of new coronavirus pneumonia, 2019 (HX-2019- nCoV-026), Sichuan University West China Hospital. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: This study received ethical approval from West China Hospital Human Research Ethics Committee.

P105: Observational study of distribution of time and activities over the course of an emergency physician's shift

Introduction: The growing scrutiny to improve Emergency Department (ED) wait times and patient flow have resulted in many efforts to increase efficiency and maximize patient throughput via systems improvements. This study investigates areas of efficiency improvement from the Emergency Physician (EP) perspective by examining EP workflow in a two phased observational time-motion study. In the initial phase, the distribution of time and activities of EPs were dissected to identify potential sources for streamlining to maximize physician productivity. The first phase was of the study was completed during the period immediately preceding the implementation of an Electronic Health Records (EHR). The second phase of the study will repeat the analysis one year post EHR implementation. This data will be dissected to again identify sources for streamlining in an EHR environment and to identify shifts in work flow from a paper-based system. Methods: An observational time motion study was conducted at St. Mary's Hospital ED, in Kitchener Ontario. An observer was paired with an EP for the duration of an 8 hour shift, to a total of 14 shifts in the first phase of the study. Nine task categories were measured concurrently with a stopwatch application on a tablet, along with the number of interruptions experienced by the EP. Means of each category were calculated and converted to percentages, representing the amount of time per 8 hour shift dedicated to each activity. The second phase will be repeated in Fall 2020, 1 year after EHR implementation. Results: A total of 14 shifts were observed, accounting for 112 hours of observation. EP's time was allocated amongst the following categories: direct patient interaction (40.8%), documentation (27.1%), reviewing patient results (18.4%), communicating with ED staff (7.63%), personal activities (5.7%), writing orders (5.1%), communicating with consultants (3.3%), teaching (1.7%) and medical information searches (1.3%). On average, EPs experienced 15.8 interruptions over the course of an 8 hour shift. Conclusion: In a paper charting system, the direct patient interaction accounts for the largest timeshare over the course of a given shift. However, the next two largest categories, documentation and reviewing patient data, both represent areas of potential streamlining via clerical improvements. Additionally, detailed measurements of EPs’ activities have proven feasible and provides the potential for future insight into the impact of EHR's on EP workflow.

The Metrics of Acute Care Reentry and Emergency Department Visits by Recently Discharged Inpatients.

Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics-within 0-3 days, 0-7 days, and 0-30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.

Utilization of an Electronic Triage System by Emergency Department Nurses.

IntroductionEmergency departments use triage systems to prioritize patients according to the severity of their condition. The Electronic Canadian Triage and Acuity Scale (E-CTAS) is a popular system that categorizes patients into five levels to manage patient flow and prioritize patient access to health-care services.MethodsWe assessed the factors that influence E-CTAS usage in emergency departments in Eastern Saudi Arabia. Seventy-one nurses were included from two emergency departments that adopted E-CTAS. We used the technology acceptance model (TAM) to assess the influencing factors. The TAM was reliable in the study setting (Cronbach’s α = 0.87).ResultsAll of the TAM domains were significantly related to the usage of E-CTAS: perceived ease of use, perceived usefulness, importance of training, social influence, behavior intention, and attitude. We also showed that E-CTAS use significantly increased with years of experience and training.DiscussionMany factors influenced the use of this electronic triage system. Focusing on these factors in future electronic triage system implementations might increase the hospital staff’s compliance, thus improving accuracy and better organizing the patient flow in emergency departments.

Reducing the Throughput Time for Patient Flow in Emergency Department: Simulation and Modelling Overview

Satisfaction of patient considered as a main issue of quality of service in the healthcare sector. Typically, this satisfaction depends on the services quality provided by hospitals. Emergency Department (ED), as a critical department in the hospital, has a complicated registration system that may lead to increase the patient throughput time. Thus, to minimize this growing in the throughput time, numerous simulation and modelling, in the literature, have been developed and introduced. However, the throughput time in ED still represent in issue need for improvement to increase the ED performance. Therefore, in this paper, the main objective is providing an overview related to the characteristics and significance of current simulation and model techniques. As a result, in the ED realistically, integrating Agent-Based Simulation (ABS), Desecrate Event Simulation (DES), and System Dynamic (SD) techniques has been preferred as the solution to modelling the patient flow in ED and in turn may lead to decrease the throughput time. The proactive and independent characteristics of aforementioned techniques can contribute to the good representation the patients flow and their throughput time in ED.

Discrete event simulation modelling to evaluate the impact of a quality improvement initiative on patient flow in a paediatric emergency department

ObjectiveWe developed a discrete event simulation model to evaluate the impact on system flow of a quality improvement (QI) initiative that included a time-specific protocol to decrease the time to...

A Front-end Redesign With Implementation of a Novel "Intake" System to Improve Patient Flow in a Pediatric Emergency Department.

Introduction:Children’s Hospital Colorado is an academic, tertiary-care Level 1 Trauma Center with an emergency department (ED) that treats >70,000 patients/year. Patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (LWBS) rates. In 2015, the ED’s median door-to-provider time was 49 minutes [interquartile range (IQR) = 26–90], with a 3.2% LWBS rate. ED leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual LWBS rate to <1%.Methods:An inter-professional team utilized quality improvement and Lean methodology to study, redesign, and implement significant changes to ED front-end processes. Key process elements included (1) new Flow Nurse/EMT roles, (2) elimination of traditional registration and triage processes, (3) immediate “quick registration” and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel “Intake” system staffed by a pediatric emergency medicine physician.Results:In the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (IQR = 13–50), and the LWBS rate decreased from 3.2% to 1.4% (a 56% relative decrease). Additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ED length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred.Conclusions:Using quality improvement and Lean methodology, an inter-professional team decreased door-to-provider times and LWBS rates in a large pediatric ED by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led Intake system.

Who is Next: Patient Prioritization Under Emergency Department Blocking

Upon arrival at emergency departments (EDs), patients are classified into different triage levels indicating their urgency. Using data from a large hospital in Canada, we find that within the same triage level, the average waiting time (time from triage to initial assessment by a physician) of patients who are discharged is shorter than that of patients who are admitted for middle-to-low acuity patients, suggesting that the order in which patients are served deviates from FCFS (first-come-first-served), and to a certain extent, discharged patients are prioritized over admitted patients. This observation is intriguing as among patients of the same triage level, admitted patients--who need further care in the hospital--should be deemed no less urgent than discharged patients who only need treatment at the ED. To understand how ED decision makers choose the next patient for treatment, we estimate a discrete-choice model and find that ED decision makers apply urgency-specific delay-dependent prioritization. Moreover, we find that when the ED blocking level is sufficiently low, admitted patients are prioritized over discharged patients for high acuity patients, whereas disposition does not affect the prioritization of middle-to-low acuity patients. When the ED blocking level becomes sufficiently high, decision makers start to prioritize discharged patients in an effort to avoid further blocking the ED. We then analyze a stylized model to explain the rationale behind the change in decision makers' prioritization behavior as the ED blocking level increases. Using a simulation study, we demonstrate how policies inspired by our findings improve ED operations by reducing the average patient waiting time and length of stay, resulting in significant cost savings for hospitals. We also show how to leverage our findings to improve the accuracy of ED waiting time predictions. By testing and highlighting the central role of decision makers' patient prioritization behavior, this paper advances our understanding of ED operations and patient flow.

Accumulating priority queues versus pure priority queues for managing patients in emergency departments

Improving the quality of healthcare in emergency departments (EDs) is at the forefront of many hospital managers’ efforts, as they strive to plan and implement better patient flow strategies. In this paper, a new approach to manage the patient flow in EDs after triage is proposed. The new queue discipline, named accumulative priority queue with finite horizon and denoted by APQ-h, is an extension of the accumulative priority queue (APQ) discipline that considers not only the acuity level of patients and their waiting time but also the stage of the healthcare treatment. APQ disciplines have been studied in the literature from a queueing theory point of view, which requires assumptions rarely found in real EDs, such as homogeneity in the patient arrival pattern and only one service stage. The APQ-h discipline accumulates priority from the point of waiting for the first physician consultation until the moment the waiting time exceeds the upper time limit set to access the physician after the patient’s arrival. A recent study shows that a management strategy of this type is applied in practice in several Canadian EDs. The main aim of this paper is to explore the implementation of APQ-h managing policies in a real ED. For this purpose, a simulation model replicating a real ED is developed. This simulation model is also used to obtain the optimal APQ type polices through a simulation-based optimization method that solves a multi-objective and stochastic optimization problem. Arrival to provider time and total waiting time in the ED are considered to be the key ED performance indicators. An extensive computational analysis shows the flexibility of the APQ-h and APQ discipline and their superiority over other pure priority disciplines in a real setting and in a variety of ED scenarios. In addition, no superiority over the APQ discipline is demonstrated.

The Effect of Medicaid Expansion on the Patient Flow in Emergency Department

We study the effect of Medicaid expansion on wait time in the emergency department (ED), using a difference-in-differences approach, where the treatment group includes the states that expanded Medicaid at the beginning of 2014 and the control group includes the states that did not expand Medicaid before 2016. We first focus on the average treatment effect and find Medicaid expansion increases ED wait time by 10.4% (or 3.5 minutes). We then develop a first difference causal tree (FDCF) approach for heterogeneous treatment effect analysis by incorporating the first difference approach into the causal forest approach. Our comprehensive simulation studies show the FDCF approach has smaller mean-squared errors than direct applications of the causal forest approach. Finally, we apply the FDCF approach to our empirical example and find the effect of Medicaid expansion varies widely across different hospitals. Our results are useful to policymakers deciding whether to expand Medicaid and to hospital managers seeking to understand the effect of Medicaid expansion on their hospitals. Our results are also useful to researchers applying causal machine learning methods for heterogeneous treatment effect analysis.

The impact of a multimodal intervention on emergency department crowding and patient flow

ObjectiveThe objective of this study is to assess the impact of a multimodal intervention on emergency department (ED) crowding and patient flow in a Dutch level 1 trauma center.MethodsIn this cross-sectional study, we compare ED crowding and patient flow between a 9-month pre-intervention period and a 9-month intervention period, during peak hours and overall (24/7). The multimodal intervention included (1) adding an emergency nurse practitioner (ENP) and (2) five medical specialists during peak hours to the 24/7 available emergency physicians (EPs), (3) a Lean programme to improve radiology turnaround times, and (4) extending the admission offices’ openings hours.Crowding is measured with the modified National ED OverCrowding Score (mNEDOCS). Furthermore, radiology turnaround times, patients’ length of stay (LOS), proportion of patients leaving without being seen (LWBS) by a medical provider, and unscheduled representations are assessed.ResultsThe number of ED visits were grossly similar in the two periods during peak hours (15,558 ED visits in the pre-intervention period and 15,550 in the intervention period) and overall (31,891 ED visits in the pre-intervention period vs. 32,121 in the intervention period). During peak hours, ED crowding fell from 18.6% (pre-intervention period) to 3.5% (intervention period), radiology turnaround times decreased from an average of 91 min (interquartile range 45–256 min) to 50 min (IQR 30–106 min., p < 0.001) and LOS reduced with 13 min per patient from 167 to 154 min (p < 0.001). For surgery, neurology and cardiology patients, LOS reduced significantly (with 17 min, 25 min, and 8 min. respectively), while not changing for internal medicine patients. Overall, crowding, radiology turnaround times and LOS also decreased. Less patients LWBS in the intervention period (270 patients vs. 348 patients, p < 0.001) and less patients represented unscheduled within 1 week after the initial ED visit: 864 (2.7%) in the pre-intervention period vs. 645 (2.0%) patients in the intervention period, p < 0.001.ConclusionsIn this hospital, a multimodal intervention successfully reduces crowding, radiology turnaround times, patients’ LOS, number of patients LWBS and the number of unscheduled return visits, suggesting improved ED processes. Further research is required on total costs of care and long-term effects.

A Review on Simulation and Modelling for Patient Flow in Emergency Department

At the moment, most of the hospitals are more interested in patient satisfaction because this has been identified as a main issue of quality of service indexes. In most of the Asian countries’ the type of registration system being operated in the healthcare systems are a sort of mixed-mode. Specifically, there are scheduled patients, as well as patients who just walk in and register. Unfortunately, this type of registration structure could increase the patient waiting period even in emergency cases. Interestingly, various methodologies have been explored in order to shorten this undesirable waiting time. This paper focuses on exploration of the characteristics and significance of existing models and simulation techniques from the literature. The combination of agent-based modelling (ABM), DES and integration of DES and ABS technique has been chosen as the solution to modelling patient emergency waiting time in the emergency department realistically. The proactive and independent characteristics of agents in both approaches will contribute to the good representation of patient emergency waiting time in the especially in the emergency department.

The Use of a Discrete Event Simulation Model to Evaluate the Impact of a Quality Improvement Initiative on Patient Flow in a Pediatric Emergency Department

The Use of a Discrete Event Simulation Model to Evaluate the Impact of a Quality Improvement Initiative on Patient Flow in a Pediatric Emergency Department

Interprofessional teamwork versus fast track streaming in an emergency department-An observational cohort study of two strategies for enhancing the throughput of orthopedic patients presenting limb injuries or back pain.

ObjectiveTo compare two strategies, interprofessional teams versus fast track streaming, for orthopedic patients with limb injuries or back pain, the most frequent orthopedic complaints in an emergency department.MethodsAn observational before-and-after study at an adult emergency department from May 2012 to Nov 2015. Patients who arrived on weekdays from 8 am to 9 pm and presented limb injury or back pain during one year of each process were included, so that 11,573 orthopedic presentations were included in the fast track period and 10,978 in the teamwork period. Similarly, another 11,020 and 10,760 arrivals presenting the six most frequent non-orthopedic complaints were included in the respective periods, altogether 44,331 arrivals. The outcome measures were the time to physician (TTP) and length of stay (LOS). The LOS was adjusted for predictors, including imaging times, by using linear regression analysis.ResultsThe overall median TTP was shorter in the teamwork period, 76.3 min versus 121.0 min in the fast track period (-44.7 min, 95% confidence interval (CI): -47.3 to -42.6). The crude median LOS for orthopedic presentations was also shorter in the teamwork period, 217.0 min versus 230.0 min (-13.0 min, 95% CI: -18.0 to -8.0), and the adjusted LOS was 22.8 min shorter (95% CI: -26.9 to -18.7). For non-orthopedic presentations, the crude median LOS did not differ significantly between the periods (2.0 min, 95% CI: -3.0 to 7.0). However, the adjusted LOS was shorter in the teamwork period (-20.1 min, 95% CI: -24.6 to -15.7).ConclusionsThe median TTP and LOS for orthopedic presentations were shorter in the teamwork period. For non-orthopedic presentations, the TTP and adjusted LOS were also shorter in the teamwork period. Therefore, interprofessional teamwork may be an alternative approach to improve the patient flow in emergency departments.

SurgeCon: Priming a Community Emergency Department for Patient Flow Management.

IntroductionCanadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED.MethodsWe implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis.ResultsDuring the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA – 19.8 minutes (p<0.01), and LWBS – 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention.ConclusionSurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.

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.