Better Patient Flow in the ED

By Joseph Guarisco, M.D., Mary Ellen Bucco and Kevin Roche	December 22, 2011
The Door-to-Doc model helps avoid long waits in the emergency department with appropriate staffing levels and effective patient evaluation.

As physicians and hospitals move toward a performance-based reimbursement model ? and as patients demand more information, more choices and better services ? health care leaders will need to embrace the same operations management principles that have yielded a competitive edge in many other sectors of American industry.

Hospital leaders can apply an operations management approach to all services, but focusing on the emergency department can generate significant improvements at low cost. While many managers of EDs believe that patient arrival times are unpredictable, they actually follow a pattern throughout the day. In addition, many ED patients do not require the services of a physician ? or a bed ? so hospitals can lower costs by assigning patients to the appropriate care plan. Matching the demand to services, beds and providers can result in savings and better care.

The Importance of an Efficient ED

There are many reasons to invest in operations research and management in the emergency department. For example:

Customers make patient care decisions based on information about quality. In a competitive market, patient satisfaction means customer satisfaction, and customer satisfaction is critical to any organization's success. Patients ? the customers of health care services ? make choices based on service quality.

Time to service is a critical success factor in emergency medicine. Delays affect both clinical quality and patient safety, especially for certain conditions. For example, delays in the delivery of clot busters in stroke or heart attack patients result in poorer quality care and outcomes.

Long wait times lead to lower profitability. Hospital growth and profitability are affected when patients leave before they are evaluated. It is estimated that for ED volumes of 50,000 patients, lost revenue is approximately $500,000 for every 1 percent of patients who leave before a care provider sees them.

Door-to-Doc ED Model

When beds and caregivers are scarce, the ED staff are forced to get creative to minimize the impact on patients. They implement protocols and advance triage guidelines to initiate treatment before a room or a provider is available. Unfortunately, their attempt to solve the problem creates additional delays, increasing utilization and length of stay and requiring additional staff members. The response of many hospital leaders is to remodel their EDs to add patient rooms at a cost of about $250,000 per room.

The Door-to-Doc model can avoid these expenses and improve care. It is an operations management-driven solution that takes into account both the predictability of patient arrival times and the variability of patient needs. The result is a less costly staffing model as well as shorter wait times.

Patient arrival times. Data collection and analysis, part of operations management, show that the patient arrival rate is predictable. The diagram below shows average patient arrival data for seven different hospitals. (The actual patients-per-hour curve for each facility is normalized so different volumes are all shown on the same axis.) The arrival patterns are remarkably similar by facility and by hour of day; thus, the demand and variability on EDs are predictable and measurable.

����������������������������������� ��� Patient Arrival Patterns by Hour of Day

Many hospitals manage the ED without any knowledge of this demand curve. But even those hospital leaders who are aware of the demand curve typically staff according to the average demand. In these cases, during the busier part of the day, patients will experience long waits for service, while during the slow times, the ED will be underused.

In the D2D model, more ED staff members work during the busy hours, and fewer staff members work during the slow hours.

Patient evaluation. The dynamics of the entire hospital affect the ED's ability to function in a timely manner. For example, both the ED and perioperative departments contend for inpatient beds, yet surgical patients have priority. Additionally, hospitals struggle to discharge early and free up inpatient beds. Therefore, ED beds may be "blocked" with inpatients and, in turn, ED staff are unable to care for new patients. Many waiting patients may leave the ED before seeing a provider, obtaining test results or receiving treatment and a care plan.

But not all patients need a bed during their stay: In traditional EDs, 75 percent of patients are discharged. D2D reduces the number of patients assigned to beds unnecessarily and decreases the time a patient spends waiting to be seen. It also discourages hospitals from building out each new $250,000 space for a patient to wait for test results.

In the D2D model, patients are evaluated in an intake room upon arrival. The intake room does not contain a bed and does not need to be a physical room. From the intake room, tests and treatments are ordered, and if a bed or admission is not necessary, the patient is discharged to a continuing care waiting area. There the patient waits to be seen by a physician or for tests results and a treatment plan.

The D2D model divides patients into those with complex, high-acuity disease states and those with lower-acuity, less complex disease states. This segmentation allows the creation of a higher-margined staffing structure. Among the lower-acuity patients, 80 percent do not require a highly skilled emergency physician. For these patients, providers gather physical supplies, collect data, construct an electronic list, verify allergies, reconcile patient medications, handle computer entry of the encounter details, create electronic prescriptions and write discharge instructions ? all tasks that can be performed by a physician extender at much lower cost.

A More Efficient Emergency Department

The D2D model is a paradigm shift in providing care in the ED, creating an opportunity to provide safe, excellent patient care more quickly and at reduced costs. The process drives D2D times to their theoretically lowest limits. The D2D model is a best-practice solution to improve patient satisfaction, reduce risk, and improve patient care quality and safety, thereby providing for better financials and competitive growth in the marketplace.

Joseph Guarisco, M.D., is the chairman of the department of emergency medicine at Ochsner Health System in New Orleans. Mary Ellen Bucco, M.B.A., and Kevin Roche, Ph.D., are program directors for process engineering at Banner Health in Phoenix.

AHA's Hospitals in Pursuit of Excellence promotes quality improvement in health care and provides a variety of resources, including hospital case studies that apply the six Institute of Medicine aims in such disciplines as care coordination, efficiency and patient safety. Visit www.hpoe.org.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

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