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ED Case Studies

Case I

Medical Center – University affiliated
80,000 ED visits a year pre-engagement
96,000 ED visits current annualized volume

Due to the growth, this large department developed problems with overcrowding, lengthy waiting times and ambulance diversions. Therefore, we were contacted to help establish a more operationally efficient system. The client had vested hopes in having a Rapid Clinican Evaluation intake format incorporated as part of the strategic design. Nevertheless, during discovery we identified the department did not have the right capabilities for it. Although the department already used midlevel providers, their scope of practice was limited and they were not allowed to work independently. In addition, they had only a few fulltime midlevel providers which meant several more would have to be hired and those already on staff would have to be retrained.

In contrast, the department was well staffed with physicians and had a good pool of nurses. Because it also had a Fast Track, there was space available to redirect patient flow. Therefore, a decision was made to use an RN Rapid Screening Intake format and utilize resources more effectively. The Fast Track was converted into a Clinical Decision Unit and the former triage was turned into several rapid screening spaces. After implementation, the department was able to redirect 53% of the daily patient load through these areas allowing the ED to immediately bed most ambulances. Door to Provider times were decreased by 67%, ambulance diversions decreased sharply and their patient satisfaction scores reached unprecedented heights.

The story does not end here… Because this client engaged our services for a longer term… we worked further with them to beef-up its midlevel provider skill set, training and capabilities, helped redesign further internal processes and finally; helped establish a Rapid Clinical Evaluation Program able to treat and release more than 40% of their entire daily patient volume in less than 120 minutes even though their annualized volumes have continued to increase and are now close to 100K visits a year.

Case II

Community Emergency Department
34,000 ED visits a year
18 bed main ED, 6 bed Fast Track

This department had average Door to Provider times of 81 minutes, which at peak times, frequently lengthened to 3 hours. Door to Release times were 187 minutes. Fast Track was seeing 25% of the patient load which meant 75% needed to be seen in the main ED. Besides hallways, this department routinely placed 8 to 10 ambulance patients in a surge waiting area where they waited up to 3 hours to be seen.

This prompted the Department of Health to give the hospital three months to come up with a solution. They were clear that use of hallways and the ambulance waiting area were not acceptable. At any given time, up to 14 patients could be placed in those areas. Therefore, the ED had to become far more efficient while also eliminating the only surge spaces available. This also meant all ambulances would now have to be immediately bedded.

Because of the 3-month deadline a decision was made to predominantly use patient flow redirection and “fine-tune” the strategy after stabilization. Since the main ED saw 75% of the daily patient load, to immediately bed all ambulances the workload of the main ED would have to be decreased by at least 30%. This meant the underutilized Fast Track space, which processed 25% of patients, would now have to process 55% or more. Because of the time constraint and lack of resources we decided to only redirect patient flow through this area for 12 hours a day (10:00AM to 10:00 PM) therefore only influencing a main portion of the actual backlog producing time. The rational was that if backlogs could be prevented during that time, the protective effect would carry for several more hours and out of the peak volume times.

Prior to the deadline, this department decreased the Door to Release times from 187 to 128.5 minutes and the average Door to Provider times from 81 to 35 minutes. It saved an average of 58.5 minutes per discharged patient and reclaimed 78 hours a day of previous nonproductive time. The ED went from being threatened by the Department of Health to active marketing and advertisement of their ED service within a few months.

Case III:

Community Emergency Department
36,000 volume pre-conversion
50,000 yearly ED volume currently
18 bed ED, No Fast Track

Our pilot site is a department built to handle about 28,000 visits a year. Because of population growth over the years, overcrowding and lengthy waiting times had become commonplace. The average Door to Provider time was around 70 minutes and lengthened to the 2.5 hour range at peak times. In addition, the average Door to Release times was 170 minutes. The department had no Fast Track space but 4 out of 18 department beds were treated as such whenever volumes allowed. By the time the department’s yearly volume was at 36,000 this practice had been outgrown. Because the hospital finances at the time would not allow for ED physical expansion a strategy entirely based on operational efficiency had to be devised.

Because the department had no Fast Track, the ED handled 100% of the daily patient load and there was no space to redirect patient flow. Because of pervasive overcrowding, and limited ED capacity, the workload of the ED had to be decreased by at least 50% to make the strategy viable. Therefore a decision was made to use alternative treatment areas to accomplish the necessary flow redirection and establish a synergistic Rapid Clinician Evaluation intake system. The former triage area was converted into provider evaluation areas and an adjacent storage room was converted into a Clinical Decision Space with several evaluation tables. If providers evaluated a patient that did not require testing, they would discharge them right from the Intake area. If patients required ancillary tests or further treatment, they would utilize the Clinical Decision Area to prevent unnecessary use of ED beds as long as discharge was anticipated. To further increase the overall capacity of this setup, chairs were arranged outside of the Clinical Decision area for patients who were waiting for X-rays or who did not require the use of evaluation tables. To obtain the most benefit from patient flow redirection the program was scheduled to cover the major backlog producing time (9:00 AM to 11:00 PM)

After implementation, the department was able to redirect more than 50% of the daily patient load through these alternative treatment areas. Door to Provider times was decreased to an average of 7 to 10 minutes. In addition, Door to Release times was decreased to 100 minutes. Overcrowding was no longer an issue and the department was able to establish a no ambulance diversion policy. Because of this, ambulance volumes immediately surged by 33% and many more inpatient admissions came through the department each month. Active marketing and advertisement of the ED service was also started and the department volume increased from 36,000 to 42,000 within less than a year. By the second year the department was seeing almost 50,000 patients without adding a single bed or additional staff. The finances of the hospital were so influenced by the program that the hospital became consistently profitable for the first time in a decade.