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Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care
The Journal of Emergency Medicine, Vol. 50, No. 2, pp. 339–348, 2016 Copyright Ó 2016 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.06.068
Administration of Emergency Medicine
EMERGENCY DEPARTMENT EXPANSION VERSUS PATIENT FLOW IMPROVEMENT: IMPACT ON PATIENT EXPERIENCE OF CARE Assaad Sayah, MD, FACEP,*† Melisa Lai-Becker, MD, FACEP,*† Lisa Kingsley-Rocker, RN, BSN, MM,‡ Tasha Scott-Long, BA,* Kelly O’Connor, MPH,* and Luis F. Lobon, MD, MS, FACEP†§ *Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, †Harvard Medical School, Boston, Massachusetts, ‡Department of Emergency Medicine, Lahey Medical Center, Burlington, Massachusetts, and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Assaad J. Sayah, MD, FACEP, Chief Medical Officer, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139
, Abstract—Background: Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Objectives: To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a mediumsize safety net ED. Methods: This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. Results: In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (25.8 minutes) and total duration of stay (66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. Conclusions: Our results demonstrate that the impact of process improvement and rapid assessment
implementation is far greater than the impact of renovation and facility expansion. Ó 2016 Elsevier Inc. , Keywords—total duration of stay; ED crowding; patient experience; patient satisfaction; ED renovation; emergency department; diversion
INTRODUCTION Crowding in the emergency department (ED) and the ensuing problem of ambulance diversion have long attracted national attention. Additionally, long waiting and turnaround times in the ED have been shown to negatively affect both quality outcomes and patient satisfaction (1–3). Among U.S. EDs in 2010, only 31% achieved the appropriate flow targets for their patients, whereas only 48% admitted their patients within 6 h (4). Most of the tactics that have been suggested to help ease crowding in the ED and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Accordingly, most of these strategies also require institutions to make considerable investments of money and time that may not be readily available. Cambridge Health Alliance (CHA) Whidden is a medium-size ED in a community safety net public
RECEIVED: 25 July 2014; FINAL SUBMISSION RECEIVED: 16 June 2015; ACCEPTED: 25 June 2015 339
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hospital. Like many other EDs around the country, the CHA ED suffered from patient flow issues, including long waits, inefficient processes, and poor patient satisfaction. This work compares the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) at CHA’s Whidden Hospital Campus ED. Materials and Methods This work describes a study of a single safety-net ED with a volume that ranged between 30,126 visits in 2005 and 45,459 visits in 2012 by the use of an interrupted time series analysis. During this period, the ED first undertook a physical expansion followed by a reorganization of patient flow and the establishment of an RAU. Measured metrics were collected on all patients who entered the ED from January 2005 to December 2012. They included diversion time, arrival to provider time, duration of stay, patient satisfaction scores, and percent left without being seen. The protocol received an Exempt Status from the Cambridge Health Alliance institutional review board (IRB). Between the second quarter of 2006 and the second quarter of 2007 the Whidden ED underwent a major expansion and renovation process resulting in an almost doubling of the physical space. The original ED had 12 acute care treatment areas, six express care rooms, and two triage/registration areas. The expansion took place in multiple phases and resulted in 24 acute care treatment areas, seven express care rooms, and two triage/registration rooms. During the second quarter of 2009, the CHA ED underwent a process improvement project aimed at optimizing patient flow by reengineering the arrival phase. This change included the creation of the ‘‘Patient Partner’’ role, implementing bedside registration and establishing an RAU. Our existing greeters and receptionists were transformed into Patient Partners and received special training in customer service and registration. The nonclinical, multilingual Patient Partners greeted and welcomed our diverse patients, performed a mini-registration, generated a ‘‘patient encounter’’ in the electronic medical record, and escorted the patients immediately to the RAU. We simplified our initial registration process to the bare minimum to identify the patient and create a unique ED electronic health record encounter in the most expeditious way. This new mini registration consisted of three questions: name, social security number (or date of birth), and chief complaint. Eventually, during downtime between tests and procedures, full bedside registration was performed after nursing and physician assessment, patient stabilization, and initiation of patient care.
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The nine-room RAU space was created by combining the previously existing seven room express care with the two rooms used for triage/registration, thereby facilitating assessment and treatment at the point of entry to the ED. The RAU was staffed by the same compliment of nurses and physicians assistants that previously covered triage and express care. Combining these functions in one area minimized redundancies and created parallel functions across staff and physical space without adding new resources. Patients were triaged in accordance with the Emergency Severity Index (ESI) Triage Protocol. Low-acuity patients (ESI 4 and 5) received complete care in the RAU without ever entering the acute ED area. Patients triaged with higher levels of ESI (1, 2, and 3) were immediately moved to the acute ED areas, where they were evaluated and treated. Data Collection and Processing Data was collected using CHA’s electronic medical record systems (Meditech and EPIC). Timestamps were used to compute the total duration of stay. Patient records were used to determine whether a patient left without being seen (LWBS). Patient Satisfaction Surveys were sent and data compiled by Press Ganey Associates. Statistical Methods An interrupted time series design was used to evaluate the impact of the two system changes occurring at the site (i.e., ED expansion and implementation of RAU) on each of the outcomes of interest. Interrupted time series is one of the strongest quasiexperimental designs for studying impacts of policy/process change (5). Controlling for the baseline rate and trend for the outcome of interest, we estimated changes in the level and slope of the outcome after ED expansion took place and after rapid assessment was implemented. The regression equation was specified as: Yt ¼ b0 þ b1 timet ED expansion þ b3 time after expansiont þ b4 rapid assessmentt þ b5 time after rapid assessmentt þ et Maximum likelihood estimation was used to estimate the models. We controlled for autocorrelation by including all significant autocorrelation parameters (Number of lags [NLAG] = 5) and backward elimination was used to include covariates in the final model with a type 1 error for inclusion of 0.05. Statistical analyses were performed using PROC AUTOREG in SAS (Statistical Analysis System Institute Inc., Cary, NC), version 9.3.
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Table 1. Segmented Regression Results for Outcomes of Interest Covariate Press Ganey Raw Score ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Press Ganey Percentile ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Median Door to Provider Time ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Median duration of stay time ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Percent Left without being seen ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Total volume ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend)
p Value
Coefficient
SE
t
0.8183 0.429 1.9631 0.4776
1.3711 0.231 1.1207 0.2018
0.6 1.86 1.75 2.37
0.5532 0.069 0.0857 0.0217
7.9441 4.0943 7.5439 4.0865
11.21 1.6141 8.6124 1.4971
0.71 2.54 0.88 2.73
0.4817 0.0143 0.3852 0.0087
0.8034 4.866 25.79 4.5003
2.8942 0.4376 2.2747 0.3972
0.28 11.12 11.3 11.3
0.7824 <0.0001 <0.0001 <0.0001
15.5337 13.2099 66.8218 15.6412
10.631 1.7615 8.6516 1.5481
1.46 7.5 7.72 10.1
0.15 <0.0001 <0.0001 <0.0001
0.6006 0.1092 0.2692 0.1233
0.2474 0.0502 0.2177 0.0427
2.43 2.18 1.24 2.89
0.0186 0.0339 0.2216 0.0056
23.8248 14.6583 338.7104 9.3591
51.093 8.4481 41.925 7.4254
0.47 1.74 8.08 1.26
0.643 0.0888 <0.0001 0.2133
SE = standard error; ED = emergency department.
RESULTS ED Expansion As detailed in Table 1 and Figures 1–6, few immediate effects were observed at the time ED expansion was completed (Q2 of 2007). The percent of patients who left without being seen was found to decrease significantly (0.60%; p < 0.05), and all other outcomes remained consistent with the level observed in the time periods before ED expansion. The trend effects observed after ED expansion for most outcomes, however, were statistically significant and indicative of a negative impact of the expansion. Press Ganey Percentile rank decreased (4.1 percentile per quarter; p < 0.05), median door-to-provider time increased (+4.9 minutes per quarter; p < 0.0001), median duration of stay increased (+13.2 minutes per quarter; p < 0.0001), and the percent of patients who left without being seen increased (+0.11 per quarter; p < 0.05). Total patient volume was increasing during the time period before and after ED expansion, no significant changes were observed concurrent with ED expansion. Our ED expansion helped us eliminate diversion in 2007 (Figure 7).
Rapid Assessment As also detailed in Table 1 and Figures 1–6, Press Ganey outcomes were not impacted immediately by the implementation of Rapid Assessment; however, trends for both raw score (+0.48 points per quarter; p < 0.05) and percentile (+4.1 percentiles per quarter, p < 0.01) changed significantly after Rapid Assessment was implemented, representing a reversal of the negative trend observed after ED expansion. The trend for percent of patients who left without being seen also was observed to differ significantly after Rapid Assessment (0.12% per quarter; p < 0.01), similarly reversing the direction of the trend observed in the previous time period. Immediate impacts were observed for median door-toprovider time, which decreased by 25.8 min, and duration of stay, which decreased by 66.8 min at the time Rapid Assessment was implemented (both p < 0.0001). Furthermore, the trends for these outcomes over the quarters after Rapid Assessment suggested these improvements continued to improve over time: median door-toprovider time 4.5 minutes per quarter (p < 0.0001) and median duration of stay 15.6 min per quarter (p <
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Figure 1. Median total duration of stay.
0.0001). Total patient volume continued to increase steadily between ED expansion and the implementation of Rapid Assessment (the trend did not significantly differ); however, the volume was observed to increase
Figure 2. Median door-to-provider time.
significantly at the time rapid assessment was implemented (+338.7 patients; p < 0.0001). Our process improvement innovations helped us maintain flow and remain off diversion (Figure 7).
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Figure 3. The number of patients who left without being seen (percent of total volume).
DISCUSSION The ED often is the location of first patient contact in a hospital. Inefficiencies in the throughput process of
EDs not only decrease patient satisfaction but also worsen patient outcomes as the result of delays in treatment (6). Like many EDs around the country, the Whidden ED struggled with flow and patient
Figure 4. Patient satisfaction in the emergency department (Press Ganey mean score).
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Figure 5. Patient satisfaction in the emergency department (Press Ganey percentile).
satisfaction scores for many years. Poor ED performance affected CHA’s reputation and contributed to historically stagnant ED volumes. Diversions were routine, patient satisfaction scores were among the worst in the state, and there was a culture that accepted
Figure 6. Total volume in the emergency department.
inefficient processes. In 2005, The Whidden ED was on diversion 8.2% of the time (716 hours), scored in the 15th percentile in Patient Satisfaction, and had more than 4% of patients leave prior to receiving care (i.e., LWBS).
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Figure 7. Diversion from the emergency department.
ED inefficiencies and the resulting overcrowding is caused by disruptions in the three steps of patient flow: input (e.g., ambulance diversion), throughput (e.g., rapid assessment zones/pods, clinical decision units), and output (e.g., full capacity protocols, bed managers) (7). A review of the literature shows that many interventions have been designed to alleviate ED overcrowding at each of these three steps. Some these include: the ‘‘Disneyfication’’ or ‘‘Waiting management’’ of the ED patient experience, which is defined as improving the psychological perception of waiting with various distractions, updates on waiting, and environmental modifications. They also include techniques that strive to reduce wait or improve the waiting experience like Lean strategy from the Toyota Motor Corporation, which emphasizes elimination of waste and delays to allow for smooth continuous patient flow (8,9); ‘‘Immediate Bedding,’’ which, in line with Lean strategy, allows for rapid intake and early treatment by aligning parallel processes (10,11); ‘‘Splitflow Design,’’ where triaged patients with lower-acuity levels are directed to fast-track areas (12); early assignment of a provider to a patient after triage has led to faster throughput (13); and lastly, additional investment through renovation and expansion of physical ED’s or the addition of staff such as clinical assistant (14,15). Our RAU could be described as a modified split-flow design where all patients are immediately placed in a room where they are evaluated. Only patients with greater acuity are subsequently moved to the main ED.
The rest remain in the RAU, where they complete their care. In an assessment of the improvement options available to the Whidden ED, it was noted that these techniques experience varying levels of success. ‘‘Split-flow design’’ requires the segregation of patients into separate care processes with additional usage of personnel, space, and equipment resources (13,16,17). Adding staff, such as clinical assistants, improves wait times and decreases LWBS (18); however, although additional physicians and mid-level providers, such as Nurse Practitioners and Physician Assistants, can speed up ED flow by bringing the patient to a provider faster, it is at an increased financial cost (1924). Similarly, an admission hospitalist designated as the lead triage physician, intended to expedite admission orders, has been shown to have no positive impact on flow in the ED (25). Renovation and expansion of the physical ED, which allowed for additional beds and treatment space, was undertaken at the Whidden ED. Although this has been suggested to improve ED flow and decrease duration of stay (15), increasing the number of physical beds does not always improve ED throughput (26). This was clearly evident in our case. Expanding the Whidden ED resulted in some operational improvements with positive trending in metrics (Table 1 and Figures 1–6), but, most of these improvements were transitory. Metrics began moving in the wrong direction, as volume increased and the staff
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continues to follow the same flow and operational approach. It is important to note that our ED expansion helped us eliminate diversion more than 2 years before it was banned in Massachusetts by the Department of Public Health. In addition, our process improvement innovations helped us maintain flow and remain off diversion (Figure 7). After the expansion of the ED, the flow and operational approach was scrutinized in a comprehensive assessment. Activities occurring during the front-end processing of patients typically include: initial patient presentation, registration, triage, bed placement, and medical evaluation. The time needed to complete these steps contributes to the total duration of stay in the ED. Using the ‘‘immediate bedding’’ approach, the front-end process was reengineered to eliminate sequential intake tasks. Instead of a patient going through extended triage and a comprehensive registration before entering the ED and receiving care, the patient is greeted by a Patient Partner, a customer service expert, and placed in an ED bed immediately after the three-question mini-registration. Once inside, the patient is evaluated by any care team member that is available, and care is initiated. Full-registration takes place after nursing and physician assessment, stabilization, and initiation of care. As a result of these improvement efforts, more patients stay in the same room and are cared for by the same clinical team throughout their ED stay, which has minimized the number of times patients are moved, the number of times they have to present their story, the number of nursing and physician handoffs, the likelihood of miscommunication and errors, and the total duration of stay (Figure 1). After implementation of these initiatives, statistically significant improvements were observed (Table 1). These data clearly show that process and flow improvement positively impact the patient experience to a greater degree than renovation and space expansion. Budget-neutral operational changes, such as implementation of the RAU in the ED by repurposing space, expanding the role of staff, and eliminating waste, have significant impact on the efficiency of the department without major capital investment (27). With this frontend redesign, we were able to dramatically improve all metrics, and more importantly, sustain the improvement trends for more than 3 years while managing doubledigit volume growth (Table 1, Figure 6). Limitations These changes were implemented in a medium-sized, urban ED, and some of the initiatives described and results derived from their implementation may not be applicable to EDs operating under different constraints and with
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different patient populations. However, we believe that the changes implemented in the Whidden ED would be beneficial to many EDs facing the challenges of overcrowding in times of limited resources. We also recognize that the period of time between the ED expansion and process innovations may have been too short to establish a new stable baseline from which to measure the key metrics. Finally, because the process innovations happened after the expansion, it probably benefited from the additional space and had a greater chance to succeed. CONCLUSION Transformation of the ED is manageable, strategic, inexpensive, and sustainable, and it positively impacts the patient experience of care. Although physical space and appropriate resources are important, it is even more essential to have efficient flow and patient-centered care. Our results demonstrate that the impact of process improvement and Rapid Assessment implementation on ED patient experience of care is far greater than the impact of renovation and facility expansion.
REFERENCES 1. Moskop JC, Sklar DP, Geiderman J, Schears R, Bookman K. Emergency department crowding, part 1–concept, causes, and moral consequences. Ann Emerg Med 2009;53:605–11. 2. Sayah AJ. D-to-D slashed 85% in seven weeks. ED Management 2009;21:90–1. 3. Horwitz LI, Green J, Bradley EH. US emergency department performance on wait time and length of visit. Ann Emerg Med 2009; 55:133–41. 4. Wiler J, Gentle C, Halfpenney J. Optimizing emergency department front-end operations. Ann Emerg Med 2010;55:142–60. 5. Shadish W, Cook T, Campbell D. Experimental and quasiexperimental designs for generalized causal inference. Boston: Houghton Mifflin; 2002. 6. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000;35:63–6. 7. Rowe Brian H. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systemic review. Acad Emerg Med 2011;18:111–20. 8. Eller A. Rapid Assessment and Disposition: applying LEAN in the emergency department. J Healthc Qual 2009;31:17–22. 9. Holden R. Lean Thinking in emergency departments: a critical review. Ann Emerg Med 2011;57:265–78. 10. Rowe BH. The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systemic review. Acad Emerg Med 2011;189:1349–57. 11. Wiler J. Optimizing emergency department front-end operations. Ann Emerg Med 2009;55:142–61. 12. Harris M. Resuscitate ED metrics with split-flow design. Healthc Financ Manage 2012;66:76–9. 13. Murrell K. Use of an early patient-physician assignment system on emergency department arrival decreases time to physician and emergency department length of stay. Ann Emerg Med 2012;60: S50. 14. Han JH. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med 2007;14: 338–43.
Expansion vs. Flow Improvement 15. Redesign helps EDs improve patient flow. ED Manag 2009;21: 41–2. 16. Kwa P. Fast track: has it changed patient care in the emergency department? Emerg Med Australas 2008;20:10–5. 17. Peck J. Improving emergency department patient flow through optimal fast track usage. Ann Emerg Med 2008;52:S88. 18. Huang EP, Liu SS, Fang CC, et al. The impact of adding clinical assistants on patient waiting time in a crowded emergency department. Emerg Med J 2013;30:1017–9. 19. Holroyd BR. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med 2007;14:702–8. 20. Illuzzi F, King R, Dabakis M, Talati A, Turocy J, Bradley K. 350 SPEED Study (Serving Patients Efficiently in the ED) improvement in emergency department flow from an emergency physician at the initial point of patient contact. Ann Emerg Med 2011;58:S295–6. 21. Imperato J. Physician in triage improves emergency department patient throughput. Intern Emerg Med 2012;7:457–62.
347 22. Love RA. The effectiveness of a provider in triage in the emergency department: a quality improvement initiative to improve patient flow. Adv Emerg Nurs J 2012;34:65–74. 23. Partovi SN. Faculty triage shortens emergency department length of stay. Acad Emerg Med 2001;8:990–5. 24. Oredsson S, Jonsson H, Rognes J, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med 2011;19:43. 25. Haydar SA. ‘‘Lead Triage Physician’’ initiative: an unsuccessful hospitalist-based attempt to address emergency department crowding and patient flow. Ann Emerg Med 2011;58:S234. 26. Khare RK. Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion? Ann Emerg Med 2009;53:575–85. 27. Lobon L, Sayah A, Lai-Becker M, et al. Emergency Department Rapid Assessment Unit at the Cambridge Hospital: Why and How? Ann Emerg Med 2009;54:S6–7.
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ARTICLE SUMMARY 1. Why is this topic important? Emergency department (ED) crowding, ambulance diversion, long patient waits, and patients leaving without being seen have affected ED patient care and satisfaction. Most of the tactics that have been suggested to help ease ED crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Accordingly, most of these strategies also require institutions to make considerable investments of money and time that may not be readily available. 2. What does this study attempt to show? This paper compares the impact of ED expansion vs. patient flow improvement and the establishment of a RAU at Cambridge Health Alliance’s Whidden Hospital Campus ED. 3. What are the key findings? Transformation of the ED is manageable, strategic, inexpensive, and sustainable, and it positively impacts the patient experience of care. Although physical space and appropriate resources are important, it is even more essential to have efficient flow and patient-centered care. Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion. 4. How is patient care impacted? Our work shows that EDs can improve flow and patient experience with affordable process improvement interventions.
http://dx.doi.org/10.1016/j.jemermed.2015.06.068
Administration of Emergency Medicine
EMERGENCY DEPARTMENT EXPANSION VERSUS PATIENT FLOW IMPROVEMENT: IMPACT ON PATIENT EXPERIENCE OF CARE Assaad Sayah, MD, FACEP,*† Melisa Lai-Becker, MD, FACEP,*† Lisa Kingsley-Rocker, RN, BSN, MM,‡ Tasha Scott-Long, BA,* Kelly O’Connor, MPH,* and Luis F. Lobon, MD, MS, FACEP†§ *Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, †Harvard Medical School, Boston, Massachusetts, ‡Department of Emergency Medicine, Lahey Medical Center, Burlington, Massachusetts, and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Assaad J. Sayah, MD, FACEP, Chief Medical Officer, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139
, Abstract—Background: Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Objectives: To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a mediumsize safety net ED. Methods: This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. Results: In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (25.8 minutes) and total duration of stay (66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. Conclusions: Our results demonstrate that the impact of process improvement and rapid assessment
implementation is far greater than the impact of renovation and facility expansion. Ó 2016 Elsevier Inc. , Keywords—total duration of stay; ED crowding; patient experience; patient satisfaction; ED renovation; emergency department; diversion
INTRODUCTION Crowding in the emergency department (ED) and the ensuing problem of ambulance diversion have long attracted national attention. Additionally, long waiting and turnaround times in the ED have been shown to negatively affect both quality outcomes and patient satisfaction (1–3). Among U.S. EDs in 2010, only 31% achieved the appropriate flow targets for their patients, whereas only 48% admitted their patients within 6 h (4). Most of the tactics that have been suggested to help ease crowding in the ED and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Accordingly, most of these strategies also require institutions to make considerable investments of money and time that may not be readily available. Cambridge Health Alliance (CHA) Whidden is a medium-size ED in a community safety net public
RECEIVED: 25 July 2014; FINAL SUBMISSION RECEIVED: 16 June 2015; ACCEPTED: 25 June 2015 339
340
hospital. Like many other EDs around the country, the CHA ED suffered from patient flow issues, including long waits, inefficient processes, and poor patient satisfaction. This work compares the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) at CHA’s Whidden Hospital Campus ED. Materials and Methods This work describes a study of a single safety-net ED with a volume that ranged between 30,126 visits in 2005 and 45,459 visits in 2012 by the use of an interrupted time series analysis. During this period, the ED first undertook a physical expansion followed by a reorganization of patient flow and the establishment of an RAU. Measured metrics were collected on all patients who entered the ED from January 2005 to December 2012. They included diversion time, arrival to provider time, duration of stay, patient satisfaction scores, and percent left without being seen. The protocol received an Exempt Status from the Cambridge Health Alliance institutional review board (IRB). Between the second quarter of 2006 and the second quarter of 2007 the Whidden ED underwent a major expansion and renovation process resulting in an almost doubling of the physical space. The original ED had 12 acute care treatment areas, six express care rooms, and two triage/registration areas. The expansion took place in multiple phases and resulted in 24 acute care treatment areas, seven express care rooms, and two triage/registration rooms. During the second quarter of 2009, the CHA ED underwent a process improvement project aimed at optimizing patient flow by reengineering the arrival phase. This change included the creation of the ‘‘Patient Partner’’ role, implementing bedside registration and establishing an RAU. Our existing greeters and receptionists were transformed into Patient Partners and received special training in customer service and registration. The nonclinical, multilingual Patient Partners greeted and welcomed our diverse patients, performed a mini-registration, generated a ‘‘patient encounter’’ in the electronic medical record, and escorted the patients immediately to the RAU. We simplified our initial registration process to the bare minimum to identify the patient and create a unique ED electronic health record encounter in the most expeditious way. This new mini registration consisted of three questions: name, social security number (or date of birth), and chief complaint. Eventually, during downtime between tests and procedures, full bedside registration was performed after nursing and physician assessment, patient stabilization, and initiation of patient care.
A. Sayah et al.
The nine-room RAU space was created by combining the previously existing seven room express care with the two rooms used for triage/registration, thereby facilitating assessment and treatment at the point of entry to the ED. The RAU was staffed by the same compliment of nurses and physicians assistants that previously covered triage and express care. Combining these functions in one area minimized redundancies and created parallel functions across staff and physical space without adding new resources. Patients were triaged in accordance with the Emergency Severity Index (ESI) Triage Protocol. Low-acuity patients (ESI 4 and 5) received complete care in the RAU without ever entering the acute ED area. Patients triaged with higher levels of ESI (1, 2, and 3) were immediately moved to the acute ED areas, where they were evaluated and treated. Data Collection and Processing Data was collected using CHA’s electronic medical record systems (Meditech and EPIC). Timestamps were used to compute the total duration of stay. Patient records were used to determine whether a patient left without being seen (LWBS). Patient Satisfaction Surveys were sent and data compiled by Press Ganey Associates. Statistical Methods An interrupted time series design was used to evaluate the impact of the two system changes occurring at the site (i.e., ED expansion and implementation of RAU) on each of the outcomes of interest. Interrupted time series is one of the strongest quasiexperimental designs for studying impacts of policy/process change (5). Controlling for the baseline rate and trend for the outcome of interest, we estimated changes in the level and slope of the outcome after ED expansion took place and after rapid assessment was implemented. The regression equation was specified as: Yt ¼ b0 þ b1 timet ED expansion þ b3 time after expansiont þ b4 rapid assessmentt þ b5 time after rapid assessmentt þ et Maximum likelihood estimation was used to estimate the models. We controlled for autocorrelation by including all significant autocorrelation parameters (Number of lags [NLAG] = 5) and backward elimination was used to include covariates in the final model with a type 1 error for inclusion of 0.05. Statistical analyses were performed using PROC AUTOREG in SAS (Statistical Analysis System Institute Inc., Cary, NC), version 9.3.
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Table 1. Segmented Regression Results for Outcomes of Interest Covariate Press Ganey Raw Score ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Press Ganey Percentile ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Median Door to Provider Time ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Median duration of stay time ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Percent Left without being seen ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend) Total volume ED expansion (level) Time after ED expansion (trend) Rapid assessment (level) Time after rapid assessment (trend)
p Value
Coefficient
SE
t
0.8183 0.429 1.9631 0.4776
1.3711 0.231 1.1207 0.2018
0.6 1.86 1.75 2.37
0.5532 0.069 0.0857 0.0217
7.9441 4.0943 7.5439 4.0865
11.21 1.6141 8.6124 1.4971
0.71 2.54 0.88 2.73
0.4817 0.0143 0.3852 0.0087
0.8034 4.866 25.79 4.5003
2.8942 0.4376 2.2747 0.3972
0.28 11.12 11.3 11.3
0.7824 <0.0001 <0.0001 <0.0001
15.5337 13.2099 66.8218 15.6412
10.631 1.7615 8.6516 1.5481
1.46 7.5 7.72 10.1
0.15 <0.0001 <0.0001 <0.0001
0.6006 0.1092 0.2692 0.1233
0.2474 0.0502 0.2177 0.0427
2.43 2.18 1.24 2.89
0.0186 0.0339 0.2216 0.0056
23.8248 14.6583 338.7104 9.3591
51.093 8.4481 41.925 7.4254
0.47 1.74 8.08 1.26
0.643 0.0888 <0.0001 0.2133
SE = standard error; ED = emergency department.
RESULTS ED Expansion As detailed in Table 1 and Figures 1–6, few immediate effects were observed at the time ED expansion was completed (Q2 of 2007). The percent of patients who left without being seen was found to decrease significantly (0.60%; p < 0.05), and all other outcomes remained consistent with the level observed in the time periods before ED expansion. The trend effects observed after ED expansion for most outcomes, however, were statistically significant and indicative of a negative impact of the expansion. Press Ganey Percentile rank decreased (4.1 percentile per quarter; p < 0.05), median door-to-provider time increased (+4.9 minutes per quarter; p < 0.0001), median duration of stay increased (+13.2 minutes per quarter; p < 0.0001), and the percent of patients who left without being seen increased (+0.11 per quarter; p < 0.05). Total patient volume was increasing during the time period before and after ED expansion, no significant changes were observed concurrent with ED expansion. Our ED expansion helped us eliminate diversion in 2007 (Figure 7).
Rapid Assessment As also detailed in Table 1 and Figures 1–6, Press Ganey outcomes were not impacted immediately by the implementation of Rapid Assessment; however, trends for both raw score (+0.48 points per quarter; p < 0.05) and percentile (+4.1 percentiles per quarter, p < 0.01) changed significantly after Rapid Assessment was implemented, representing a reversal of the negative trend observed after ED expansion. The trend for percent of patients who left without being seen also was observed to differ significantly after Rapid Assessment (0.12% per quarter; p < 0.01), similarly reversing the direction of the trend observed in the previous time period. Immediate impacts were observed for median door-toprovider time, which decreased by 25.8 min, and duration of stay, which decreased by 66.8 min at the time Rapid Assessment was implemented (both p < 0.0001). Furthermore, the trends for these outcomes over the quarters after Rapid Assessment suggested these improvements continued to improve over time: median door-toprovider time 4.5 minutes per quarter (p < 0.0001) and median duration of stay 15.6 min per quarter (p <
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Figure 1. Median total duration of stay.
0.0001). Total patient volume continued to increase steadily between ED expansion and the implementation of Rapid Assessment (the trend did not significantly differ); however, the volume was observed to increase
Figure 2. Median door-to-provider time.
significantly at the time rapid assessment was implemented (+338.7 patients; p < 0.0001). Our process improvement innovations helped us maintain flow and remain off diversion (Figure 7).
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Figure 3. The number of patients who left without being seen (percent of total volume).
DISCUSSION The ED often is the location of first patient contact in a hospital. Inefficiencies in the throughput process of
EDs not only decrease patient satisfaction but also worsen patient outcomes as the result of delays in treatment (6). Like many EDs around the country, the Whidden ED struggled with flow and patient
Figure 4. Patient satisfaction in the emergency department (Press Ganey mean score).
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Figure 5. Patient satisfaction in the emergency department (Press Ganey percentile).
satisfaction scores for many years. Poor ED performance affected CHA’s reputation and contributed to historically stagnant ED volumes. Diversions were routine, patient satisfaction scores were among the worst in the state, and there was a culture that accepted
Figure 6. Total volume in the emergency department.
inefficient processes. In 2005, The Whidden ED was on diversion 8.2% of the time (716 hours), scored in the 15th percentile in Patient Satisfaction, and had more than 4% of patients leave prior to receiving care (i.e., LWBS).
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Figure 7. Diversion from the emergency department.
ED inefficiencies and the resulting overcrowding is caused by disruptions in the three steps of patient flow: input (e.g., ambulance diversion), throughput (e.g., rapid assessment zones/pods, clinical decision units), and output (e.g., full capacity protocols, bed managers) (7). A review of the literature shows that many interventions have been designed to alleviate ED overcrowding at each of these three steps. Some these include: the ‘‘Disneyfication’’ or ‘‘Waiting management’’ of the ED patient experience, which is defined as improving the psychological perception of waiting with various distractions, updates on waiting, and environmental modifications. They also include techniques that strive to reduce wait or improve the waiting experience like Lean strategy from the Toyota Motor Corporation, which emphasizes elimination of waste and delays to allow for smooth continuous patient flow (8,9); ‘‘Immediate Bedding,’’ which, in line with Lean strategy, allows for rapid intake and early treatment by aligning parallel processes (10,11); ‘‘Splitflow Design,’’ where triaged patients with lower-acuity levels are directed to fast-track areas (12); early assignment of a provider to a patient after triage has led to faster throughput (13); and lastly, additional investment through renovation and expansion of physical ED’s or the addition of staff such as clinical assistant (14,15). Our RAU could be described as a modified split-flow design where all patients are immediately placed in a room where they are evaluated. Only patients with greater acuity are subsequently moved to the main ED.
The rest remain in the RAU, where they complete their care. In an assessment of the improvement options available to the Whidden ED, it was noted that these techniques experience varying levels of success. ‘‘Split-flow design’’ requires the segregation of patients into separate care processes with additional usage of personnel, space, and equipment resources (13,16,17). Adding staff, such as clinical assistants, improves wait times and decreases LWBS (18); however, although additional physicians and mid-level providers, such as Nurse Practitioners and Physician Assistants, can speed up ED flow by bringing the patient to a provider faster, it is at an increased financial cost (1924). Similarly, an admission hospitalist designated as the lead triage physician, intended to expedite admission orders, has been shown to have no positive impact on flow in the ED (25). Renovation and expansion of the physical ED, which allowed for additional beds and treatment space, was undertaken at the Whidden ED. Although this has been suggested to improve ED flow and decrease duration of stay (15), increasing the number of physical beds does not always improve ED throughput (26). This was clearly evident in our case. Expanding the Whidden ED resulted in some operational improvements with positive trending in metrics (Table 1 and Figures 1–6), but, most of these improvements were transitory. Metrics began moving in the wrong direction, as volume increased and the staff
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continues to follow the same flow and operational approach. It is important to note that our ED expansion helped us eliminate diversion more than 2 years before it was banned in Massachusetts by the Department of Public Health. In addition, our process improvement innovations helped us maintain flow and remain off diversion (Figure 7). After the expansion of the ED, the flow and operational approach was scrutinized in a comprehensive assessment. Activities occurring during the front-end processing of patients typically include: initial patient presentation, registration, triage, bed placement, and medical evaluation. The time needed to complete these steps contributes to the total duration of stay in the ED. Using the ‘‘immediate bedding’’ approach, the front-end process was reengineered to eliminate sequential intake tasks. Instead of a patient going through extended triage and a comprehensive registration before entering the ED and receiving care, the patient is greeted by a Patient Partner, a customer service expert, and placed in an ED bed immediately after the three-question mini-registration. Once inside, the patient is evaluated by any care team member that is available, and care is initiated. Full-registration takes place after nursing and physician assessment, stabilization, and initiation of care. As a result of these improvement efforts, more patients stay in the same room and are cared for by the same clinical team throughout their ED stay, which has minimized the number of times patients are moved, the number of times they have to present their story, the number of nursing and physician handoffs, the likelihood of miscommunication and errors, and the total duration of stay (Figure 1). After implementation of these initiatives, statistically significant improvements were observed (Table 1). These data clearly show that process and flow improvement positively impact the patient experience to a greater degree than renovation and space expansion. Budget-neutral operational changes, such as implementation of the RAU in the ED by repurposing space, expanding the role of staff, and eliminating waste, have significant impact on the efficiency of the department without major capital investment (27). With this frontend redesign, we were able to dramatically improve all metrics, and more importantly, sustain the improvement trends for more than 3 years while managing doubledigit volume growth (Table 1, Figure 6). Limitations These changes were implemented in a medium-sized, urban ED, and some of the initiatives described and results derived from their implementation may not be applicable to EDs operating under different constraints and with
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different patient populations. However, we believe that the changes implemented in the Whidden ED would be beneficial to many EDs facing the challenges of overcrowding in times of limited resources. We also recognize that the period of time between the ED expansion and process innovations may have been too short to establish a new stable baseline from which to measure the key metrics. Finally, because the process innovations happened after the expansion, it probably benefited from the additional space and had a greater chance to succeed. CONCLUSION Transformation of the ED is manageable, strategic, inexpensive, and sustainable, and it positively impacts the patient experience of care. Although physical space and appropriate resources are important, it is even more essential to have efficient flow and patient-centered care. Our results demonstrate that the impact of process improvement and Rapid Assessment implementation on ED patient experience of care is far greater than the impact of renovation and facility expansion.
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ARTICLE SUMMARY 1. Why is this topic important? Emergency department (ED) crowding, ambulance diversion, long patient waits, and patients leaving without being seen have affected ED patient care and satisfaction. Most of the tactics that have been suggested to help ease ED crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. Accordingly, most of these strategies also require institutions to make considerable investments of money and time that may not be readily available. 2. What does this study attempt to show? This paper compares the impact of ED expansion vs. patient flow improvement and the establishment of a RAU at Cambridge Health Alliance’s Whidden Hospital Campus ED. 3. What are the key findings? Transformation of the ED is manageable, strategic, inexpensive, and sustainable, and it positively impacts the patient experience of care. Although physical space and appropriate resources are important, it is even more essential to have efficient flow and patient-centered care. Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion. 4. How is patient care impacted? Our work shows that EDs can improve flow and patient experience with affordable process improvement interventions.