- Email: [email protected]
Shortening the Wait: A Strategy to Reduce Waiting Times in the Emergency Department
RESEARCH
SHORTENING THE WAIT: A STRATEGY REDUCE WAITING TIMES IN THE EMERGENCY DEPARTMENT
TO
Authors: Sheila R. Finamore, RN, MSN, and Sheila A. Turris, RN, PhD, Burnaby and Vancouver, BC, Canada
Earn Up to 8.5 CE Hours. See page 597. Abstract: Emergency Department crowding (EDC), extended wait times, and the issues arising as a result are well described in the health-care literature. Accordingly, reducing waiting times has become a focus across Canada. Less-urgent patient presentations represent a large proportion of the individuals presenting for care in Canadian emergency departments (ED). This patient population contributes to congestion in the ED. In light of these issues, an innovative program is being trialed at Burnaby Hospital, in the lower mainland of British Columbia. The goals of the program include: a reduction of EDC, a shortening of the duration of time between patient presentation and treatment, and an increase reported levels of patient satisfaction. Key words: Emergency department overcrowding; Triage; Waiting times; Satellite clinic
E
D crowding, extended wait times, and the issues arising as a result are well described in the health care literature.1-6 Accordingly, reducing wait times in the emergency department has become a focus across Canada.7,8 As defined by the Canadian Association of Emergency Physicians, 7 overcrowding is a situation in which the demand for services exceeds the ability of health care professionals to provide care within a reasonable length of time. A complex phenomenon, ED crowding has been well modeled by Ospina et al,9 who have conceptualized the variSheila R. Finamore, Member, National Emergency Nurses Affiliation BC Chapter, is Faculty, Health Part Time Studies, British Columbia Institute of Technology, Burnaby, BC, Canada. Sheila A. Turris is Nurse Practitioner (Family), Vancouver Coastal Health, Vancouver, BC, Canada. For correspondence, write: Sheila R. Finamore, RN, MSN, Health Part Time Studies, British Columbia Institute of Technology, 3700 Willingdon Ave, Burnaby, BC, V5G 3H2, Canada; E-mail: [email protected].
ables of ED crowding as being associated with input, throughput, and output. In their model input refers to the number of patients seeking care; throughput refers to all factors related to ED efficiency, workload, and capacity; and the output component measures ED length of stay as well as the capacity of the inpatient system to move ED admit patients to inpatient hospital beds. ED crowding also results from an inability to efficiently triage large numbers of patients presenting to the emergency department. Specifically, factors identified as being associated with extended patient wait times include the triage process, access block (admitted patients occupying ED beds), and diagnostic availability, as well as facility size and design.9-11 Emergency patients having the longest waits are those who present with less urgent symptoms and those who present to the emergency department at a highvolume community hospital (>30,000 visits annually) or a teaching hospital.12 Whereas increasing hospital capacity may be out of the locus of control for the majority of front-line health care professionals, re-evaluating and altering the process by which less urgent ED patients access the emergency department provide an opportunity for front-line health care professionals to be innovative, improve patient satisfaction, and decrease ED crowding for all ED patients in general. In this article we explain an innovative new project that addresses input, throughput, and output. The project is aimed at providing efficient care, reducing ED crowding, and improving patient experiences of care. Background and Context
doi: 10.1016/j.jen.2009.03.001
The Fraser Health Authority (FHA) serves a small demographic area with a high population density. The local population included 1,489,342 individuals in 2006. Over the past 10 years, the FHA has had tremendous population growth, and as a result, the region is currently the home of approximately 34% of British Columbians.13 Burnaby Hospital is a busy community-based facility within the FHA that houses 1 of the region’s 12 emergency departments. In 2006 there were 50,700 patient visits. This figure increased
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by 6.5% in 2007. Of particular interest, the number of patients categorized as less urgent according to the Canadian Triage Acuity Scale (eg, level 4 or 5) increased by 12% over the same time period14; however, the ED admission rate only increased by 3.2%. The previously mentioned data and our anecdotal experience demonstrate that there is an increasing dependency on the acute care sector for less urgent patient care services. The reasons for this are multifactorial and include population growth in the area, the decreasing availability of primary health care providers, longer waits for surgery and medical imaging in the community, and the “one-stop” availability of ED services 24 hours a day, 7 days a week.15-17 With regard to the relationship between the less urgent patient group and ED congestion, there is no consensus in the health care literature. One perspective is that this group frequently represents the “walking wounded,” that is, individuals who do not require an acute stretcher and therefore do not contribute to ED crowding. This argument may be flawed because it targets ED crowding as primarily a capacity (or throughput) issue. In fact, as noted by Ospina et al,9 access block is only one of many variables that contribute to ED crowding. Another perspective is that caring for the less urgent patient population within the emergency department does contribute to ED crowding because this requires resource utilization (triage, registration, nurses, and physicians)17 and has the potential to block timely entry to the department.18 We note that the latter position, also held by us, is in contrast to the statements issued by the Canadian Medical Association (CMA). The CMA argues that diverting nonurgent patients from the emergency department would not have an impact on the overcrowding issue.7
TABLE 1
Examples of patients appropriate for ED satellite clinic J. is a 23-year-old woman who presented to the emergency department at midnight for the treatment of right lower quadrant abdominal pain. She was assessed and treated. Her pain had resolved, and her initial laboratory work was unremarkable. She was discharged and asked to return at 8:30 AM for an ultrasound. P. is a 55-year-old short-order cook who sustained a seconddegree burn to his right hand. He has no family physician and is being followed up in the emergency department for ongoing wound assessment and management over the next 72 hours. R. is a 15-year-old soccer player who sustained a fracture to his left ankle, associated with excessive swelling. He has been asked to return to the emergency department for the application of a cast once the swelling has begun to subside.
Having identified trends in the data, we strategized about how best to meet the needs of our community members. Specifically, we focused on the less urgent patients in the emergency department while simultaneously addressing issues related to overcrowding. In particular, we focused on understanding the needs of those patients returning to the emergency department for predictable health care needs (Table 1). Those returning for scheduled ultrasound appointments, follow-up fracture care, or intravenous antibiotics were identified as groups who might benefit from a targeted approach to care, given that these patients have conditions that do not require urgent or emergent care but must be seen in an acute care setting because diagnostics and definitive diagnoses are often pending. As discussed by Turris and Bell19 and the Canadian Association of Emergency
Physicians,20 the scope of practice in the emergency department has increased in the last decade and treatment that would have been provided on an inpatient basis 10 years ago is now commonly provided in the emergency department, thereby requiring return visits to the emergency department. After reviewing the literature on the issue of overcrowding, and considering the context of practice in our emergency department, we concluded that one way to address the issue of overcrowding would be to ensure that patients who were not in need of urgent care were not treated in the emergency department after their initial diagnoses and treatments. Instead, we proposed that such individuals would receive follow-up care at a satellite/follow-up care clinic staffed by an emergency nurse and physician, operating 4 hours a day, Monday through Friday. Diverting individuals presenting with a scheduled appointment or a follow-up visit to another location theoretically held several benefits. First, diverting this population from the emergency department would reduce the bottleneck at triage and registration, thereby ensuring that patients with urgent or emergent complaints were not “stuck in line” behind follow-up patients delaying triage and assessment. The triage process, at least initially, is linear (one patient at a time), and until a particular patient is in the view of the triage nurse, it is difficult to ascertain whether the most urgent patient is being triaged first. Second, relocation would ensure that individuals with urgent complaints would not be competing for ED physical and human resources. Third, diversion had the potential to impact the length of stay for individuals presenting with nonurgent complaints. For example, a patient visit that may require an
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actual stay of less than 30 minutes carried an average arrival-to-departure time of 157 minutes, much of which was spent waiting at triage.14 This length of stay did not meet the Ministry of Health target, and we hypothesized that by identifying a discrete target population, specifically the “follow-up patient” seeking treatment for an already assessed illness or injury; we could improve patient experiences of care, be more efficient with our triage and admitting processes, and reduce ED crowding. INITIATIVE AND PURPOSE
We sought to create a satellite clinic for patients who required follow-up ED visits (eg, for intravenous therapy, cast replacement or follow-up care, or wound care). Our goal was to improve the service provided to this patient population and to decrease the overall demand on ED resources. We predicted surge times for the follow-up patients and reallocated resources for this group. Indirectly, this served to increase the resources available for patients with urgent and emergent health concerns. In September 2007 we identified key stakeholders and consulted informally with members of each of the following groups: emergency nurses, emergency physicians, admitting staff, medical imaging staff, and the orthopaedic group. Themes that arose included funding, space requirements, and human resources. We located space adjacent to the emergency department and radiology department for the proposed satellite clinic. One of the human resource issues was how to staff the clinic for shifts that were of a brief duration (eg, 4 hours) without compromising staffing in the emergency department. One unanticipated challenge was determining where patients could be registered as an alternative to the ED waiting area. At the conclusion of the consultation process (5 months in duration), we obtained the fiscal, physical, and human resources required for the emergency satellite clinic. Subsequently, we convened a planning team consisting of the ED manager, educators, physicians, and staff members who were scheduled to work consistently in this area. The team met weekly or biweekly to assess progress and set new goals.
nurse during their initial visit and subsequently referred to the ED satellite clinic for follow-up. On weekdays, schedules are printed and sent to the ED patient care coordinator from the various departments (eg, medical imaging, cast clinic, and ED fast track) to ensure that the satellite clinic nurse and the physician know who will be returning on a given day. Patients are asked to report to the main admitting area (not the emergency department), where a designated admitting clerk registers them and sends them to the satellite clinic. On weekends and holidays, all follow-up patients report through ED admitting because the satellite clinic is closed. The outcomes of the project were related to patient, physician, and nurse experiences of care as well as length of stay. Information in the Figure describes the surge times and length of stay before and after the project commenced. When interpreting the illustration, “MP” is the follow-up clinic and “FT” is within the emergency department itself. Feedback with regard to patient satisfaction was collected for the purposes of quality assurance, via an informal questionnaire. Themes that arose are detailed in Table 2. Discussion
The clinic hours are 7:30 to 11:30 AM, Monday through Friday. The location is a small treatment room across the hall from both the emergency department and the radiology department. The space is also adjacent to the cast clinic, which is staffed by a cast technician. The follow-up clinic is staffed by an emergency registered nurse and an emergency physician. In terms of operations, all patients appropriate for the clinic are identified by a physician or
Over the last decade, a number of innovative strategies have been trialed in an attempt to address the issue of ED crowding. Of note, Bradley21 provided a lucid and comprehensive review of innovations to address ED overcrowding. These strategies may be divided into 3 main categories: reducing intake, increasing capacity, and streamlining process. Reducing intake through ambulance diversion or the practice of triaging away has been reported with varying degrees of success. However, reducing intake may carry substantial consequences. For example, Schull et al22 identified that prehospital delays are associated with ambulance diversion and that delays in transport that occur when ambulances are diverted may cause clinically important delays for critically ill patients. Focusing on patients who walk into the emergency department, Carret et al17 argued that an effective strategy for reducing ED crowding may be to redirect patients to appropriate services. The program described in this article represents a strategy aimed at reducing intake into the emergency department by streaming patients away from the primary location where overcrowding occurs. Increasing capacity, either directly or indirectly, has also been attempted. As a response to the issue of overcrowding, administrators have created satellite units to hold admitted patients, pending the availability of inpatient beds.23,24 Alternatively, administrators have created specialty units for large subgroups of patients such as those admitted for substance abuse, psychiatric issues, or cardiac observation.5,24
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TABLE 2
Patient and stakeholder satisfaction Patients
Physicians
Emergency nurses
FIGURE Snapshot of surge times and length of stay in emergency department (FT ) and in follow-up clinic (MP ). CTAS, Canadian Triage Acuity Scale; BH, Burnaby Hospital. (L. Lopez [“System analysis and performance improvement: ED chief complaints at Burnaby Hospital”], personal written communication, 2008.)
Others have argued that an overall increase in the systemwide capacity is required.18 Strategies aimed at streamlining process may be the most commonly reported interventions with regard to ED crowding. For example, Howell et al25 reported the use of hospitalists to reduce the delay between ED treatment and admission to an inpatient bed moving away from the traditional use of specialists as the primary referral point. Similarly, a Manitoba hospital is trialing a nurse practitioner–led clinic to treat patients with non-emergency injuries and illnesses.26 Tanabe et al27 reported on an innovation to improve patient flow by closing the waiting room and instead sending patients directly to a stretcher or chair inside the department. Additional examples include the use of rapid assessment areas for patients who have non-emergent health concerns, as well as the formation of programs to improve the use of existing resources from a provincial, national, and international perspective. One such initiative is BC (British Columbia) Bedline. BC Bedline collaborates with physicians and other health care professionals to facilitate the safe and timely transfer of acute and critically ill patients to the appropriate level of care, using an Internet-based provincial
512
Reduced length of stay Improved access to care Improved quality of care (perception of focused care) Decreased workload in emergency department with this patient population Decreased ED crowding Quality care Extra shifts Decreased workload in emergency department with this patient population Decreased ED crowding Quality care Extra shifts
bed registry Web site and a toll-free call center available 24 hours a day, 7 days a week. Miró et al28 suggested that focusing on the improvement of internal factors such as the layout of the work environment might be an effective strategy for streamlining patient flow through the emergency department. In addition, the application of “Lean” principles, as pioneered by the Toyota Motor Corporation (Aichi, Japan), has been attempted with some success. For example, Kulkarni29 reported that by applying Lean principles, one hospital managed to reduce the time between admission to an inpatient bed and transfer to a ward by 33%. Finally, there is also discussion in the health care literature about evidence-based practice and the need for practice algorithms to stratify patients by risk in order to assign the few remaining beds appropriately.5 The creation of an ED satellite clinic that allows patients returning for follow-up diagnostics or treatment to bypass the main emergency department is consistent with several aspects of the approaches described previously. We have increased capacity by removing returning patients from the pool of patients requiring care in the emergency department. We have streamlined the process by creating a separate registration area and a separately staffed treatment area. In addition, we have increased throughput, reducing the length of stay for returning patients. Next Steps
The opportunity to pilot this project arose out of a need to better manage space and workload during an ED renovation. We have shown measurable success in terms of length
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of stay and patient/provider satisfaction and have determined there to be absolute improvement in the care of the follow-up patients and improved timely access to care. Stakeholders agree that there is value in continuing with this program. In 2007 the British Columbia Ministry of Health created the Health Innovation Fund. The fund supports innovative proposals to promote and improve efficiencies in patient care. We applied for access to this fund, and our proposal was approved, providing the fiscal resources necessary to support this initiative. We have identified some key variables that we are addressing to ensure the continued success of this program. First, a larger space is required. We currently treat an average of 20 to 25 patients per 4-hour day in a space equivalent to a 2-bed patient room. With a larger space, we could expand on the good work that has begun. We have presented a business plan to secure a larger space that has been favorably received. Second, designated resources for this program are a consistent issue. With the exception of a reallocated registration clerk for a 4-hour period Monday through Friday, during the pilot period, this clinic operated without additional funding and has been staffed through reallocation of baseline ED nursing staff. The funding for an appropriately skilled staff member to work in this clinic has been approved. Third, we would like to pursue cross training unit clerks to perform secondary registration. As exampled in the Lean model, dual training will increase our efficiencies and will ensure that we can continue to divert patients not requiring acute care services away from the emergency department to be registered in a secondary location by a unit clerk who will also be able to assist in unit functions as time allows. Fourth, looking into the future, we would like ED physician coverage to increase to allow this clinic to expand service beyond follow-up patients, extending the population to include the “walking wounded” individuals presenting to the emergency department. This proposal has been received favorably. Patients initially presenting to the emergency department who would be deemed suitable for the clinic (as supported by guidelines and protocol) may be initially received by the triage nurse and diverted over to the satellite clinic for the completion of their registration. Limiting triage assessments to “rapid assessments” or “90-second triage” for the nonurgent patient and eliminating the succession of often inefficient steps will expedite the patient’s time to physician.30 Summary and Conclusions
Howard et al16 and others15,17 have described the myriad of compelling reasons for which individuals will continue
November 2009 35:6
to visit emergency departments. In the current context of overcrowding at the national level, such decisions to seek care will further exacerbate the issue of overcrowding. In this article we described the innovative use of a satellite clinic to divert patients returning to the emergency department for care on a scheduled basis. Addendum
At time of publication this initiative is now serving to care for all follow-up emergency patients with hours expanded to 7:30 a.m.-6:00 p.m. seven days a week. In addition, those triaged as a CTAS 4 or 5 are being streamed to this area to have their registration completed by a dual trained unit clerk. This initiative received the fiscal resources to secure a unit clerk/ registration clerk, a full scope licensed practical nurse and an emergency nurse. This team is supported by a designated Emergency Room Physician. In the 3 months this initiative has been expanded, Burnaby Hospital Emergency Department has recognized an overall decrease in length of stay meeting British Columbia Ministry of Health targets for all CTAS groups an average of 70% of the time. During this same period the ED volume as increased by 20%. Acknowledgment We thank Chris Windle, Director Health Services, and Holly KennedySymonds, Director of Burnaby Acute Programs and Projects, for their review and comments on drafts of this report.
REFERENCES 1. Eastaugh SR. Overcrowding and fiscal pressures in emergency medicine. Hosp Top 2002;80(1):7-11. 2. Velianoff GD. Overcrowding and diversion in the emergency department. Nurs Clin North Am 2002;37(1):59-66, vi. 3. Schafermeyer RW, Asplin BR. Hospital and emergency department crowding in the United States. Emerg Med (Freemantle) 2003;15(1):22-7. 4. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency department crowding: A point in time. Ann Emerg Med 2003;42(2):167-72. 5. Blomkalns AL, Gibler WB. Emergency department crowding: Emergency physicians and cardiac risk stratification as part of the solution. Ann Emerg Med 2004;43(1):77-8. 6. Kennedy J, Rhodes KV, Walls CA, Asplin BR. Access to emergency care: Restricted by long waiting times and cost and coverage concerns. Ann Emerg Med 2004;43(5):567-73. 7. Canadian Association of Emergency Physicians. Taking Action on the Issue of Overcrowding in Canada’s Emergency Departments. Ottawa: Canadian Association of Emergency Physicians; 2005. 8. Canadian Institute of Health Information. Understanding ED Wait Times. Ottawa: Canadian Institute of Health Information; 2005:1-55.
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9. Ospina MB, Bond K, Schull M, Innes G, Blitz S, Rowe BH. Key indicators of overcrowding in Canadian emergency departments: A Delphi study. CJEM 2007;9(5):339-46.
19. Turris S, Bell D. Once upon a time: ED staffing should reflect complex, comprehensive care and not just the census. J Emerg Nurs 2004;30(5):400-1.
10. Estey A, Ness K, Saunders LD, Alibhai A, Bear RA. Understanding the causes of overcrowding in emergency departments in the Capital Health Region in Alberta: A focus group study. CJEM 2003;5(2):87-94.
20. Position statement on emergency overcrowding. Canadian Association of Emergency Physicians. Available at: http://www. caep.ca. Accessed June 16, 2008. Published 2007.
11. Rowe BH, Bond K, Ospina MB, Blitz S, Schull M, Sinclair D, et al. Data collection on patients in emergency departments in Canada. CJEM 2006;8(6):417-24. 12. Canadian Institute for Health Information: Analysis in Brief, Understanding Emergency Department Wait Times: How Long do People Spend in Emergency Departments in Ontario? Ottawa: Canadian Institute of Health Information; 2007:1-21. 13. British Columbia Ministry of Health. Profiles of British Columbia’s Six Health Authorities. Available at: www.bcbudget.gov.bc.ca/2007/ sp/hlth/default.aspx?hash=10. Accessed June 16, 2008. 14. Fraser Health Authority. ED Visits, ED Admits & Total Admits to Burnaby Hospital and Royal Columbian Hospital. Burnaby: Fraser Health Authority; 2007. 15. Guttman N, Nelson MS, Zimmerman DR. When the visit to the emergency department is medically nonurgent: Provider ideologies and patient advice. Qual Health Res 2001;11(2): 161-78. 16. Howard MS, Davis BA, Anderson C, Cherry D, Koller P, Shelton D. Patients’ perspective on choosing the emergency department for nonurgent medical care: A qualitative study exploring one reason for overcrowding. J Emerg Nurs 2005;31(5): 429-35.
21. Bradley V. Placing emergency department crowding on the decision agenda. Nurs Econ 2005;23(1):14-24. 22. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003;168(3): 277-83. 23. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emerg Med J 2003;20(5):402-5. 24. Gantt LT. A strategy to manage overcrowding: Development of an ED holding area. J Emerg Nurs 2004;30(3):237-42. 25. Howell EE, Bessman ES, Rubin HR. Hospitalists and an innovative emergency department admission process. J Gen Intern Med 2004;19(3):266-8. 26. Lett D. Manitoba to fast-track less critical emergency patients. CMAJ 2004;171(9):1031. 27. Tanabe P, Gisondi MA, Medendorp S, Engeldinger L, Graham LJ, Lucenti MJ. Should you close your waiting room? Addressing ED overcrowding through education and staff based participatory research. J Emerg Nurs 2008;34(4):285-9. 28. Miró O, Sánchez M, Espinosa G, Coll-Vinent B, Bragulat E, Millá J. Analysis of patient flow in the emergency department and the effect of an extensive reorganization. Emerg Med J 2003;20(2):143-8.
17. Carret MLV, Fassa AG, Kawachi I. Demand for emergency health service: Factors associated with inappropriate use. BMC Health Serv Res 2007;7:1-9.
29. Kulkarni RG. Going lean in the emergency department: A strategy addressing emergency department overcrowding. MedGenMed 2007;9(4):58.
18. Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J 2003;20(5):406-9.
30. Advisory Board Company. (1999). The clockwork ED, Volume I; Expediting time to physician. Washington, DC: The Advisory Board Company.
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SHORTENING THE WAIT: A STRATEGY REDUCE WAITING TIMES IN THE EMERGENCY DEPARTMENT
TO
Authors: Sheila R. Finamore, RN, MSN, and Sheila A. Turris, RN, PhD, Burnaby and Vancouver, BC, Canada
Earn Up to 8.5 CE Hours. See page 597. Abstract: Emergency Department crowding (EDC), extended wait times, and the issues arising as a result are well described in the health-care literature. Accordingly, reducing waiting times has become a focus across Canada. Less-urgent patient presentations represent a large proportion of the individuals presenting for care in Canadian emergency departments (ED). This patient population contributes to congestion in the ED. In light of these issues, an innovative program is being trialed at Burnaby Hospital, in the lower mainland of British Columbia. The goals of the program include: a reduction of EDC, a shortening of the duration of time between patient presentation and treatment, and an increase reported levels of patient satisfaction. Key words: Emergency department overcrowding; Triage; Waiting times; Satellite clinic
E
D crowding, extended wait times, and the issues arising as a result are well described in the health care literature.1-6 Accordingly, reducing wait times in the emergency department has become a focus across Canada.7,8 As defined by the Canadian Association of Emergency Physicians, 7 overcrowding is a situation in which the demand for services exceeds the ability of health care professionals to provide care within a reasonable length of time. A complex phenomenon, ED crowding has been well modeled by Ospina et al,9 who have conceptualized the variSheila R. Finamore, Member, National Emergency Nurses Affiliation BC Chapter, is Faculty, Health Part Time Studies, British Columbia Institute of Technology, Burnaby, BC, Canada. Sheila A. Turris is Nurse Practitioner (Family), Vancouver Coastal Health, Vancouver, BC, Canada. For correspondence, write: Sheila R. Finamore, RN, MSN, Health Part Time Studies, British Columbia Institute of Technology, 3700 Willingdon Ave, Burnaby, BC, V5G 3H2, Canada; E-mail: [email protected].
ables of ED crowding as being associated with input, throughput, and output. In their model input refers to the number of patients seeking care; throughput refers to all factors related to ED efficiency, workload, and capacity; and the output component measures ED length of stay as well as the capacity of the inpatient system to move ED admit patients to inpatient hospital beds. ED crowding also results from an inability to efficiently triage large numbers of patients presenting to the emergency department. Specifically, factors identified as being associated with extended patient wait times include the triage process, access block (admitted patients occupying ED beds), and diagnostic availability, as well as facility size and design.9-11 Emergency patients having the longest waits are those who present with less urgent symptoms and those who present to the emergency department at a highvolume community hospital (>30,000 visits annually) or a teaching hospital.12 Whereas increasing hospital capacity may be out of the locus of control for the majority of front-line health care professionals, re-evaluating and altering the process by which less urgent ED patients access the emergency department provide an opportunity for front-line health care professionals to be innovative, improve patient satisfaction, and decrease ED crowding for all ED patients in general. In this article we explain an innovative new project that addresses input, throughput, and output. The project is aimed at providing efficient care, reducing ED crowding, and improving patient experiences of care. Background and Context
doi: 10.1016/j.jen.2009.03.001
The Fraser Health Authority (FHA) serves a small demographic area with a high population density. The local population included 1,489,342 individuals in 2006. Over the past 10 years, the FHA has had tremendous population growth, and as a result, the region is currently the home of approximately 34% of British Columbians.13 Burnaby Hospital is a busy community-based facility within the FHA that houses 1 of the region’s 12 emergency departments. In 2006 there were 50,700 patient visits. This figure increased
November 2009 35:6
JOURNAL OF EMERGENCY NURSING
J Emerg Nurs 2009;35:509-14. Available online 1 May 2009. 0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
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by 6.5% in 2007. Of particular interest, the number of patients categorized as less urgent according to the Canadian Triage Acuity Scale (eg, level 4 or 5) increased by 12% over the same time period14; however, the ED admission rate only increased by 3.2%. The previously mentioned data and our anecdotal experience demonstrate that there is an increasing dependency on the acute care sector for less urgent patient care services. The reasons for this are multifactorial and include population growth in the area, the decreasing availability of primary health care providers, longer waits for surgery and medical imaging in the community, and the “one-stop” availability of ED services 24 hours a day, 7 days a week.15-17 With regard to the relationship between the less urgent patient group and ED congestion, there is no consensus in the health care literature. One perspective is that this group frequently represents the “walking wounded,” that is, individuals who do not require an acute stretcher and therefore do not contribute to ED crowding. This argument may be flawed because it targets ED crowding as primarily a capacity (or throughput) issue. In fact, as noted by Ospina et al,9 access block is only one of many variables that contribute to ED crowding. Another perspective is that caring for the less urgent patient population within the emergency department does contribute to ED crowding because this requires resource utilization (triage, registration, nurses, and physicians)17 and has the potential to block timely entry to the department.18 We note that the latter position, also held by us, is in contrast to the statements issued by the Canadian Medical Association (CMA). The CMA argues that diverting nonurgent patients from the emergency department would not have an impact on the overcrowding issue.7
TABLE 1
Examples of patients appropriate for ED satellite clinic J. is a 23-year-old woman who presented to the emergency department at midnight for the treatment of right lower quadrant abdominal pain. She was assessed and treated. Her pain had resolved, and her initial laboratory work was unremarkable. She was discharged and asked to return at 8:30 AM for an ultrasound. P. is a 55-year-old short-order cook who sustained a seconddegree burn to his right hand. He has no family physician and is being followed up in the emergency department for ongoing wound assessment and management over the next 72 hours. R. is a 15-year-old soccer player who sustained a fracture to his left ankle, associated with excessive swelling. He has been asked to return to the emergency department for the application of a cast once the swelling has begun to subside.
Having identified trends in the data, we strategized about how best to meet the needs of our community members. Specifically, we focused on the less urgent patients in the emergency department while simultaneously addressing issues related to overcrowding. In particular, we focused on understanding the needs of those patients returning to the emergency department for predictable health care needs (Table 1). Those returning for scheduled ultrasound appointments, follow-up fracture care, or intravenous antibiotics were identified as groups who might benefit from a targeted approach to care, given that these patients have conditions that do not require urgent or emergent care but must be seen in an acute care setting because diagnostics and definitive diagnoses are often pending. As discussed by Turris and Bell19 and the Canadian Association of Emergency
Physicians,20 the scope of practice in the emergency department has increased in the last decade and treatment that would have been provided on an inpatient basis 10 years ago is now commonly provided in the emergency department, thereby requiring return visits to the emergency department. After reviewing the literature on the issue of overcrowding, and considering the context of practice in our emergency department, we concluded that one way to address the issue of overcrowding would be to ensure that patients who were not in need of urgent care were not treated in the emergency department after their initial diagnoses and treatments. Instead, we proposed that such individuals would receive follow-up care at a satellite/follow-up care clinic staffed by an emergency nurse and physician, operating 4 hours a day, Monday through Friday. Diverting individuals presenting with a scheduled appointment or a follow-up visit to another location theoretically held several benefits. First, diverting this population from the emergency department would reduce the bottleneck at triage and registration, thereby ensuring that patients with urgent or emergent complaints were not “stuck in line” behind follow-up patients delaying triage and assessment. The triage process, at least initially, is linear (one patient at a time), and until a particular patient is in the view of the triage nurse, it is difficult to ascertain whether the most urgent patient is being triaged first. Second, relocation would ensure that individuals with urgent complaints would not be competing for ED physical and human resources. Third, diversion had the potential to impact the length of stay for individuals presenting with nonurgent complaints. For example, a patient visit that may require an
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DEFINING THE PROBLEM
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actual stay of less than 30 minutes carried an average arrival-to-departure time of 157 minutes, much of which was spent waiting at triage.14 This length of stay did not meet the Ministry of Health target, and we hypothesized that by identifying a discrete target population, specifically the “follow-up patient” seeking treatment for an already assessed illness or injury; we could improve patient experiences of care, be more efficient with our triage and admitting processes, and reduce ED crowding. INITIATIVE AND PURPOSE
We sought to create a satellite clinic for patients who required follow-up ED visits (eg, for intravenous therapy, cast replacement or follow-up care, or wound care). Our goal was to improve the service provided to this patient population and to decrease the overall demand on ED resources. We predicted surge times for the follow-up patients and reallocated resources for this group. Indirectly, this served to increase the resources available for patients with urgent and emergent health concerns. In September 2007 we identified key stakeholders and consulted informally with members of each of the following groups: emergency nurses, emergency physicians, admitting staff, medical imaging staff, and the orthopaedic group. Themes that arose included funding, space requirements, and human resources. We located space adjacent to the emergency department and radiology department for the proposed satellite clinic. One of the human resource issues was how to staff the clinic for shifts that were of a brief duration (eg, 4 hours) without compromising staffing in the emergency department. One unanticipated challenge was determining where patients could be registered as an alternative to the ED waiting area. At the conclusion of the consultation process (5 months in duration), we obtained the fiscal, physical, and human resources required for the emergency satellite clinic. Subsequently, we convened a planning team consisting of the ED manager, educators, physicians, and staff members who were scheduled to work consistently in this area. The team met weekly or biweekly to assess progress and set new goals.
nurse during their initial visit and subsequently referred to the ED satellite clinic for follow-up. On weekdays, schedules are printed and sent to the ED patient care coordinator from the various departments (eg, medical imaging, cast clinic, and ED fast track) to ensure that the satellite clinic nurse and the physician know who will be returning on a given day. Patients are asked to report to the main admitting area (not the emergency department), where a designated admitting clerk registers them and sends them to the satellite clinic. On weekends and holidays, all follow-up patients report through ED admitting because the satellite clinic is closed. The outcomes of the project were related to patient, physician, and nurse experiences of care as well as length of stay. Information in the Figure describes the surge times and length of stay before and after the project commenced. When interpreting the illustration, “MP” is the follow-up clinic and “FT” is within the emergency department itself. Feedback with regard to patient satisfaction was collected for the purposes of quality assurance, via an informal questionnaire. Themes that arose are detailed in Table 2. Discussion
The clinic hours are 7:30 to 11:30 AM, Monday through Friday. The location is a small treatment room across the hall from both the emergency department and the radiology department. The space is also adjacent to the cast clinic, which is staffed by a cast technician. The follow-up clinic is staffed by an emergency registered nurse and an emergency physician. In terms of operations, all patients appropriate for the clinic are identified by a physician or
Over the last decade, a number of innovative strategies have been trialed in an attempt to address the issue of ED crowding. Of note, Bradley21 provided a lucid and comprehensive review of innovations to address ED overcrowding. These strategies may be divided into 3 main categories: reducing intake, increasing capacity, and streamlining process. Reducing intake through ambulance diversion or the practice of triaging away has been reported with varying degrees of success. However, reducing intake may carry substantial consequences. For example, Schull et al22 identified that prehospital delays are associated with ambulance diversion and that delays in transport that occur when ambulances are diverted may cause clinically important delays for critically ill patients. Focusing on patients who walk into the emergency department, Carret et al17 argued that an effective strategy for reducing ED crowding may be to redirect patients to appropriate services. The program described in this article represents a strategy aimed at reducing intake into the emergency department by streaming patients away from the primary location where overcrowding occurs. Increasing capacity, either directly or indirectly, has also been attempted. As a response to the issue of overcrowding, administrators have created satellite units to hold admitted patients, pending the availability of inpatient beds.23,24 Alternatively, administrators have created specialty units for large subgroups of patients such as those admitted for substance abuse, psychiatric issues, or cardiac observation.5,24
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TABLE 2
Patient and stakeholder satisfaction Patients
Physicians
Emergency nurses
FIGURE Snapshot of surge times and length of stay in emergency department (FT ) and in follow-up clinic (MP ). CTAS, Canadian Triage Acuity Scale; BH, Burnaby Hospital. (L. Lopez [“System analysis and performance improvement: ED chief complaints at Burnaby Hospital”], personal written communication, 2008.)
Others have argued that an overall increase in the systemwide capacity is required.18 Strategies aimed at streamlining process may be the most commonly reported interventions with regard to ED crowding. For example, Howell et al25 reported the use of hospitalists to reduce the delay between ED treatment and admission to an inpatient bed moving away from the traditional use of specialists as the primary referral point. Similarly, a Manitoba hospital is trialing a nurse practitioner–led clinic to treat patients with non-emergency injuries and illnesses.26 Tanabe et al27 reported on an innovation to improve patient flow by closing the waiting room and instead sending patients directly to a stretcher or chair inside the department. Additional examples include the use of rapid assessment areas for patients who have non-emergent health concerns, as well as the formation of programs to improve the use of existing resources from a provincial, national, and international perspective. One such initiative is BC (British Columbia) Bedline. BC Bedline collaborates with physicians and other health care professionals to facilitate the safe and timely transfer of acute and critically ill patients to the appropriate level of care, using an Internet-based provincial
512
Reduced length of stay Improved access to care Improved quality of care (perception of focused care) Decreased workload in emergency department with this patient population Decreased ED crowding Quality care Extra shifts Decreased workload in emergency department with this patient population Decreased ED crowding Quality care Extra shifts
bed registry Web site and a toll-free call center available 24 hours a day, 7 days a week. Miró et al28 suggested that focusing on the improvement of internal factors such as the layout of the work environment might be an effective strategy for streamlining patient flow through the emergency department. In addition, the application of “Lean” principles, as pioneered by the Toyota Motor Corporation (Aichi, Japan), has been attempted with some success. For example, Kulkarni29 reported that by applying Lean principles, one hospital managed to reduce the time between admission to an inpatient bed and transfer to a ward by 33%. Finally, there is also discussion in the health care literature about evidence-based practice and the need for practice algorithms to stratify patients by risk in order to assign the few remaining beds appropriately.5 The creation of an ED satellite clinic that allows patients returning for follow-up diagnostics or treatment to bypass the main emergency department is consistent with several aspects of the approaches described previously. We have increased capacity by removing returning patients from the pool of patients requiring care in the emergency department. We have streamlined the process by creating a separate registration area and a separately staffed treatment area. In addition, we have increased throughput, reducing the length of stay for returning patients. Next Steps
The opportunity to pilot this project arose out of a need to better manage space and workload during an ED renovation. We have shown measurable success in terms of length
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of stay and patient/provider satisfaction and have determined there to be absolute improvement in the care of the follow-up patients and improved timely access to care. Stakeholders agree that there is value in continuing with this program. In 2007 the British Columbia Ministry of Health created the Health Innovation Fund. The fund supports innovative proposals to promote and improve efficiencies in patient care. We applied for access to this fund, and our proposal was approved, providing the fiscal resources necessary to support this initiative. We have identified some key variables that we are addressing to ensure the continued success of this program. First, a larger space is required. We currently treat an average of 20 to 25 patients per 4-hour day in a space equivalent to a 2-bed patient room. With a larger space, we could expand on the good work that has begun. We have presented a business plan to secure a larger space that has been favorably received. Second, designated resources for this program are a consistent issue. With the exception of a reallocated registration clerk for a 4-hour period Monday through Friday, during the pilot period, this clinic operated without additional funding and has been staffed through reallocation of baseline ED nursing staff. The funding for an appropriately skilled staff member to work in this clinic has been approved. Third, we would like to pursue cross training unit clerks to perform secondary registration. As exampled in the Lean model, dual training will increase our efficiencies and will ensure that we can continue to divert patients not requiring acute care services away from the emergency department to be registered in a secondary location by a unit clerk who will also be able to assist in unit functions as time allows. Fourth, looking into the future, we would like ED physician coverage to increase to allow this clinic to expand service beyond follow-up patients, extending the population to include the “walking wounded” individuals presenting to the emergency department. This proposal has been received favorably. Patients initially presenting to the emergency department who would be deemed suitable for the clinic (as supported by guidelines and protocol) may be initially received by the triage nurse and diverted over to the satellite clinic for the completion of their registration. Limiting triage assessments to “rapid assessments” or “90-second triage” for the nonurgent patient and eliminating the succession of often inefficient steps will expedite the patient’s time to physician.30 Summary and Conclusions
Howard et al16 and others15,17 have described the myriad of compelling reasons for which individuals will continue
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to visit emergency departments. In the current context of overcrowding at the national level, such decisions to seek care will further exacerbate the issue of overcrowding. In this article we described the innovative use of a satellite clinic to divert patients returning to the emergency department for care on a scheduled basis. Addendum
At time of publication this initiative is now serving to care for all follow-up emergency patients with hours expanded to 7:30 a.m.-6:00 p.m. seven days a week. In addition, those triaged as a CTAS 4 or 5 are being streamed to this area to have their registration completed by a dual trained unit clerk. This initiative received the fiscal resources to secure a unit clerk/ registration clerk, a full scope licensed practical nurse and an emergency nurse. This team is supported by a designated Emergency Room Physician. In the 3 months this initiative has been expanded, Burnaby Hospital Emergency Department has recognized an overall decrease in length of stay meeting British Columbia Ministry of Health targets for all CTAS groups an average of 70% of the time. During this same period the ED volume as increased by 20%. Acknowledgment We thank Chris Windle, Director Health Services, and Holly KennedySymonds, Director of Burnaby Acute Programs and Projects, for their review and comments on drafts of this report.
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