Ensuring Efficient ED Patient Flow – Front End & Back End
By Stephanie J. Baker, RN, CEN, MBA, Kirk Jensen, MD, MBA, FACEP, and Thom Mayer MD, FACEP, FAAP
It's a fact: The emergency department is the major point of entry for the largest number of patients arriving to your hospital. Plus, as the "front door" to the hospital, the ED not only drives flow, but it drives the patient's perception of flow.
To ensure efficient emergency department patient flow, begin to think of the ED as a system with inputs, throughputs, and outputs. The inputs are patients coming into the ED. The outputs are discharged patients (or those admitted to the hospital or transferred to another hospital.) And while it might seem that the best place to start testing changes is to focus on throughputs (e.g. wait times for lab and radiology), the biggest opportunities to affect patient flow are actually at the front end and back end of the ED.
Six Strategies to Improve Flow on the Front End
The front end is where the ED team has the most direct control and influence over patient flow, resources, and service. Begin by understanding the demand for ED services by hour of the day and day of the week and your corresponding capacity to deliver. After all, even though your patients didn't know they'd be visiting your ED today, you knew they'd be arriving, didn't you? You may not have known their names, but if you measure, analyze, and track trends, you can plan processes to accurately anticipate their needs.
Emergency department patient flow is like a rope: It works great when you pull, but pushing doesn't get you far. To improve flow, coordinated teamwork should "pull" patients through by anticipating where patients come from and go next, rather than attempting to "push" them through by looking for available beds or waiting for the admitting physician to see the patient and write orders.
Here are six more ways to improve front-end flow:
- Measure patient demand by hour, so you can match staffing and ancillary services to handle it.
- Manage triage effectively so there is no bottleneck. Remember, triage is a process, not a place. Its function is to evaluate and expedite—not to delay—patient care. (You'll also want to segment patients so that vertical patients stay vertical and moving. Remember, the most valuable member of the ED team in many emergency departments is the gurney or bed! Flow depends on optimizing bed turns.)
- Design and deploy a "fast track" approach to move easy-to-treat patients—who require few resources—through the system efficiently. (Fast track is a verb, not a noun.)
- Get the staffing and the team right. Let doctors do "doctor stuff" and nurses do "nurse stuff." If patients are waiting for physicians or nurses, streamline processes and ensure that members of your team are only doing tasks they are uniquely qualified to do.
- Establish a results waiting area. The goal: a visible space near triage and fast track where patients can wait for radiology and lab results without using ED beds. Make customer service a top priority here.
- Track patients and results. Use a good patient flow dashboard to monitor patient care in "real time" cycles so everyone on the team can see when, where, and why ED operations and services start backing up to react quickly.
Round Hourly in the Reception Area
Once you have implemented several of the above strategies to improve flow on the front end, you can focus on improving the waiting experience. When you round hourly on patients and families in the reception area, you will reduce the number of patients who leave without being seen (LWBS). Studies have shown that average LWBS rates in hospitals across Canada can be as high as 4 percent.[i] This represents a serious patient safety risk that can be readily reduced through hourly rounding practices. Goals for rounding in the reception area: Show care and concern for the patient. Keep them informed about delays. Reassess the patient's status. And improve patient satisfaction. Who rounds? While the triage nurse owns the process, EDs that Studer Group coaches use charge nurses, registration clerks, security, chaplains, case managers, ancillary staff, and even senior leaders to help round in the reception area. It's a team sport!
A final tip on rounding: Keep a 24-hour reception area rounding log. By asking staff to initial and comment (e.g. 1 pm: "25 people waiting"), the manager can review the log for trends, compliance with rounding, any need for real-time adjustments, and communicate effectively back to staff.
Improve Back-End Flow
If the boarding burden in your ED is a real but infrequent problem, a great deal can be accomplished with the critical flow concepts discussed above. However, if one-third to one-half of your ED beds are tied up with boarders on a regular basis, your flow efforts will, in our experience, be met with minimal and only temporary success.
In this case, your team's efforts will best be leveraged by attacking and solving the boarder issue first. Take these three steps:
- Define the magnitude of the problem. Collect data on ED length of stay for admitted patients and data on total ED boarding hours or other delays in the care of admitted patients.
- Flow chart the admission process. Gather a team of four to eight people who are intimately familiar with the admission process from your department (e.g. a physician, nurse, a ward clerk and admission personnel). Flow chart the process using markers and Post-Its and then agree on ways to simplify processes and reduce wasted steps or activities.
- Collect data on delays. Monitor data for a month or two. Then identify the top three reasons for admissions delays so you can take action. (One ED we worked with that did this kind of analysis learned that 80% of their delays were because nurses did not have admission orders or a clean bed…not because they were "too busy" to take an admission as ED personnel suspected!)
Other Considerations When Discharging Patients
To maximize patient flow on the back-end, aim for a goal of 15 minutes or less from discharge order to "out the door." The goal, of course, is to ensure that once the discharge order is written, staff can expedite the discharge quickly.
Here are some additional discharge practices that have proven effective in some EDs. However, it is necessary to assess process and resources to determine feasibility and maintain quality:
- Asking physicians to provide all discharge instructions to the patient, including a patient signature on all discharge papers at this "formal close." This saves time because the nurse does not need to reiterate instructions. (However, physicians must provide the patient chart to the nurse post-discharge to close out the visit.)
- Larger EDs (50,000 patient volume or greater) may use a discharge lounge or waiting area or use provider assisted discharges.
- Other large EDs assign a "discharge nurse" during peak times who focuses specifically on anticipating and expediting discharges.
Once a patient has been discharged from the ED, ask physicians and nurses to make a follow-up phone call within 72 hours using a standardized template for questions to ask. Post-visit phone calls improve clinical outcomes, increase patient satisfaction, and decrease costly and unnecessary return visits to the ED as well as avoidable re-admissions to the hospital. (In one study of 400 patients, almost one in five patients reported an adverse event post-discharge. Forty-eight percent of those events were preventable!)
The long-term best practice goal is to attempt to call 100 percent of eligible patients discharged to home, reaching 60 percent of patients within 72 hours after discharge. Organizations using this goal typically see initial results in 60 to 90 days with higher patient satisfaction, fewer re-admits due to increased understanding of discharge instructions, fewer patient complaints, and greater patient loyalty and market share. EDs begin to get results once they attain at least a 60 percent contact rate.
In conclusion, expediting flow is critical to improving the patient experience in your ED. Remember, the primary goals of ED patients are to see a physician quickly, get the right diagnosis/right treatment, and be kept informed about their plan of care (and what they are waiting on). Patients want to have a clear understanding of their diagnosis, how to treat it, and what to do when they leave. When you improve flow, you serve more patients with less effort, and you serve them better!
 Understanding Emergency Department Wait Times. Canadian Institute for Health Information. 2005