Optimizing Emergency Department Utilization
Presented by Brenda Lee, R.N., M.S.N.
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TEAM MEMBERS
CS&E Session 13 Participants
-Joan Hall, Quality
-Don Hunt, CNO
-Dr. Gregory Johnson, Medical Director of ED
-ED Staff, Physicians, and Residents
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Background
• The mean # of patients LWBS is 12 per month (ADV 40)
• Patient Satisfaction scores for wait time and informed about
delays were two areas needing improvement
• Triage process variation between shifts
• Patient safety and risk concerns (urgent patients not
receiving care, EMTALA violations, and financial loss)
• Information regarding factors associated with patients,
physicians, and environment (acuity, length of stay, resource
utilization, long wait time, non-urgent patients with
improved condition, etc.) was not available
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What We Are Trying to
Accomplish?
PROJECT AIM STATEMENT
Reduce the number of patients who leave
without being seen (LWBS) in the Emergency
Department by 50% (approximately 6 patients)
per month.
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How Will We Know
That a Change is an Improvement?
• Reduced # of patients who leave without being
seen by a physician
• Accurate correlation of triage level to patient
wait and disposition
• Improved patient satisfaction for wait times and
delays
5
6
Time of Day LWBS
April 2009 – April 2010
45
Mean
Median
Mode
1627.4
1700
1700
40
35
30
25
21
20
15
14
22
20
13
13
13
13
13
Number of patients
11
10
6
6
5
0
0
0
0000
1
1
0700
0900
0
1000
1
1100
0
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
0
0
0
2300
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LWBS By Day of Week
April 2009 - April 2010
100.0%
95.8%
160
90.5%
140
90.0%
83.3%
80.0%
120
70.0%
Number of Patients
66.7%
60.0%
100
50.0%
49.4%
80
40.0%
60
51
30.4%
40
32
30.0%
29
20.0%
28
20
12
10.0%
9
7
Sunday
Saturday
0
0.0%
Monday
Wednesday
Tuesday
Friday
Day of Week
Thursday
8
Wait Time Prior to LWBS - ED
in Minutes
April 2009 - April 2010
126.0
121.0
116.0
107.0
106.0
103.0
97.0
Average Minutes
96.0
94.0
89.0
86.0
86.0
86.0
83.0
Average 84.5
Minutes
76.0
Average
66.0
65.0
58.0
56.0
46.0
36.0
APRIL
65.0
44.0
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
JAN
FEB
MAR
APRIL
10
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Interventions
• Create a paradigm shift for ED staff to optimize
throughput for all patients (not just emergent)
• Design a standardized sign in process
• Develop follow-up process for patients that LWBS to
identify associated patient characteristics
• Address patient expectations for wait time and
implement a process for communicating delays
• Analyze data related to physician and environmental
characteristics (triage, resource utilization, etc.)
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LEVELS OF TRIAGE ACUITY
JUNE AND JULY 2010
32% patients
admitted
69%
28.4%
1.8%
7 pm - 7 am
Non-Urgent
Urgent
Emergent
13% patients
admitted
66.2%
32.4%
1.1%
7 am - 7 pm
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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14
15
January 3, 2010 - August 28, 2010
8/22/10-8/28/10
8/15/10-8/21/10
8/8/10-8/14/10
8/1/10-8/7/10
7/25/10-7/31/10
7/18/10-7/24/10
7/11/10-7/17/10
7/4/10-7/10/10
6/27/10-7/3/10
6/20/10-6/26/10
6/13/10-6/19/10
6/6/10-6/12/10
5/30/10-6/5/10
5/23/10-5/29/10
Develop brochure explaining what to
expect while in the ED
Develop LWBS patient follow-up process
Improve patient communication regarding
delays
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5/16/10-5/22/10
5/9/10-5/15/10
6
Obtain accurate information regarding LWBS
patients (sign in process, charts)
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5/2/10-5/8/10
10
4/25/10-5/1/10
4/18/10-4/24/10
4/11/10-4/17/10
4/4/2010-4/10/10
3/28/10-4/3/10
3/21/10-3/27/10
3/14/10-3/20/10
3/4/10-3/13/10
2/28/10-3/6/10
2/21/10-2/27/10
2/14/10-2/20/10
2/7/10-2/13/10
1/31/10-2/6/10
1/24/10-1/30/10
1/17/10-1/23/10
1/10/10-1/16/10
1/3/10-1/9/10
Number of Patients
Results
Emergency Department Patients LWBS
Patients
4
Average
2
0
16
Average ED Visit cost
$450 per patient
X 157 patients =
*$70,650
*Annualized Potential Revenue for Patients that LWBS
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Conclusions/What’s Next
• Process change for admitting patients during the day shift
decreased ALOS for these patients however, mean wait time for
discharged patients did not demonstrate a significant decrease.
• Addressing expectation of wait times is instrumental in deterring
patients from leaving without being seen.
• Data validated the need for implementation of the ESI 5 level
triage system to standardize staff utilization of resources and
further increase efficiency of patient treatment; particularly for
potential admissions.
• Staff will plan the design and implementation of a parallel process
flow utilizing nurse initiated protocols while “keeping patients
vertical” and moving to decrease the length of stay for non-urgent
patients that are expected to only increase in the future.
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Questions?
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