How Fast Are We?
Throughput Times for Admissions From the Emergency Department
Brian Hom; Deborah Porter RN, NM; Kathleen Chambers RN, MSN,
CPN; Laura Gaertner RN, BSN
Background
• Overcrowding and slow patient throughput is a major problem
in hospitals throughput the U.S.
• There is a dramatic rise in E.D. wait times and diversions in the
U.S.
• Over the past two decades, the number of emergency rooms
have decreased while the number of patient visits have
increased by 35 percent.
• Capacity issues usually arise in areas of the hospital where
demand fluctuates i.e. Emergency Room
• In 2008, the Center of Disease Control reported the average
time that patients wait to see a doctor in hospital ERs grew from
38 min. to 1 hr. between 1996 and 2006.
• Emergency department visits in the U.S. increased from 90
million to 119 million from 1996 to 2006.
Effects
• Overcrowding and slow patient throughput
compromises patient safety, reduces hospital
revenues, and affects staff and patient satisfaction.
• The quality of patient care is jeopardized because
the amount of patients outweighs the availability of
resources.
• The level of stress for the staff increases
• Prolonged pain and suffering by patients
• Long patient wait times
• Increased transport times for ambulance patients
• Inconvenience and dissatisfaction for patients and
their families
Indicators of Overcrowding
• The number of hours a hospital is on
diversion status
• The number and length of time patients are
on hold in the emergency room after being
admitted
• The proportion of patients that leave the
emergency room before having a medical
evaluation since they are tired of waiting
Hypothesis
If data is collected about the average time
taken between key steps in the patient
throughput process (arrival, disposition, bed
ready, report, and transfer) in the adult
emergency room, then a baseline will be
developed that can lead to future research
on possible improvements to the patient
throughput process and the staff can focus
on improving the specific areas that may
slow down patient throughput down.
Methodology
• Retrospective study conducted on the throughput times for
normal adult admissions (no cardiac arrest or stroke) in the
emergency department of Fairview Hospital.
• The charts of over 300 patients were examined using EPIC
• Ten charts were taken each day from June 12, 2011 to July 4,
2011
• The patients were chosen randomly based on when they were
admitted
• Day shift: 7 am to 3 pm
• Evening shift: 3 pm to 11 pm
• Night shift: 11pm to 7 am
• The arrival time, disposition time, assignment/ bed ready time,
report time, and the time the patient went up to the floor were
recorded
• The amount of time in minutes was determined for each of the
key points in the throughput process
• The average time was determined for each checkpoint for each
shift in each day
• Staff from various departments were asked about their opinions
as to what slows down patient throughput
Data
400
Disposition to Bed Ready (figure 1)
350
250
200
150
100
50
Day
7/
4
7/
2
6/
30
6/
28
6/
26
6/
24
6/
22
6/
20
6/
18
6/
16
6/
14
0
6/
12
Minutes
300
Data
Average Time from Disposition to Bed Ready (figure 2)
300
250
150
Day
100
Evening
Night
50
Day
7/
4
7/
2
6/
30
6/
28
6/
26
6/
24
6/
22
6/
20
6/
18
6/
16
6/
14
0
6/
12
Minutes
200
Data
Average Time from Bed Ready to Report (figure 3)
160
140
120
Day
80
Evening
60
Night
40
20
Day
7/
4
7/
2
6/
30
6/
28
6/
26
6/
24
6/
22
6/
20
6/
18
6/
16
6/
14
0
6/
12
Minutes
100
Day
150
7/4
7/3
7/2
7/1
6/30
6/29
6/28
6/27
6/26
6/25
6/24
6/23
6/22
6/21
6/20
6/19
6/18
6/17
6/16
6/15
6/14
6/13
6/12
Minutes
Data
Average Time from Report to Time Went Up (figure 4)
350
300
250
200
Day
Evening
Night
100
50
0
Data
900
800
700
600
500
400
300
200
100
0
Day
Evening
Day
7/
4
Night
6/
12
6/
14
6/
16
6/
18
6/
20
6/
22
6/
24
6/
26
6/
28
6/
30
7/
2
Minutes
Average Time from Arrival to Time Went Up
(figure 5)
Results
• The data can act as a starting point for further research
regarding patient throughput
• All the steps of the throughput process affect the times but no
one step is responsible
• The throughput times for the evening are often longer due to a
greater influx of patients in the evening
• According to the data, the time between when the patient
arrives in the emergency department and when they are
admitted to the hospital is typically the longest
Factors That Affect Throughput
• Each department has their own factors that may contribute to
overcrowding and slow patient throughput
• According to a 2003 report on ED overcrowding by the US
General Accounting Office: “the factor most commonly
associated with crowding was the inability to
transfer emergency patients to inpatient beds
once a decision had been made to admit them as
hospital patients rather than to treat and release
them”
• These patients are known as boarding patients-they still require
care and take up space, equipment, and staff time so other
emergency patients cannot be treated
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Co-pay is collected from patients after they are ready to be discharged
The IV contrast fluid that is required for certain tests takes hours to circulate the
body
Not enough staff on duty
Beds are not cleaned in a timely manner for the next patient
Limited number of beds that have telemetry
Discharge of inpatient beds not occurring in timely fashion
ER holding admissions until later due to other priorities
Immense paperwork requires time to fill out completely
Charting slows nurses down
Doctor does not make rounds in a timely manner
Ride is late to pick up patient
Explaining what medication to take and how to take it for inpatients
ED patients tend to be older and have more complex conditions- requires more
tests
Takes time to receive results from tests
Standard for admittance is changing
ED patients compete for available beds with scheduled admissions (ex. Surgery
Patients) See next slide.
Suggestions to Improve Throughput
• Actions to address the throughput usually involve increasing
capacity or efficiency
• Build larger ED
• Focus on increasing speed of registration and triage
• Improve efficiency outside of ED
• Encourage staff to discharge patients by noon
• Set up a “dock and triage” system where a physician is
stationed in the triage and admits only the patients that need it
while quickly treating those with less severe conditions
• Assign an area specifically for inpatients beds ready to be
discharged because patients who are ready to be discharged
often wait for hours just for their doctors to make their rounds.
This occupies inpatient beds that need to be used.
Recommendations
• In future studies, test several ideas on throughput
improvement and see if they improve efficiency
• Use a larger data set to obtain more accurate results
• Make comparisons to other area hospitals
Conclusion
• The purpose of this study is to develop a base that can be used
for further research in the improvement of patient throughput
• Improving patient throughput or flow will improve patient care
and satisfaction
• This data will help the hospital and staff gain insight as to what
can be done to improve patient throughput
• Many factors that affect patient throughput are out of the
hospital and staff’s control (i.e. IV contrast fluid requires several
hours before certain tests can be done)
• Improving patient throughput is important because it directly
affects patient care, hospital revenues, and overall satisfaction
of the patients and staff
• A hospital functions as one team and all the departments need
to work together in order to resolve the patient throughput issue
Works Cited
“Emergency Department Crowding-Patient Flow/Throughput.”
Emergency Nurses Association. N.p., 2011. Web. 22 June 2011.
<http://www.ena.org/IQSIP/ENAStrategicPriorities/CrowdingPatient%20Flow/Pages/Default.aspx>.
Handel, Daniel A, MD, et al. “Emergency Department Throughput,
Crowding, amd Financial Outcomes For Hospitals .” Wiley Online
Library. N.p., 2011. Web. 19 July 2011.
<http://onlinelibrary.wiley.com/doi/10.1111/j.15532712.2010.00814.x/full>.
Joelving, Frederick. “ER crowding tied to higher death rates.” Reuters.
N.p., 13 June 2011. Web. 28 June 2011.
<http://www.reuters.com/article/2011/06/13/us-er-crowdingidUSTRE75C0Q220110613>.
“Patient Throughput.” Hospitals in Pursuit of Excellence. N.p., 2010. Web.
22 June 2011. <http://www.hpoe.org/topic-areas/patientthroughput.shtml>.
Smith, Ben. “Hospital Overcrowding.” Cartoon. CAMfitti carTOONS. N.p.,
2011. Web. 21 July 2011. <http://camffiti.blogspot.com/2010/02/willthis-solve-hospital-overcrowding.html>.
Thank You!
Mentors: Deborah Porter RN, NM; Kathleen Chambers
RN, MSN, CPN; Laura Gaertner RN, BSN
Fairview Hospital and the Emergency Department
Office of Civic Education Initiatives Summer Internship
Program