Patient Flow Efficiency
Techniques in the
Emergency Department
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
Goals of Trying to Maximize
Patient Flow Efficiency in the E.D.
Improve patient care
Improve patient satisfaction with
care
Lessen stress on E.D. staff
Limit financial costs to hospital
Allow more available staff time for
teaching
What Does Maximizing Patient
Flow in the E.D. Really Mean ?
Limiting as much as possible the
time intervals between each
sequential event that is necessary
for patient care
Maintaining quality, safety,
completeness, empathy, and
personal attention in patient care
Fundamental Principles Behind
Improving Patient Flow Efficiency
Anything that delays evaluation by the
emergency physician is detrimental
Everyone in the department must be
committed to & cooperative with
efficiency efforts
Provision of emergent care procedures
always takes precedence
Making events simultaneous rather than
sequential increases efficiency
Items for Everyone to Keep in
Mind to Enhance Efficiency
Starting patient care does not
depend on the paperwork being
ready
Maintaining efficiency and speed are
important even when the E.D. is not
busy, because this enables the E.D.
to better handle a sudden,
unexpected influx of patients
Nursing Triage : Background
Aspects Related to Efficiency
COBRA / EMTALA require that all
patients be medically evaluated prior
to being asked to register
Triage should take < 3 minutes
maximum per patient
Space & seating allowance
necessary for multiple simultaneous
presenting patients
What Exactly Constitutes Proper
Efficient Nursing Triage ?
Immediate "experienced eyeball"
assessment of the patient's
condition
"One line" chief complaint
Vital signs :
–Pulse
–BP
–Resp. rate
–Temp.
Current meds & allergies
Patient Disposition Options
for the Triage Nurse
Take patient immediately back to
emergency care area
Send patient to E.D. registration
Send patient to a "nonemergent"
care area
Send patient to X-ray or laboratory
prior to being sent into E.D.
–By preapproved written protocol based on
chief complaint
Time-Saving Techniques at
Registration
If others accompany the patient, have
them register the patient while triage
and initial E.D. care are started
If patient is preregistered in hospital
system, only record new or changed
info
Utilize bedside registration as much as
possible
Automatically obtain patient's recent
E.D. chart to accompany current chart
Standard Efficiency Criteria
for Initial Patient Care
For any potentially unstable patient,
nursing should go ahead with O2,
monitor, IV, blood draw, EKG, pulse
oximetry, & early M.D. notification
X-ray +/- resp. techs may need to be
notified & activated, but M.D. should
see patient prior to their actions
M.D. should be notified of priority of
multiple simultaneous patients
Patient Evaluation Efficiency
Techniques for Physicians
For several near-simultaneous patients :
–See 1 or 2 simple cases only requiring exam or
single x-ray first, then see a more complex or
involved patient, then recheck the x-ray results
for the simple cases while awaiting lab, etc. for
the complex case
–Hold paperwork completion till after all these
patients are seen
 Lengthy non-resuscitative procedures on patients who are
definitely going to be admitted anyway should not delay
evaluation & disposition of patients with simple or more
minor problems
Paperwork Efficiency
Techniques for E.D. Physicians
When a patient can be discharged,
fill out first the discharge orders &
instructions & get the nurses
working on the discharge ; then go
back & fill out the H&P
Preprint the discharge instructions
whenever possible
–Can be done during suturing, for instance
Additional Efficiency Techniques
for E.D. Physicians
Draw & send lab tests early if
needed
–Pelvic & secondary exams should be done
after lab is sent
–Hold split urine specimen + extra blood
tubes in case secondary tests prove
needed
Complete entire physical exam prior
to ordering X-rays so all films can be
done at once
Additional Efficiency Techniques
for E.D. Physicians (cont.)
Don't recite entire H&P over the
phone to consultant ; just tell him
what you need him to do
Verify specific times that labs were
sent to know when to check up on
them
Once a stable case is turned over to
a consultant, don't hover over the
patient
Suturing Efficiency Techniques
for E.D. Physicians
Have equipment obtained & set up
while you are doing the H&P
Don't X-ray the wound for foreign
bodies if you can explore it directly
adequately
Have staff obtain discharge meds &
instructions while suturing is being
done
Charting Efficiency Techniques
for E.D. Physicians
Dictate charts whenever free time is
available
–May split dictation (dictate initial H&P first ;
then later add addendum dictation once lab &
disposition are known)
Handwrite data prior to dictations as
needed to provide "memory jogs"
Leave charts in the locations where
they're supposed to be so time is not
wasted tracking them down
Interactive Efficiency
Techniques for E.D. Staff
Don't be rigid about job duty performance
–Helping someone else with their job may speed
things up a lot
–Extra attention should be directed to help the
person who is the most busy
Let E.D. staff know your patient care plans
so they can anticipate further actions
Have flexible room coverage assignments
Improving E.D. Patient Flow
Efficiency : Summary
All E.D. staff should take interest &
pride in efficient patient flow
Anticipation and cooperation are key
"Mapping out" of short term events
is helpful in planning
System should be geared to
minimizing time to initial M.D. exam,
& to making events simultaneous
rather than sequential