Keeping Patients Vertical Improves ED Throughput


Emergency Departments (EDs) face continuing pressures.  More than one-in-four hospitals in non-rural settings have closed their EDs, as reported by in the May 18 edition of the Journal of the American Medical Association[i].  Those EDs that have remained open have experienced continued increases in patient service volumes.  With fewer primary care physicians accessible in communities, patients turn to the local EDs as their primary source for urgent care, which contributes to the influx of patients to the ED.  The economic downturn of the past few years has added to the increasing number of ED visits, as many of those who may have previously sought preventative or routine care from private physicians now wait until the needs become urgent or emergent before seeking care in their local ED. 


[i] Renee Y. Hsia, MD, Journal of the American Medical Association, JAMA. 2011;305(19):1978-1985.

Added to this mix are the accelerating demands for higher levels of patient outcomes and patient safety.  Industry literature is replete with articles documenting the focus of patients, regulators, and advocacy groups on the need for improved outcomes and safety.  Further, the final rule of the Centers for Medicare & Medicaid Services (CMS) Medicare Program; Hospital Inpatient Value-Based Purchasing Program (Hospital VBP program) with an effective date of July 1, 2011 includes specific clinical and patient experience performance measures of which some are related to ED.  For hospitals that adopt this program, and desire to be rewarded based on actual quality performance, it is imperative that hospital leadership embrace the opportunity to change processes to improve quality and patient experiences, inclusive of the ED experience.  Growing volumes and higher performance expectations come at a time when increasing proportions of hospital inpatients find the hospital ED as their primary entry point to the hospital.  Recent data show that an average of 62 percent of hospital inpatient admissions occur through the ED[i].  IMA Consulting has experienced some client settings in which that percentage is approaching 80 percent. 

The level of patient satisfaction varies with the length of time patients spends in the ED - the longer the time, the lower the satisfaction.  Further, the level of patient satisfaction varies by category of patients - those presenting for treatment of minor illnesses or injuries have higher expectations for expedited care than do those with truly more emergent or traumatic conditions.  

The confluence of these factors create the need for hospital leaders to examine the ways patients present for service and devise treatment processes to provide safe, effective care expeditiously. 


[i] Thomson Reuters ActionOI Emergency Department Comparison Detail Report, Hospitals with Between 201 and 300 Beds, 4th Quarter 2011
One critical element affecting the timeliness of care delivery in today's EDs is the mixture of patients seen.  Patients may range from those who present with minor illnesses or incidents to those requiring life-saving interventions.  These categories of patients demonstrate widely variant expectations for the care delivery model, timeliness of care, and patient disposition.  Absent a detailed understanding about how patients present forces EDs to consider this broad mix of patients homogeneously. 

A second critical element is designing ED care delivery models based upon gaining knowledge about the underlying manner in which patient visits arrive.  While EDs tend to follow a generalized distribution of arrivals, each ED demonstrates its own unique arrival pattern.  Hour of day and day of week variation in arrivals dictates the need for necessary variation in departmental resources - physicians, nurses, technicians, and support staff.  Absent an understanding of the arrival variation, the department is left to staff "for the average." 

The variation in physician practice patterns and nurse service times represents a third factor.  Widely variant practices (e.g., batching patients for disposition at the end of a shift versus initiating plans for disposition upon completion of triage or assessment) contributes to extended lengths of stay and uneven expectations. 

Patients continue to expect quality care at an ever-increasing pace.  Meeting these continually increasing expectations calls for ideas that challenge the existing care delivery model and mindset. 

Chief among those ideas that have contributed to more expedited care is treating fast track as a process or state-of-mind, rather than as a destination.  When introduced years ago, fast track provided a place where patients who required lesser interventions could go, receive care, and leave in relative short order.  As more such patients present to the ED, they expand beyond the allocated space and become bogged down in the routine processes of care delivery.  Designating such patients as fast track patients, regardless of room placement, places them in a different connotation.  Implementing work processes to support the care of the fast track patient, rather than providing care in the fast track section of the ED will expedite care and move patient through the system more quickly.   

While it is important to expedite the care of fast track patients, it is likewise critical to overall service delivery times to treat other patients quickly, as well.  An action EDs can take in support of moving patients more quickly is "keeping vertical patients vertical."  Many Level III patients present with less acute conditions that require differential testing before making a full disposition decision.  These less acute Level III patients tend to have expectations similar to those of fast track patients, even though their conditions may be more complicated.  ED staff must manage those expectations while treating them in a more timely manner.  Once a patient climbs onto an ED stretcher, everything changes.  The more patients that ED staff can keep off of stretchers, the greater the likelihood of moving those patients through the system more quickly.  Treating these patients as they would be treated in non-emergent, non-urgent settings will expedite the patient experience and enhance satisfaction for those seeking quick, effective care.  

Reducing unnecessary variation among provider practice patterns and nursing service times will make for a more predictable experience, as well.  The existing data on patient episodes provides the pathway for embarking on this journey.  Most current ED systems provide the data from which to map descriptive statistics that provide a portrait of provider practice patterns and nursing service times.  With these data, ED leaders can initiate meaningful dialogue about successful practices that need to be adopted across the department, and with other departments.  The key to this is assuring that those data are sufficiently granular to provide meaning. 

While the above addresses some of the manageable variation involved in ED, understanding another key source of variation will provide leaders with more knowledge.  Those at the leading edge of ED management are employing predictive analytics to uncover the underlying patterns about how ED volume occurs and what the ED may expect in the next 24 hours.  Using past arrival data to forecast future arrivals provides insights into expectations for the coming period.  Doing so allows ED leadership to manage resources and patient expectations more effectively.  Layering onto these data information about treatment and disposition, ED leaders can begin to manage the expectations of patients currently in the department to assist in shaping their satisfaction levels. 


ED leaders face continuing challenges in managing the multiple patient groups who use their services.  Through increasingly sophisticated data analytics and process-based interventions, leaders can institute improvements that enhance outcomes and expedite care.  
We are pleased to have the opportunity to provide this information to you.

If you have any comments or questions about this, please call IMA Consulting at (484) 840-1984.

Best Regards,

Bob Gift
IMA Consulting