Innovation in the ED: IT & Engineering Can Improve Efficiency

Overcrowded emergency departments (EDs) are not an uncommon sight in hospitals. Patient volume has increased in EDs across the U.S., but staff sizes and physical spaces have mostly stayed the same, exacerbating the problem. Some EDs are looking to other departments, such as IT and engineering, to improve patient flow and reduce backlog.

In the early 2000s, Banner Health accounted for up to 40 percent of Phoenix-area ED admissions. As patient volume increased, so too did their wait times. Across eight local facilities, the average wait time had grown to nearly two hours and more than 7 percent of patients left without treatment (LWOT). At its busiest facility in Mesa, Ariz., the problem was even worse.

Like EDs across the U.S., Banner needed to learn how to increase capacity and improve patient safety while operating on a fixed budget. In 2002, the provider partnered with the engineering department at Arizona State University and began work on the “Door-to-Doc” (D2D) toolkit. Relying on systems engineering principles, the toolkit is designed to help a variety of EDs analyze processes for adapting to unique patient acuities and volumes, as well as facilitate the acceptance of organizational change.

Transforming triage

The D2D effort is “focused on getting the right resources to the right patient population and understanding what patients’ needs are as they come in,” according to Kevin Roche, PhD, director of process engineering at Banner Health. The toolkit, initially implemented in the Mesa medical center and then seven other Arizona facilities in 2006, helped ED providers redesign patient throughput by organizing patients into “less sick” and “sicker” groups based on preliminary assessments and treating them accordingly.

Patients entering an ED with a Banner facility that has adopted the D2D system can expect a quick intake rather than full triage to determine the acuity of their condition based on the emergency severity index. At that point, the ED experience does not change much for sicker patients. Rather than a typical waiting room, however, less sick patients are directed toward a treatment area, where the patient can undergo blood work, imaging or a physical exam for medical history. The idea is to keep them moving and upright, rather than putting them in a hospital bed for an earache, says Twila L. Burdick, MBA, VP of organizational performance at Banner.

Two years after implementation, average wait times across the eight facilities dropped by 58 percent from 117 minutes to 49 minutes, the LWOT rate dropped by 76 percent from 7.1 percent to 1.7 percent and average length of time spent in the ED dropped 76 percent from 310 to 268 minutes. Due to increased patient volume and the decreased LWOT rate, Banner EDs made progress despite seeing approximately 12,000 more patients. 

The toolkit’s role is to determine whether a two-track intake process is appropriate based on existing patient volume, whether there’s organizational support for change and where to allocate staff once implementation is undertaken. Developed for widespread use, the interactive spreadsheets and presentation slides comprising the toolkit offer clear instructions and perform calculations based on existing data.

Implementing the changes requires strong support from staff who have been trained to operate in a traditional ED setting. “Clearly, there was resistance,” says Burdick. “Providers haven’t learned this approach. The first step is getting champions on board early and getting them to advocate for the process.”

A Complete Overhaul

Collaboration among all of a hospital system’s disparate departments is key to making EDs more efficient, according to Mary Carroll Ford, MBA, vice president and CIO of Lakeland Regional Medical Center in Lakeland, Fla. Wait times at the Lakeland ED often exceeded eight hours and 3 percent of patients were leaving without treatment. Also, many patients were arriving for primary care services until the provider instituted a two-year performance improvement effort.

Computerizing the ED was one component of the improvement effort. In a complete overhaul, Lakeland adopted a new EHR system, began using computerized provider order entry for all its orders, installed a new wireless network, invested in mobile devices and implemented barcoding for positive patient identification. They also engineered a standardized workflow using simulation and modeling techniques to achieve the most efficient patient flow.

“We are now seeing 20,000 more patients per year using the same physical space, configured differently, and the same staff, working differently,” Ford says. Ambulances are no longer waiting to drop off patients, LWOT rate has fallen to less than 0.5 percent, 50 percent of patients arriving for primary care services are moved to a hospital-based primary care setting and 80 percent of patients are seen and either discharged or admitted in less than three hours after their arrival.

The process requires robust data to track patients from the ED door to a healthcare professional, and from treatment and to discharge. It also requires all departments to immediately complete and document tasks. For instance, the radiology department immediately performs and reads all imaging tests and the support staff immediately cleans patient rooms upon discharge to ensure efficient flow.
While implementing the changes was costly and labor intensive, Ford believes a return on investment will be realized through fewer visits from patients coming for primary care services and improved outcomes.

Healthcare administrators who are wondering how to improve the efficiency of their EDs may want to look to other industries, such as manufacturing, which have used IT tools like barcoding and engineering principles to improve their processes for a long time and healthcare may benefit from following suit. That doesn’t mean clinical staff don’t have a say and achieving their buy-in can be the most difficult part of implementing change, according to Roche. “Engineers can’t make the change, but we can bring some tools to the table and help the clinical team improve.”