Prolonged wait times at the emergency department (ED) are associated with increased morbidity and mortality, and decreased patient satisfaction. Reducing wait times at the ED is challenging. The objective of this study is to determine if the implementation of a series of interventions would help decrease the wait time to consultation (WTC) for patients at the ED within 6 months. Interventions include creation of a common board detailing work output, matching manpower to patient arrivals and adopting a team-based model of care. A retrospective analysis of the period from January 2015 to May 2016 was undertaken to define baseline duration for WTC. Rapid PDSA (Plan, Do, Study, Act) cycles were used to implement a series of interventions, and changes in wait time were tracked, with concurrent patient load, rostered manpower and number of admissions from ED. Results of the interventions were tracked from 1 October 2016 to 30 April 2017. There was improvement in WTC within 6 months of initiation of interventions. The improvements demonstrated appeared consistent and sustained. The average 95th centile WTC decreased by 38 min to 124 min, from the baseline duration of 162 min. The median WTC improved to 21 min, compared with a baseline timing of 24 min. The improvements occurred despite greater patient load of 4317 patients per month, compared with baseline monthly average of 4053 patients. There was no increase in admissions from ED and no change in the amount of ED manpower over the same period. We demonstrate how implementation of low-cost interventions, enabling transparency, equitable workload and use of a team-based care model can help to bring down wait times for patients. Quality improvement efforts were sustained by employing a data-driven approach, support from senior clinicians and providing constant feedback on outcomes.
Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. To improve the overall wait time to consultation, we have identified the need to reduce the wait time to triage for ED patients. We seek to determine if the implementation of a series of plan, do, study, act (PDSA) cycles would improve the wait time to triage within 1 year. The interventions related to the PDSA cycles include the refining of triage criteria, ‘eyeball’ triage by senior nurses to facilitate direct bedding of patients, formation of a triage nurse clinician role, and a needs analysis of required nursing manpower. The baseline period for this study was from January 2017 to April 2017, with the results following implementation of the respective PDSA cycles sequentially tracked from May 2017 to March 2019. There was an improvement in the wait time to triage from a baseline duration of 18 min to the postimplementation period duration of 13 min, with a 25% decrease in variance from 16 to 12 min. The improvements were sustained. Strategies to further reduce wait time to triage at the ED are discussed. We also highlight the importance of adequate triage manpower, data-driven decision making and continued engagement of stakeholders in enabling positive outcomes from this quality improvement effort.
Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage―a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor’s consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients’ average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.
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