Continuous Quality Improvement Reduces Length of Stay for Fast‐track Patients in an Emergency Department

Abstract

Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illnesshnjury in an ED.Methods: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of deiay. In Phase I, two solutions were implemented. In this Phase I1 of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase I1 intervention 48-hour periods and one post-Phase I1 intervention 48-hour period were analyzed.Results: Before the Phase I changes, the mean 2 SD LOS was 92 2 46 min. After the Phase I changes, the LOS was 67 2 31 min. After the Phase 11 changes, this was reduced to 57 2 34 min (p c 0.05). Conclusion:The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients. I Care of the so-called "nonurgent" patient remains controversial in the emergency medicine literature. While some would argue that these patients can be cared for outside the ED,'-3 others state that such patients require the "safety net" of the ED'-* to ensure receipt of timely and appropriate quality care.Quality has been defined as "meeting the customer's requirements."' To meet the customers' requirements, each institution must define the community it serves and, by extension, its customers. At St. Paul's Hospital in Vancouver, for example, a community stakeholders' meeting demonstrated that our customers included a large variety of ambulatory patients, many of whom have substance abuse and psychiatric problems. These ambulatory patients are often treated in the fast-track (FT) area of an ED. In general, FT patients present with nonurgent complaints, yet they cannot be triaged away from the ED. They often present during off-hours when no other service is available, and they may be unable or unwilling to go elsewhere in the daytime for alternative care. This population also includes a significant subset of potentially violent and often disruptive patients.While meeting the needs of such challenging patients, we cannot ignore the needs of other community members, including our pediatric population, the elderly, and the disabled. We sought to improve the quality of care to this diverse group of patients. Due to previous failures to meet this objective, our ED committed to a continuous quality improvement (CQI) process for redesign of our triage and FT areas. In a previous paper," we demonstrated how implementation of Phase I of the

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

“…However, the causes are interrelated and multifaceted and include increased medical complexity and acuity, increased overall patient volume, a lack of inpatient beds, shortages of physicians, nurses, and staff, delays in laboratory or radiology results, and limited space within the ED [20][21][22][23]. Besides the implementation of standing orders, numerous studies demonstrate that other changes in throughput, such as modifications to capacity, triage, laboratory testing, staffing, and registration, improve ED LOS [7,8,[24][25][26][27]. Along the same lines, the placement of a physician or midlevel provider at triage is an alternative strategy to triage standing orders [5,28].…”

The impact of computerized provider order entry on emergency department flow

“…[16][17][18][19][20] Such a process focuses on CTAS 4 and 5 patients, who otherwise are a very low priority and sometimes even overlooked. The LWBS proportion is primarily a measure of efficiency in the care of CTAS 4 and 5 patients.…”

“…Another possible concern is that patient satisfaction may have worsened as a result of HUGO. It has been shown that the LWBS proportion is an indicator of patient satisfaction [16][17][18][19] ; an increasing proportion of LWBS may be an early signal that a department may need to urgently address patient dissatisfaction before institutional reputation is permanently harmed.…”

A Continuous Quality Improvement Approach to IL‐372 Documentation Compliance in an Academic Emergency Department, and Its Impact on Dictation Costs, Billing Practices, and Average Patient Length of Stay

“…For example, Clawson and colleagues recently reported that, by providing emergency medical dispatchers with regular and objective performance feedback for a two-month period, their mean overall compliance score with dispatch protocols increased from 76% to 96%. 4 Other relevant ED CQI projects have been published, describing improvements in doorto-drug thrombolytic intervals, 5,6 EMS documentation, 7 patient length of stay and walkouts, 8,9 stat laboratory services, 10 radiograph callbacks, 11 and ED triage. 12 Our approach was to incorporate basic and time-proven CQI methodology into our initiative.…”