Established and Novel Initiatives to Reduce Crowding in Emergency Departments

Liu, Shan Woo; Hamedani, Azita G.; Brown, David F.M.; Asplin, Brent R.; Camargo, Carlos A.

doi:10.5811/westjem.2012.11.12171

Cited by 40 publications

(23 citation statements)

References 19 publications

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“…Consistent with previous studies, 12 a measurable impact on some of the desired throughput measures was observed by using a combination of initiatives designed to improve ED patient flow. The results of this study illustrate that FCA implementation correlated with a reduction in multiple throughput metrics, particularly for ESI level 3 and 4 patients, as well as a decreased LWBS rate.…”

Section: Resultssupporting

confidence: 85%

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The Impact of a Flexible Care Area on Throughput Measures in an Academic Emergency Department

McGrath

LeGare

Hermanson

et al. 2015

Journal of Emergency Nursing

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Introduction Crowding in emergency departments is a multifaceted problem. We hypothesized that implementing an on-call “Flexible Care Area” (FCA), utilizing multiple front-end throughput solutions, would reduce emergency department (ED) length of stay (LOS). Methods This retrospective study evaluates the impact of an FCA on ED throughput at one hospital over a two-year period (2011–2012). The average arrival-to-room time, arrival-to-physician time, LOS, number of inpatient admissions, and number of discharges during FCA hours were collected, comparing days with and without FCA functionality. Results The FCA was open 165 days in 2011 and 252 days in 2012. The mean daily ED census as well as number of ED visits and inpatient admissions during FCA hours were higher on days with FCA functionality than without. Total ED LOS was shorter for Emergency Severity Index (ESI) 3 patients on days with FCA than days without it in 2011, but this finding was not repeated in 2012. ESI 4 patients had shorter LOS on FCA days in both years. The arrival-to-room and arrival-to-physician times showed variable improvement for ESI 3 and 4 patients over the study period. There was no statistically significant difference for these measures when evaluating ESI levels 2 and 5. Discussion Implementing upfront throughput solutions through use of the FCA correlated with reduced ED LOS for all ESI 3–4 patients, not just those who were seen in FCA.

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Section: Resultssupporting

confidence: 85%

“…Utilizing the vertical patient model, particularly through a fast track area, has been implemented at many of the United States academic medical centers surveyed in a recent study. 12 Inherent to utilizing this model is the need to define which patients would qualify for such an approach.…”

Section: Introductionmentioning

confidence: 99%

The Impact of a Flexible Care Area on Throughput Measures in an Academic Emergency Department

McGrath

LeGare

Hermanson

et al. 2015

Journal of Emergency Nursing

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“…Level 5 patients also had an improvement, although the number was too small to be statistically significant. This study adds evidence to the effectiveness of “vertical patient flow” models described in a recent survey of ED medical directors by Liu et al., which found that 29% had adopted these in response to the American College of Emergency Physicians Task Force on Boarding.…”

Section: Discussionmentioning

confidence: 53%

Decreasing Length of Stay in the Emergency Department With a Split Emergency Severity Index 3 Patient Flow Model

et al. 2013

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Objectives: There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients.Methods: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe.Results: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7. 2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%).

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“…This practice is usually not the case in the main section of our ED, where as is common in many EDs, patients usually occupy rooms for their entire stays. While the concept of keeping patients “vertical” during their stays in the ED has been described in the ED design literature, midtrack and physician in triage with an internal waiting area are two interventions that leverage this idea to improve the utilization of ED beds and improve patient flow . Recognizing that the availability of ED beds is a key bottleneck, especially in EDs with high inpatient boarding rates and limited space to expand, redesigning EDs such that patients use ED bays only when clinically appropriate will be critical to maximizing patient flow in crowded EDs, as we demonstrate with our midtrack intervention.…”

Section: Discussionmentioning

confidence: 80%