The hospital emergency department (ED) has long been considered one of the primary “gateways” for patients entering hospitals and health care systems, yet many struggle to keep pace with increasing patient demand for emergency services. More than ever, emergency rooms are struggling with inadequate room capacity, unacceptably long patient wait times, and generally poor patient throughput. These problems will only be exacerbated by community populations that are projected to grow in size and will require more acute care interventions with shrinking reimbursement.

To assure the highest standard of patient care while promoting overall hospital functionality, it is imperative that the emergency room operate smoothly and keep pace with demand. There are three primary phases of a “typical” ED patient visit. These three phases include:

1. Pre-diagnostic phase: The time from when the patient crosses the doorway into the ED until they are seen by a nurse or physician in an exam room.
2. Diagnostic phase: The period during which the patient is receiving treatment for his/her complaint, along with diagnostic labs, tests, or imaging to determine the cause of the patient’s complaint.
3. Disposition phase: The time required for the clinician to make a diagnosis and develop the appropriate treatment plan based on the information gleaned from any and all diagnostic procedures performed.

This article will discuss all three of these major ED visit phases providing commentary on the latest trends in ED operating programs and efficiency protocols. In facility planning, it is imperative facilities be built around efficient and contemporary operating protocols.

Only after an ED is running efficiently should expansion or renovation of the physical plant be considered. Thus, the last portion of this article will provide commentary on when your ED should look to renovate or expand your facility and the design principles that will help your organization maintain and improve quality of care while speeding patient throughput.

National trends are increasing ED demand

The root cause of many capacity issues impacting EDs today is often simply an issue of supply versus demand. In response to declining reimbursement and a trend towards consolidation, the total number of EDs across the country has been on the decline.

• ED closures have outpaced hospital closures 21 percent to 11 percent (percent decline in number of facilities), according to the American Hospital Association's "2005 AHA Hospital Statistics."
• Although the total quantity of EDs has declined, the overall number of exam rooms has remained stable as existing EDs have expanded to handle ever-growing demand.
• Growth in average annual visits per ED reflects the aforementioned growth in volume as visits per ED grew approximately 45 percent to 22,690 in 2003, according to the AHA 2004 Survey of Hospital Leaders.

The decline in the overall number of EDs has been accompanied with an unprecedented growth in ED utilization and volume.

• The overall number and percent of uninsured is back on the rise, growing to over 16 percent in 2003 from a five-year low of 14 percent in 2000. The ED serves as the “last line of defense” for this population, and as their numbers increase, so will demand for ED services, according to the AHA 2004 survey.
• National ED utilization rates per 1,000 population reached a ten-year low of 350.0 in 1994, but have grown substantially to 381.9 in 2003, according to the Advisory Board Clinical Initiatives Center (ABCIC). As the population continues to age and require more acute health care services, the ED utilization rate per 1,000 is expected to exceed 400.0 in the near future.
• Overall ED visit volume has increased 30 percent since 1988 to 110 million visits in 2003, according to the AHA 2004 survey.

Fewer EDs combined with greater patient volumes results in inevitable bottlenecks, patient flow difficulties, and ultimately diversions during peak demand periods. According to the AHA 2004 survey,

• Most EDs report they are either “at” or “over” their existing capacity.
• Most urban and teaching hospitals report their EDs have been on diversion at some point in the last 12 months.
• The No. 1 reason quoted for ED diversion is the lack of critical care beds.
• The lack of appropriate staffing during peak periods is also a major contributor to ED bottlenecks.

Bottlenecks and poor patient throughput in the ED translate to long wait times for patients. In fact, according to the National Healthcare Advisory Board, waiting compromises approximately 80 percent of a typical ED patient visit. Not surprisingly, the longer the patient’s average visit length in the ED is, the lower their satisfaction scores.

EDs represent a significant “touch point” to the community in which they serve. In fact, inpatient admissions from the ED typically represent 45-60 percent of total hospital admissions. Thus, it is crucial from both a volume and patient satisfaction standpoint that a hospital maintains efficient flow and acceptable ED wait times during peak periods.

Framing your emergency department

Before diving directly into operational improvement initiatives, it is important ED administrators effectively “frame their ED.” Effective framing involves gaining a firm understanding of the market/community in which you provide ED services. Typically, framing involves the following key steps:

1. Define the market in which you provide ED services based on patient origin information. Define primary and secondary service areas by county or ZIP code. Also, understand “immigration” trends regarding patients that seek services from outside your primary and secondary service area.
   
   
   
2. Define current and historical ED market share by comparing your ED volumes to those of other EDs in your service area, if available. If you do not have access to the ED volumes of your major competitors, market share can still be estimated using local and national ED utilization trends.
   
   
   
3. Begin tracking key utilization characteristics that will aid you in better understanding your ED’s current operational strengths and weaknesses. Some key operating statistics that should be tracked include:
   • Overall ED and Urgent Care volumes
   • Time of patient entry
   • Reason for visit
   • Presenting level of acuity
   • Length of stay
   • Disposition
   • Those patients with three or more annual visits

   Once these and other operational statistics are accurately tracked, a statistically valid pool of data can be gathered. Proper analysis can then begin on the existing operational state of your ED. This analysis includes defining the existing average time period between key patient visit “milestones.” For example, the average time between a patient’s arrival in the ED to exam room placement is a key driver of patient satisfaction. Knowing how long your patients wait before entering an exam room (on average and during peak periods) is a critical data point that can be compared to local and national averages.
   
   The table below lists some key milestones in the pre-diagnostic phase of the typical ED visit. The table also lists the average, goal, and “best practice” times (in minutes) to use as benchmarks in assessing your existing state.
   
   
   
   Of course, this table is not comprehensive; it focuses on just a few discrete steps of the pre-diagnostic phase, but it provides enough flavor to understand the basic thought process. By tracking key milestone times throughout the entire patient encounter you can compare yourself to local and national benchmarks for the pre-diagnostic phase, the diagnostic phase, and the disposition phase.
   
   

4. Perform a detailed age and gender analysis for the counties or ZIP codes you have defined as your primary and secondary service areas. Understand not only historical population trends but also examine future estimated trends as determined by national census or local government services. Compare your service area population age distributions to local and national averages. Gaining a firm understanding of the various trends in age cohorts will help you better prepare for the types of ED services your patients will seek. As the table below shows, the younger your service area population, the more your ED will treat visits related to accidents and bodily injuries. In contrast, the older your service area population, the more your ED will treat visits related to pain issues and chronic disease.
   
   
   
   
   
5. Ensure appropriate physical inpatient bed capacity and streamline the inpatient admission process to improve the flow of your ED. The ED cannot operate “on an island” independent from other hospital departments. As stated previously, the ED is inextricably tied to hospital inpatient units. The ED relies on hospital inpatient units (in particular, critical care units) to successfully “off-load” patients in order to free up ED exam room availability. When inpatient beds become unavailable or the time required to admit a patient into a bed becomes excessive, bottlenecks result in the ED. Admitted patients who are “boarded” in the ED not only take up valuable ED space and resources, but may also be subjected to a standard of care that is lower than they require (especially for more critical patients).
   
   
   
6. Understand your current staffing patterns to ensure appropriate flow. While it makes sense to “flex” ED staffing up and down with peak and down periods, the actual mix of staff (by type) varies greatly from one ED to the next depending on staff availability and operating/treatment protocols. Comparing your existing staffing patterns to local and national ratios can help you better maximize your staffing mix.
   
   
   
7. Establish an existing baseline patient satisfaction score. This step is essential to understanding existing sources of dissatisfaction and set a backdrop for future improvement goals. Low scores indicate to administration, physicians, and staff that a problem exists that needs resolution. Improvement in satisfaction scores serve as indicators of success and create incentive to continue improvement for physicians and staff. Improved patient satisfaction also improves word-of-mouth marketing by patients which results in improved volumes and market share. It is critical that EDs do not act like they are a monopoly because patients will revolt and go elsewhere.

“Best practice” operational recommendations

In order to achieve better patient flow, it is necessary to reduce average patient time in as many of the major visit phases as possible. Given the great variability in size and operational efficiency of EDs relative to each other, there are few protocols or recommendations that can be applied universally in all ED settings.

On one extreme, there are some EDs that flow efficiently and meet or exceed the best-of-practice time benchmarks for virtually all major milestones. For these highly functional EDs, there still may be room for improvement; however, these departments will likely have implemented many of the most contemporary and effective operating protocols. In addition, they likely operate in a facility that enhances these efficient operations.

On the other extreme are those EDs whose volumes have not been historically high enough to negatively impact flow. These EDs may have experienced significant volume growth in recent years and are now “feeling the pinch” during high-volume peak periods. These EDs may still have significant operational “low-hanging fruit” that can easily be “picked” to enhance performance and flow. In addition, these EDs may also operate in facilities that are undersized relative to their existing volume or designed in a manner that limits their operational productivity.

Wherever your ED lies on this continuum, the following high-level recommendations may provide you with some insight on contemporary operating protocols that can be used to speed patient flow.  (The following recommendations should be considered representative only and do not constitute the full spectrum of contemporary operating protocols.)

As stated previously, the initial wait to see a clinician is the single biggest driver of patient satisfaction, according to the ABCIC. Once the patient has passed the initial waiting room phase of their visit, it has been proven they are more tolerant of wait-times. Thus it is imperative that EDs do whatever they can to minimize that up-front waiting period. The following recommendations strive to achieve that goal.

Action: Implement a “nurse first” model that establishes a nurse as the first point of contact performing triage instead of a receptionist or greeter.

Rationale:

• EMTALA vulnerabilities are reduced
• Serious illnesses likely to be identified earlier in process
• Patient is more likely to be satisfied having seen a clinician and less likely to leave without being seen
• Triage interventions and guideline protocols can be initiated
• Having a nurse as the first contact works well with other best practice methodologies as they have the clinical knowledge to implement many of the more clinically complex triage protocols

Action: Develop a triage “short” form.

Rationale:

• Traditional triage methods are inefficient
• The majority of information gathered by triage nurses are unnecessary for prioritizing purposes and the process is often duplicated by the ER nurse once the patient is in an exam room. (ABCIC)
• The triage process can be sped through the development and utilization of a triage short form
• Explicitly limit triage assessments to essentials pertaining to chief complaint
• Emphasize a few, focused questions
• Avoid collecting complete patient histories and vital signs
• Should be used on ambulance patients as well to ensure beds are used as appropriately as possible and reduce “gaming” the system

Action: Move the registration process to the bedside.

Rationale:

• Patient is moved to bed quicker
• Patient satisfaction is improved as they view the ED as being more concerned about their immediate clinical needs as opposed to administrative tasks, (ABCIC)
• Requires some information technology upgrades
• Computers in ED bays, wireless laptops, or computers on carts

Action: Improve front-house and back-house communication.

Rationale:

• Triage nurse(s) located at the “front” of the ED must be knowledgeable about availability of exam rooms in the main ED to enable immediate patient placement when a room becomes available. Implementing one of the following devices would improve front- and back-house communication:
• Placing a camera over the white boards allows the triage nurse to view room availability
• Install room “ready” lights near the door of each room to signal triage that room is open
• ED tracking system (ED information system -- from "Solving Emergency Department Overcrowding," 2004, by Bud Pate and Pete Derenda)

Action: Avoid ED bed “classifications.” Some EDs are designed with small modules based on a particular specialty (i.e., pediatrics, cardiac); these treatment room classifications should be avoided.

Rationale:

• Expensive to staff as nurse-to-patient ratios are frequently higher than necessary
• Cross coverage is difficult
• Rare that the average “planned” number of patients is ever in the department
• Best to keep ED rooms as universal as possible to maximize flexibility and flow

Action: Dedicate a nurse for all communication responsibilities.

Rationale:

• Telephone and administrative communication responsibilities in the ED can be intense and frequent
• Dedicating a nurse to handle the majority of telephone communications frees the other nurses to be focused on patient care and improving throughput, (ABCIC)
• Fielding requests from primary care providers
• Placing outgoing status updates to primary care providers
• Handles preauthorization requests to payers

Action: Ensure appropriate resources, medications, and equipment are always at hand for clinicians.

Rationale:

• The ED must work with materials management and the pharmacy to establish “Par” levels for medications and supplies so operations do not slow down due to running out of resources
• Automated pharmaceutical and supply machines (Pyxis) are becoming common in EDs

Action: Develop pre-printed orders for high-volume or high-risk orders.

Rationale:

• ED physician is reminded of commonly agreed upon diagnostic studies and interventions for various situations (i.e., cardiac)
• Less potential of misunderstanding physician orders which leads to fewer questions to the physician and less errors
• Physician spends less time writing/ordering and more time with patients

Action: Establish emergency department physician profiling.

Rationale:

• Physician profiling is a report that details personal efficiency as compared to other ED physician peers
• A typical ED physician profile compares responsiveness measures such as:
  • Initial time to patient
  • Length of time with patient
  • Overall LOS
• The ED physicians receive reports and the reports are also posted in staff areas
• Physician peer-to-peer relationships and knowledge of performance will help improve physician productivity

Other potential diagnostic phase action items:

• Reduce quantity of unnecessary imaging orders and lab tests
• Reduce overall turn around time to receive results from lab or imaging
• Dedicated staffing for phlebotomy or imaging (if volumes dictate)
• Add-sub-waiting areas for patients awaiting results of diagnostics to keep rooms turning over
• Re-engineer hospital admission protocols

Action: Remove the inpatient nurse from the inpatient bed status “availability” equation.

Rationale:

• The typical admission and transfer process from the ED to the inpatient unit is often complex with a heavy communication burden
• Bed control typically plays the “middleman” between the ED and inpatient unit. The ED and bed control typically relies on information from the inpatient nurses to determine bed availability. Inpatient nurses have no incentive to take on additional patients, however, (ABCIC)
• Alternatively, bed control could rely on housekeeping and transport staff to communicate when a bed is ready and available for admission
• An automated bed tracking system could be implemented that automatically pages the appropriate staff for the next step in the bed placement process

Action: Allow hospitalists to admit ED patients.

Rationale:

• To ensure continuity of care, many hospitals require an attending physician to write the admitting order for the patient which causes significant bottlenecks due to the time required for a physician to respond to the ED and the time required for the admitting orders, (ABCIC)
• Alternatively, a hospitalist could take on the responsibility of admitting patients from the ED. This would reduce the time needed to track down the community physician and subsequently awaiting their response. Instead, the hospitalist is paged by the ED when admission is required for rapid evaluation and order writing

Action: Develop an early admission unit or observation unit.

Rationale:

• Observation units are used to rule in/rule out diagnosis in lieu of transferring patients to an inpatient unit
• Continuity of care is better because the patient often remains the responsibility of the physician that first admitted him/her into the unit. In addition, nursing staff is often more experienced in caring for observation patients and can better meet their unique needs.
• Observation units generally are a more appropriate use of resources for 4-23 hour stay patients as compared to an inpatient setting

Action: Develop pre-printed discharge instructions.

Rationale:

• Saves time required to write up discharge instructions for high-volume complaints
• It is important to ensure physicians have reviewed and approved the use of the discharge instructions before implemented
• Ensure they are available in languages spoken by your patients if you serve a diverse community

Action: Develop a discharge area.

Rationale:

• Dedicated area for use by patients who are ready to go home but still need instruction, require a last-minute nurse check, or need a place to wait to be picked up
• Frees up exam rooms and/or inpatient beds sooner to facilitate turn-over
• Possible to assign a single nurse to coordinate/provide discharge instructions for all discharged ED patients

ED facility planning

The last topic this article will discuss is ED physical facility planning and development. The reason this topic is last in this article is because facility/construction solutions are typically the most expensive and are thus deemed “the solutions of last resort.” A typical knee-jerk reaction for an ED that is experiencing bottlenecks in flow is to say, “We do not have enough exam rooms.” Rarely do EDs think of improving operations first before expanding capacity.

In reality, fixing operations should be the first priority before any facility solution is explored. This is simply because efficient operations should drive facility design. If a facility is built upon operations that are inefficient, then the facility itself will be designed inefficiently. Thus, it is imperative that EDs look to streamline their operations before any facility solution is even considered.

There comes a point when, no matter how efficient or “lean” your operation, the existing facility cannot handle the patient and required staff volume during peak periods. At this point it is time to explore adding new facilities to increase treatment capacity. There are several options for growth that range from internal renovation all the way to complete replacement in a new facility. Which option will best suit your ED will depend on a variety of different factors including space and site availability, patient accessibility, and of course, capital cost.

Contrary to popular belief, there is no “cookie cutter” ED design deemed the most efficient. Every ED should be designed based on that organization’s unique operating protocols and preferences. However, every ED should have embedded in its design certain planning principles or “goals” that have been consistently proven to improve both staff efficiency and quality of outcomes. Some of these planning principles include:

• Customer-focused care (patient satisfaction is priority #1)
• Operational flexibility (facility has the flexibility to adapt to new treatment protocols)
• “Consolidate and collapse at periods of low use” (maximize staffing and resource efficiency)
• Maximal lines of sight (better nurse to patient site equals better care)
• Minimal walking distances (the less clinical staff must physically travel, the less fatigued they become and the better care that can be provided)
• Minimal patient movement (reduce distance from parking areas to entrances, simplify route-finding and reduce confusion)
• Separation of traffics (public from patient and staff)
• Multi-shared spaces (to optimize resource utilization)
• Structural flexibility (to allow for future growth)
• Security (ensure the ED is safe at all times for patients and staff)

The above principles are certainly not exhaustive, but they do represent a solid core of planning principles that can serve as a strong foundation upon which your new ED can be developed.

Conclusion

The emergency department should be considered a lifeline of the hospital. A well-functioning ED not only provides a hospital a steady influx of patients but it also can serve as a powerful marketing device. Patients who receive fast, high-quality care through their ED develop confidence in the care system and will return for their future health care needs. On the contrary, patients who have negative experiences with their local ED often will not only tell others of their unfortunate visit, they will be more likely to seek another provider for their acute care needs. Thus, it is imperative that hospitals take the appropriate steps necessary to ensure their ED is performing above expectations and providing quality care in a timely manner.

John Dao is a senior healthcare consultant for Partners Healthcare Consulting (“Partners”), a service of Wipfli LLP. His consulting career has spanned a wide breadth of hospital and ambulatory settings, ranging from large academic hospitals and integrated delivery systems to small regional hospitals. John can be reached at (952) 548-3377 or jdao@wipfli.com.