Proposed actions to improve waiting times at the emergency room
Proposed Actions To Improve WaitingTimes At The Emergency RoomIn Nova Scotia HospitalsHESA 4003 & HESA 4020Quality Management and Quality ImprovementDalhousie University .N.S.winter 2009Xiomara Arias-Fernandez.
Emergency Room Wait Time Issue. A Need For a Change.According to the Canadian Association of Emergency physicians (CAEP, 2005 )reducing waiting times is a clear priority at national level established in the document“A Ten Year Plan to Strength the Healthcare". In effect, from 2004 to 2010, Federaland Provincial governments have assigned more than 4.5 billion dollars to implementstrategies that aim to accomplish this goal in priority areas. Prolonged waiting timesare also concerning for lack of effectiveness in Canada’s Emergency Departments(CED). An excess of patients overusing the emergency service impedes their ability toprovide them of effective and timely services. The shortage of beds in hospitals and inthe Intensive Care Unit are the causes of the overload of patients requiring services atthe emergency room. Also, government funding cuts have lead to reduced hospital bedcapacity, generating an overload crisis in emergency departments and this is worsenedby the increasing number of aging users.
Emergency Room Wait Time Issue. A Need For A ChangeAdditionally, patients who require alternate services (alternate level care, or ALC) suchas palliative care, contribute to the overcrowding crisis, because approximately20% of these patients have to use beds that should be assigned for acute care. Bedwaiting times and patient flow are affected by in-patients who no longer requireacute care (Canadian Institute for Health Information , 2007) “Most hospitals inCanada currently operate on 95% bed occupancy rates” (CAEP, 2005 p.3) whichmeans that overcrowding is occurring consistently, deteriorating the service andhaving harmful repercussions in health’s patients, ranging from worsening medicalconditions to loss of life. The aim of this presentation is to expose differentapproaches based on the research of authors . These approaches could reduce thewait times in ED. Also is presented an hypothetical design based on a previoussuccessful model put in operation in 2007 at Mary Washington Hospital in VAUSA . The intent of this hypothetical project is to help in making the necessaryimprovements that lead in reducing wait times in ED.
Emergency Department Wait Time Issue InThe Healthcare System Across Canada(Canadian Association of Emergency physicians, 2005)Delays in treatment/Reduction in flow of patients to others wardsWorsened medical condition- Life-threateningOwercrowding –crisis + overuse of ED serviceIneffective and untimely serviceGovernment funding cut + High # of ALC patientsBeds shortage
Emergency Department (ED) Overuse By ALC PatientsA Brief Look To Part Of The IssueThe Toronto District Health Council defines an ALC patient as one that is “considered a nonacute treatment patient but occupies an acute care bed. This patient is awaiting placement in a chroniccare unit, home for the aged, nursing home, rehabilitation facility, other extend care institution or homeprograms etc. The patient is classified as an ALC when the patient’s physician gives an order to changethe level of care from acute care and requests at transfer to another facility.” (GTA Rehab, 2004 , p.3)In 2007-2008 ALC patients accounted for 14% of hospital days in acute facilities across Canadianprovinces “This means that, on any given day, almost 5,200 beds in acute care hospitals were occupied byALC patients.” (Canada Institute for Health Information, 2009 p.3). One of the major clinicalhospitalization categories was mental diseases and disorders -17% of the hospitalizations- (DischargeAbstract Database, 2007–2008, Canadian Institute for Health Information, 2009 p8).
Discerning The Dynamic of Waiting Times In The E DOutpatient status Inpatient statusTotal ED length of stayTime to dispositionInitial physician assessment wait time bed-wait timeED registration triage Initial physician assessment decision to admit leave Ed (move to acute care ward)The bed wait time is calculated as the time a patient spends waiting in the EDfrom the physician(s) decision to admit them to an inpatient bed to the time that the patient leavesthe ED. (source: Canadian Institute for Health Information ,2007. Access to inpatient beds ,p8 )
Plan Action To Reduce Waiting Times In Emergency RoomActions To Reduce Owercrowding –Crisis(strategy based on Karpiel, 2004)At Inflow process level: To Implement a triage-driven bed placement method (Patients aretaken immediately to a treatment area after triage and quickly registered).Enforce the use of bedside registration.At Throughput process level: create a separate "fast-Track” area staffed with mid-level careproviders such as nurse practitioners to care for low-acuity patients. In this way, less criticalpatients would be seen quickly and leave ED physicians to focus on critically ill or injuredpatients. Create a reasonable not limited access to lab services and diagnostic imaging by havingdedicated radiology and lab technicians assigned to the ED during the busiest hours of operation.By implementing a point of care satellite laboratory ( Lee-Lewandrowski et al, 2003) thepatient length of stay and turnaround time can be reduced .At Outflow process level: Use of :Pre-emptive bed requests to allow ED physicians to request ahospital bed previous authorization patient admission. Perform faxed admission reports, toeliminate consumed time for ED nurse give call to inpatient nurse .Carry out a capacityManagement System, to replace the floor nurses role in alerting housekeeping of empty rooms.(This action improves housekeeping productivity and expedite bed availability).
Plan Action To Reduce Wait Times In Emergency RoomActions To Decrease Overuse Of ED Service By ALC Patients.In the case of mental health patients and based on information provided by TheOntario Partnerships Report, 2008 three alternatives can be used:• Develop a 24/7 Crisis Response System. A comprehensive and coordinated crisisresponse system should include the following components: crisis response line,safe beds, mobile teams, direct links to emergency departments, and direct links tocommunity-based case management .• Support peer support workers involvement in discharge planning to offersupport and facilitate transitions from institutional to community care, i.e. socialworkers.• Invest in community mental health and addiction services that connect directlywith hospitals, to facilitate appropriate diversion from emergency rooms; andsupport access to the most appropriate community based services and supports
Plan Action To Reduce Wait Times In Emergency RoomActions To Improve Patient Flow(strategy based on Jensen and Crane, 2008)1- To organize a measure of patient demand by hour, and outline a system to manage it. Toconform staffing to patient ingress and capacity. To break down ingress by main complaint,triage, emergency medical services arrivals, emergency severity index (ESI) level, andancillary utilization. (all are calculable). To design a response plan for times when demandunusually spikes (It is critical to match hours of operation to patient demand.)2- To Justly empower triage processes and systems. Triage is a support, a function to help in theprocess of reducing waiting times, and is not useful for properly staffing an ED or decide whocan wait or who not.3- To consider using team triage to promptly discharge patients at CTAS level III .This processinvolves quickly assessing, registering, and processing through team triage, and thenallocating or sorting patients CTAS levels I,II,IV and V to either a treatment area or results-waiting area.4- To appraise ongoing triage protocol By switching to a "see-and-treat“ model, EDs will haveone in-process queue, where patients wait just one time for a one-stage assess, treat, anddischarge process5- To use a technician or secretary to follow patients who dont need a bed and their results6- To prepare and handle a vigorous staff with an eager platform.
Time frames developed in 1998 byCAEP and defined as reasonable times tophysician-directed care in person ortelephone advice or as care provided bynursing staff in accordance with medicaldirectives agreed to in advance by thephysician (Beveridge R. 1998)Objective: "more accurately definepatients needs for timely care and to allowemergency departments to evaluate theiracuity level, resource needs and performanceagainst certain operating objectives.“(Beveridge et al ,1998 p.2). The primaryobjective of the triage scale is to define theoptimal time to see a physicianThe Canadian Emergency Department Triageand Acuity Scale (CTAS)
CTAS I: requires resuscitation and includesconditions that are threats to life or imminentrisk of deterioration, requiring immediateaggressive interventions (for example, cardiacarrest, major trauma, or shock states).CTAS II: requires emergent care and includesconditions that are a potential threat to life orlimb function requiring rapid medical interventionor delegated acts (for example, head injury, chest pain,gastrointestinal bleeding, abdominal pain with visceralsymptoms, or neonates with hyperbilirubinemia).CTAS III: requires urgent care and includes conditionsthat could potentially progress to a serious problemrequiring emergency intervention, such as mild moderateasthma or dyspnea, moderate trauma, orvomiting and diarrhoea in patients younger than 2 years.CTAS IV: requires less-urgent care and includesconditions related to patient age, distress, orpotential for deterioration or complications thatwould benefit from intervention or reassurancewithin one to two hours, such as urinary symptoms,mild abdominal pain, or ear ache.CTAS V: requires non-urgent care and includesconditions in which investigations or interventionscould be delayed or referred to other areas of thehospital or health care system, such as a sorethroat, menses, conditions related to chronic problems,or psychiatric complaints with no suicidalideation or attempts.The CanadianEmergencyDepartmentTriage andAcuity Scale(CTASSource: Canadian Institute forHealth Information ( p.7) 2005Time to assessmentnurse: 0 minPhysician: 0 minTime to assessmentNurse:0 minPhysician 15 min.Time toassessmentNurse:30 min.Physician: 30 min.Time ofassessment.Nurse:60 minPhysician:60 minTime ofassessmentNurse: 120min.Physician: 120min
The Maximum Efficiency Care ProjectHypothetical design based on RATED.ER project ( Crane J, 2007 )Project developed to improve waiting times andenhance Emergency department serviceXiomara Arias Fernandez
The Maximum Efficiency Care ProjectXiomara Arias Fernandez( Based on Crane J, 2007 RATED.ER project)The Maximum Efficiency Care Project must be performed in a triage setting at the hospital ED.This project will be based in the called RATED.ER ( Rapid assessment, Triage, and Efficient Disposition in theEmergency Department) project performed by Crane Jody at the ED in Mary Washington V.A. USA in 2007.Crane’s project focus on apply Lean tools to a value stream of Emergency Severity Index (ESI) level 3patients, instead The Maximum Efficiency Care Project will focus on improve the efficiency through of patientsclassified as level III in the CTAS. To set up this project also some Lean tools will be applied , such as Rapidimprovement Teams, (teams who analyzed processes to make quickly improvements) Takt Times, (the timerequired to produce a component or set of components to meet a customer demand )and Visual Signals,(use ofindicators and signs to share critical information) among others. In order to provide a comprehensive evaluation,early treatment and to determinate the bed needs of these type o patients The Maximum Efficiency Care Projectwill include a staff comprised of physicians, nurses and medical assistants. It will also be necessary toimplement a waiting area where patients will wait for ancillary test results, and where will be set beds andtreatment/ discharge chairs. These resources will be compiled according the demand presented. To accomplisTheMaximum Efficiency project when beds are required it will be created an Intake Team System integrated byphysicians, midlevel ,Register nurses , a paramedic and a Unit secretary with a group of beds behind triage. Oneof the core purpose of this team will be appropriately identify CTAS levels I,II and IV,V patients, so that theycan be seen quickly in Main ED or in a fast track area in order to alleviate potential backlogs.
Goals to be achieved with the creation of “The MaximumEfficiency Care project” in Emergency Department (ED)• To reduce work in process (patients long waiting at ED ).• To reduce wait times in Ed.• Decreasing length of stay(LOS) for fast track patients .This action willallow to see the patients who are sicker.• To eliminate waste of human time and material resources by decreasingthe non -value -added patient processes.• To accurately determine the quantity of beds needed in the area ofemergency.• To maximized the value of patients by being seen in a primary caresetting.• To improve revenue (funding for the next fiscal year) throughenhance throughput and flow of patients.
Strategy to perform The Maximum Efficiency care projectAction Purpose/Targets1)To create a platform consisting of an expeditiousnursing assessment, a brief triage assessment and anintermediate evaluation by the team of providers.To provide efficient patient flow2)To create a System Reception where the patient willbe received by a ED medical technician, a registrationclerk and an Ed nurse ( Pivot nurse).Pivot nurse will complete a brief sign –in sheet (based on themain patient complain and general appearance) to be deliveredto the medical technician and also will assign the patient toMain ED if the patient is an ESI levels I ,II, or to The fast- Trackarea if patient is IV ,V CTAS levels or to a mini-triage. Then tothe intake team if patient is a CTAS level III or some IV level .The Pivot nurse also places patients in the waiting and resultswaiting area. The registration clerk will perform a quickregistration3) To calculate takt times (based on patientdemand)To allow staffing the Intake team system and toidentify bed needs a s well as to complete initial nurseand physician assessment4) To Perform a limited initial assessment To meet criteria that satisfy the need to assign an ESItriage level as well as not to delay further progress ofthe patient through the system5) To set up a treatment area with treatmentbeds , nurses and techs.To eliminate backlogs by providingquickly and efficient service6) To update physicians periodically as to thepatients status and t he status of ancillary testresultingTo advise physicians come to discharge or to admitthe patients (continue the flow). To provide quickly andefficient service. To eliminate waste of resources
The Maximum Efficiency Care ProjectPatient atthe Receptionteam(QuickPre-assessmentby Pivotnurse andregistrationby clerk )10minMain ED (levels I,II )Mini-triage process .Vitalsigns, main complain,allergies, pain scales13 minTo complete assessment ,initiate treatment, testingand bed decision needs20 minFast Track (levels IV, V) Performed byIntake team systemESI levelassignedLevelIII
Intake Team System FlowPatientSent to ancillaryservicesLaboratory/ Radiology (Nobed needed. Levels 3,4,5)Main ED.(Bed needed-Levels 1,2 )Discharged athomeSent to atreatment areaIv FluidsmedicationsWaitingareaVirtualbed
ConclusionsThe shortage of beds in hospitals and in Intensive Care Unit, theovercrowding originated by an increasing number of ALC patients usingE.D beds, and the consequent low flow produced, seem to be the maincauses of prolonged wait times at the emergency room . There does notappear to be a single solution to address the issue of overcrowding andshortage of beds in the E.D, causes that lead to inefficiency in the service.Several factors should be taken in account when strategies areimplemented to help reduce the time patients spend in the E.D, forexample, type of hospital, day of the week etc. However, the success ofthese strategies also will depend upon the cooperation of other hospitaldepartments as well as the involvement of top management. The strategicareas to improve wait times must be focused mainly on E.D overcrowdingmanagement, E.D ,ALC patients overusing management, and E.D patientunderflow management. Improving the access to primary health care andcommunity-based services also can be a measure used to reduce theunnecessary visits to E.D by ACL patients. Recurrent visits to the E.Dcould be curtailed if opportune community discharge plans are aligned thefirst time.
ConclusionsA significant percentage of emergency visits by individuals could be moreappropriately served through alternative programs and services, i.e. visits tofamily doctor, crisis counsellors, etc. Implementation of triage systems withfast-track areas has been shown to improve throughput and reduce waitingtimes (mainly for patients with CTAS IV and CTAS V levels ). This arise as ananswer to diminish overcrowding in E.D in these group of patients. Additionalstaff in the areas of laboratory, radiology and others support diagnosis duringthe busiest hours in E.D, is going to cover part of the needs of patients withCTAS III level. By implementing a design that incorporate the use of LeanTools on CTAS III level patients, length of stay could be reduced in ED. Theexpected reduction in time at the different stages of this model is going todepend on the patient demand in each institution. To successfully set up theproject data should be analyzed and Takt Times should be calculated.
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