1. How IT Can Help Emergency
Department Flow?
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Health Informatics Division, Faculty of Medicine Ramathibodi Hospital
January 28, 2013
http://www.SlideShare.Net/Nawanan

2. The Mission

3. Ideal Process in ED
Input Process Output
Emergency Urgent Care Treated
Patients Patients

4. Ideal ED Characteristics
• Predictable patient arrivals
• All patients are truly emergency patients
• Staff & resources match demands
• Little or no wait times
• Good patient outcomes & satisfaction
• Efficient use of resources

5. The Unfortunate Truth

6. Real Process in ED
Input Process Output
Emergency Urgent & Treated
& Non- Non-Urgent Patients
Emergency Care
Patients

7. Real ED Characteristics
• Unpredictable patient arrivals
• Mixture of urgent & non-urgent patients
• Staff & resources don’t match demands
• Looooooooong wait times
• Poor patient outcomes & satisfaction
• Inefficient use of resources

8. A Closer Look
ED
Emergency Patients
Triage Investigations
Non-Emergency
Patients
Observation Treatment
Disposition

9. Conceptual Model of ED Crowding
Asplin et al (2003)

10. Simplified Model
Demand Supply
Input Process Output
Emergency Urgent & Treated
& Non- Non-Urgent Patients
Emergency Care
Patients

11. Process Improvements
• Operations Management
– “The science of understanding and improving
business processes” (Soremekun et al., 2011)
• Close linkage to
– Operations Research
– Industrial Engineering
– Business Process Reengineering/Redesign/
Improvement/Management
– Quality Improvement (e.g. Lean Management)

12. How IT Can Help ED Operations?
• Delivers information at point of care
– Timely access to useful information
– Prevention of potential adverse events
– Such as
• Past history
• Drug allergies
• Medication list
• Problem list

13. IT Role: Timely Access to Information
E-mail Postal Mail
(Snail Mail)

14. How IT Can Help ED Operations?
• Enables improvement of business
processes
• Changes workflow
– More efficient
– More effective
– Parallel processes (not serial)
– Concurrent access
• Business process redesign/reengineering
(BPR) facilitated by IT

15. IT Role: Facilitates Workflow Redesign

16. Key To Leveraging IT for ED
• Think of IT as operations management
tools
• Recognize values of IT in
– Facilitating Patient Flow
– Controlling Information Flow
• How these two flows can be optimized &
aligned?

17. Operations Management Strategies
• Increasing Capacity
• Eliminating Waste
• Reducing Variability
• Increasing Flexibility
Soremekun et al. (2011)

18. Key Operations Management Concepts
• Flow Time
– Total time spent by a flow unit within process boundaries
• Flow Rate
– Number of flow units that flow through a specific point in
the process per unit of time
• Inventory
– Total number of flow units present within process
boundaries
• Throughput or Arrival Rate
– Average number of flow units that flow through (into and
out of) the process per unit of time
Modified from Anupindi et al. (2006)

19. A Simplified ED Process
Process
Input Output
Flow Time (hours)
Time
Throughput = # of Flow Units Per Time
Crowded ED
= Flow Unit means too much
(Patient) inventory

20. Little’s Law
Average Inventory = Arrival Rate x Average Flow Time
I = RxT
Modified from Anupindi et al. (2006)

21. Little’s Law: Manipulating Process
Average Inventory = Arrival Rate x Average Flow Time
I = RxT
What We What Needs to Be Reduced
Want to
Reduce
Modified from Anupindi et al. (2006)

22. Fixing ED Crowding
I = RxT
• Reducing inventory through
– Reduction in ED arrival rate
– Reduction in flow time

23. Strategies to Reduce ED Arrival Rate
• Ambulance diversion
– Communications & situational awareness among EDs
& dispatch
• Non-urgent referrals
• Improved primary care access & insurance
coverage
• Patient education & counseling
• Telephone triage

24. Strategies to Reduce ED Arrival Rate
• Preventing repeated ED arrivals
– Reducing “Leave Without Being Seen”
– Improving post-ED ambulatory follow-up care
– Predicting high risk patients and intervene before ED
visits

25. Fixing ED Crowding
I = RxT
• Reducing inventory through
– Reduction in ED arrival rate
– Reduction in flow time

26. Critical Path
• “The longest path in the process flowchart”
(Anupindi et al., 2006)
B E
Start A
G Finish
80%
C D F
20%
A C D F G Time
A B E G Critical Path’s Time

27. Reducing Flow Time
• Shorten length of critical paths
(bottlenecks) by
– Eliminate work of critical activities
• Eliminate non-value added work (“work smarter”)
• Reduce repetitions of activity (“do it right the first
time”)
• Increase speed (“work faster”)
– Work in parallel
Anupindi et al. (2006)

28. Reducing Flow Time
A C BF D GF F E G G
C D G Total Time
Eliminate Non-Value Added Work
(Work Smarter)
B E
Work In Parallel
Start A
D G Finish
Work Faster
80% 97%
CC D F
Do It Right The First Time
20% 3%
Time

29. Strategies to Reduce ED Flow Time
• Work Smarter
– Provider in Triage/Team Triage
– RFID Location Tracking
• Patients
• Equipment
• Charts
• Personnel

30. Strategies to Reduce ED Flow Time
• Work In Parallel
– Bedside registration
• Role of mobile devices
– Bedside triage
• Role of mobile devices
– Prehospital data transmission
– Self-registration kiosk

31. Strategies to Reduce ED Flow Time
• Work Faster
– Fast access to patient information
• Electronic Health Records (from hospitals)
• Personal Health Records (from patients)
• Well-designed user interface
– Advanced order sets
• Paper or Computerized
– Effective provider communications (mobile, pager, etc.)
– Reducing lab/imaging turnaround time
• LIS/PACS
• Point of care testing of certain lab tests
– Tracking/Monitoring of Patient Status (Online Dashboards)

32. Strategies to Increase Capacity
• Indirectly reduce flow time through increase in
throughput or capacity of bottleneck activities
– Add more resources (e.g. staff, space, equipment)
– Increase availability of bottleneck resources (e.g.
24-hr. MRI, reducing equipment breakdowns through
preventive maintenance)
– Reducing wasting setup time

33. Strategies to Increase Capacity
• Dealing with ED Boarding of Inpatients
– “Full-capacity Protocol”
– Better inpatient discharge planning
– Faster discharge procedures
– More efficient use of beds (e.g. bed pooling)
– Comprehensive bed occupancy status monitoring
– “Bed Czars”

34. Strategies to Reduce ED Variability
• Dedicated fast-track non-urgent care
• Standardized protocols
– Practice guidelines
– Order sets
– Clinical Decision Support Systems (CDSS)
• Surgical schedule smoothing
• Ambulance diversion

35. Strategies to Increase Flexibility
• Avoid high utilization rates (degree to
which a resource is working, not idle,
compared to full capacity)
• Predictive modeling & forecasting
• Full-capacity protocols
• Cancellation of elective cases
• Flow flexibility (e.g. dynamic bed
management & treatment location
depending on needs)

36. Summary
• Operations management approach is
critical to solving ED crowding problems
• IT can play various roles in improving ED
patient flow, but key is in process redesign
and finding operations management
solutions
• Success will depend on context
• Be careful of “unintended consequences”
of poor implementation

37. References
• Anupindi R, Chopra S, Deshmukh SD, Van Mieghem JA, Zemel E. Managing
business process flows: principles of operations management. 2nd ed. Upper
Saddle River (NJ): Pearson Prentice Hall; c2006. 340 p.
• Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A
conceptual model of emergency department crowding. Ann Emerg Med. 2003
Aug;42(2):173-80.
• Handle D, Epstein S, Khare R, Abernethy D, Klauer K, Pilgrim R, Soremekun O,
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Emerg Med. 2011 Dec;18(12):1295-302.
• Hoot NR, Aronsky D. Systematic review of emergency department crowding:
causes, effects, and solutions. Ann Emerg Med. 2008 Aug;52(2):126-36.
• Pines JM, McCarthy ML. Executive summary: interventions to improve quality in
the crowded emergency department. Acad Emerg Med. 2011 Dec;18(12):1229-33.
• Soremekun OA, Terwiesch C, Pines JM. Emergency medicine: an operations
management view. Acad Emerg Med. 2011 Dec;18(12):1262-8.
• Wiler JL, Gentle C, Halfpenny JM, Heins A, Mehrotra A, Mikhail MG, Fite D.
Optimizing emergency department front-end operations. Ann Emerg Med. 2010
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