The implementation of a flow coordinator role in an emergency department did not improve key throughput metrics like length of stay and left without being seen rates. While the flow coordinator aimed to improve efficiency, an electronic medical record change slowed processes down for months, counteracting any benefits. Analysis found that males and patients aged 20-40 were highest risk for poor throughput outcomes. Patient satisfaction still improved despite worse metrics. Recommendations include studying different clinical roles for flow coordination and its impact on other areas like admissions and diversions.

1. The Effect of Implementing a
Flow Coordinator on
Emergency Department
Throughput
Susan Flaming
CSULB, Dept of Nursing
Spring 2015

2. Problem
• ED overcrowding is a nation-wide, growing
problem
• ED demand far exceeds capacity
• Prolonged wait times affect patient safety, patient
satisfaction, staff morale and hospital financial
performance

3. Recap of Project
• Flow coordinator was implemented to improve the
efficiency of the throughput process in the ED
• An experienced RN focused on “pushing” patients
through the process by communicating test results,
following up on delays, moving patients, updating
patients and caregivers on status
• Measures:
• Discharge Length of Stay (DCLOS): registration to
dischgarge (minutes)
• Left Without Being Seen (LWBS): leaving without being
seen by a provider (%)
• Elopement: leaving prior to official discharge (%)

4. Common ED Throughput
Interventions in the Literature
• Split-flow by acuity or patient type (fast track)
• Rapid Triage/Team Triage (parallel processes)
• PIT model (Provider in Triage)
• Flow Expeditor (Tech, RN, NP/PA, Paramedic)
• Technology (POC, Utz in ED, mapping software)

5. Conceptual Model

6. Study Design
• Retrospective, comparative study
• Pre & Post groups (“Pre FC” and “Post FC”)
• Data analysis was blind to any patient specific
information
• No consents required because no human subjects
were tested; no patient-specific information was
seen/used by researcher
• Data extracted from existing reports by hospital
analyst, blinded and released to researcher

7. Setting
• Urban ED in a diverse community; median annual salary is $48,000
• 46% white, 13% black, 13% Asian and nearly 40% of Hispanic
descent
• Academic teaching hospital
• Specialty center
• STEMI
• Stroke Center
• EmergencyDept Approved for Pediatrics
• Base Station for the city
• 21 acute care beds, 5 urgent care beds (plus chairs, hallway gurneys)
• 145 patients daily; 55,000 patient annually

8. Sample Selection
• All ED patients who completed registration
process for both the Pre FC group and Post FC
groups
• Pre FC= 26,386
• Post FC= 26,765
• Female 54%, Male 46%

9. Flow Coordinator JD
Requirement: RN (at least three years experience)
Hours: 6:30am-7:00pm; 6:30pm-1:00am (until Rapid Triage side closes)
• Facilitates the flow of patients from arrival, through registration, Rapid Triage, to internal waiting room
and to main waiting room when needed.
• Communicates collaboratively with ED charge nurse to progress patients through the process toward
disposition with emphasis on Rapid Triage patients that need to be moved to the acute side for
evaluation
• Maintains updated location of all patients on the tracking board
• Checks charts for order completion and assists with handoffs between providers
• Works proactively to alleviate bottlenecks by moving patients, assisting staff with tasks and
interventions and completes triage and discharge when available
• Monitors laboratory and other diagnostic results and notifies providers
• Updates patients on their plan of care by rounding frequently
• Night shift Flow Coordinator ensures handoff of all patients to the acute site prior to Rapid Triage
closing

10. Hypotheses
1. The length of stay in minutes for patients
discharged (DCLOS) from the emergency
department will be lower in the experimental group
after the implementation of the flow coordinator role.
2. The percentage of patients who left without being
seen (LWBS) by a provider will be lower in the
experimental group after the implementation of the
flow coordinator role.
3. The percentage of patients who elope from the
emergency department will be lower in the
experimental group after the implementation of the
flow coordinator role.

11. Results
…not as hoped for regarding throughput
efficiency, but important insights did emerge
from analysis of age, gender and patient
satisfaction

12. Distribution of DCLOS

13. Discharge Length of Stay
0
50
100
150
200
250
300
Pre FC Post FC
Minutes
Discharge Length of Stay (DCLOS)
n= 26765n= 26386
p < 0.001
(187 min; SD = 43)
(216 min; SD = 58)
Discharge Length of Stay
greater by 29 minutes in
Post FC group

14. LWBS
0
0.5
1
1.5
2
2.5
3
Pre FC Post FC
PercentageofLWBS
Left Without Being Seen (LWBS)
n= 26765n= 26386
p < 0.001
(1.34%; SD = .11)
(1.94%; SD = .14)
Left Without Being Seen
greater by nearly 50% in
Post FC group

15. Eloped
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Pre FC Post FC
PercentageofElopement
Eloped
n= 26386 n= 26765
p = 0.238
(3.75%; SD = .19)
(3.95%; SD = .19)
Difference in Post FC
group for Eloped not
statistically significant

16. Age & Gender Effect
• Age and gender were analyzed for each
throughput metric to uncover patient-type trends
• The idea behind this analysis is to determine what
patient types are high risk for an extended
DCLOS, LWBS or elopement
• Example: 20-40 yr old male patients are HIGH RISK
• Identifying these patient types can help caregivers
to focus interventions to improve throughput

17. Gender on DCLOS
190
195
200
205
210
215
Female Male
Minutes
Gender Effect on DCLOS
n= 28668 n= 24483
p = 0.001
(211 min; SD = 10)
(198 min; SD = 11)
Female patients stayed in
the ED 13 minutes longer
than males on average

18. Gender on LWBS
0
0.5
1
1.5
2
2.5
3
Female Male
PercentageofLWBS
Gender Effect on LWBS
n= 24483n= 28668
p = 0.001
(1.43%; SD = .11)
(1.88%; SD = .14)
Males 32% more likely to
LWBS than females

19. Gender on Eloped
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Female Male
PercentageofElopement
Gender Effect on Eloped
n= 24483n= 28668
p = 0.001
(3.63%; SD = .19)
(4.12%; SD = .19)
Males 14% more likely to
Elope than females

20. Age on DCLOS
0
50
100
150
200
250
300
< 20 y.o. 20-40 y.o. > 40 y.o.
Minutes
Age Effect on DCLOS
n= 11559 n= 17826 n= 23766
p = 0.001
(146 min; SD = 41)
(199 min; SD = 2)
(239 min; SD = 5)
Discharge Length of Stay
increased by age with the
> 40 y.o. group staying
longest in the ED

21. Age on LWBS
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
<20 y.o. 20-40 y.o. > 40 y.o.
PercentageofLWBS
Age Effect on LWBS
n= 28668n= 17826n= 11559
p = 0.001
(1.44%; SD = .11)
(1.76%; SD = .11) (1.65%; SD = .13)
Left Without Being Seen
was highest in the 20-40
y.o. group

22. Age on Eloped
0
1
2
3
4
5
6
<20 y.o. 20-40 y.o. > 40 y.o.
PercentageofElopement
Age Effect on Eloped
n= 11559 n= 17826 n= 23766
p = 0.001
(3.29%; SD = .21)
(4.52%; SD = .19)
(3.07%; SD = .11)
Eloped was highest in the
20-40 y.o. group

23. Patient Satisfaction
“Given my medical condition, I did not have to wait
long”
• Pre FC: 83.2% answered “always”
• Post FC: 84% answered “always”
• p= .08324
“My health condition was checked immediately when
I got to Emergency”
• Pre FC: 85% answered “always”
• Post FC: 86.7% answered “always”
• p= .5326

24. Patient Satisfaction
“The Emergency staff kept me comfortable while I
waited to see the physician”
• Pre FC: 83.7% answered “always”
• Post FC: 84.4% answered “always”
• p= .8404
“The Emergency staff took my problem seriously and
responded quickly to help me”
• Pre FC: 83.7% answered “always”
• Post FC: 86.2% answered “always”
• p= .3172

25. Summary of Results
• DCLOS & LWBS were higher (worse) in Post FC group
• Flow coordinator had neutral effect on Elopement
• Age & Gender were significant for all three metrics
• Men had LOWER DCLOS but HIGHER LWBS &
Elopement
• Women had HIGHER DCLOS but LOWER LWBS &
Elopement
• 20-40 y.o. group had highest LWBS & Elopement
• Patient Satisfaction improved, despite worse DCLOS &
LWBS

26. Discussion
• Electronic Medical Record had a much larger
impact on length of stay than anticipated
• 4-5 min increase in registration/triage alone
• All ED operations slowed down and lasted > 6
months

27. Discussion
0
50
100
150
200
250
300
350
400
450
500
Minutes
May-
13
Jun-13 Jul-13
Aug-
13
Sep-
13
Oct-
13
Nov-
13
Dec-
13
Jan-14
Feb-
14
Mar-
14
Apr-
14
May-
14
ALOS 340 322 325 376 335 324 362 371 434 423 382 385 397
DCLOS 126 139 130 170 192 188 177 207 202 191 193 216 201
Patient Length of Stay
May 2013-May 2014
Data Source: ER Monthly Metrics- 5/2013 - 5/2014 ALOS- Admission Length of Stay DCLOS= Discharge Length of Stay

28. Implications
• Confirmed what the literature has established with
results of age & gender effect on throughput
metrics
• Confirmed what the literature has established that
technological implementations add value but often
slow processes for months after implementation
• Patient satisfaction and patient safety

29. Recommendations
• Implement the flow coordinator using different
clinical roles- EMT, LVN, MA
• Study FC impact on other areas of throughput:
Left Without Being Registered, Admit LOS,
ambulance diversion
• Analyze impact on patient satisfaction and patient
safety
• Analyze impact on employee satisfaction (staff
now see the flow coordinator role as
indispensable)

30. Thank you
• Committee members
• Dr. McGuire
• Ann Kim
• Gail Daly
Slaying the beast (me vs.
thesis)