Patient Flow Efficiency Techniques in the Emergency Department

1. Patient Flow Efficiency Techniques in the Emergency Department Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2. Goals of Trying to Maximize Patient Flow Efficiency in the E.D. • Improve patient care • Improve patient satisfaction with care • Lessen stress on E.D. staff • Limit financial costs to hospital • Allow more available staff time for teaching

3. What Does Maximizing Patient Flow in the E.D. Really Mean ? • Limiting as much as possible the time intervals between each sequential event that is necessary for patient care • Maintaining quality, safety, completeness, empathy, and personal attention in patient care

4. Fundamental Principles Behind Improving Patient Flow Efficiency • Anything that delays evaluation by the emergency physician is detrimental • Everyone in the department must be committed to & cooperative with efficiency efforts • Provision of emergent care procedures always takes precedence • Making events simultaneous rather than sequential increases efficiency

5. Items for Everyone to Keep in Mind to Enhance Efficiency • Starting patient care does not depend on the paperwork being ready • Maintaining efficiency and speed are important even when the E.D. is not busy, because this enables the E.D. to better handle a sudden, unexpected influx of patients

6. Nursing Triage : Background Aspects Related to Efficiency • COBRA / EMTALA require that all patients be medically evaluated prior to being asked to register • Triage should take < 3 minutes maximum per patient • Space & seating allowance necessary for multiple simultaneous presenting patients

7. What Exactly Constitutes Proper Efficient Nursing Triage ? • Immediate "experienced eyeball" assessment of the patient's condition • "One line" chief complaint • Vital signs : • Pulse • BP • Resp. rate • Temp. • Current meds & allergies

8. Patient Disposition Options for the Triage Nurse • Take patient immediately back to emergency care area • Send patient to E.D. registration • Send patient to a "nonemergent" care area • Send patient to X-ray or laboratory prior to being sent into E.D. • By preapproved written protocol based on chief complaint

9. Time-Saving Techniques at Registration • If others accompany the patient, have them register the patient while triage and initial E.D. care are started • If patient is preregistered in hospital system, only record new or changed info • Utilize bedside registration as much as possible • Automatically obtain patient's recent E.D. chart to accompany current chart

10. Standard Efficiency Criteria for Initial Patient Care • For any potentially unstable patient, nursing should go ahead with O2, monitor, IV, blood draw, EKG, pulse oximetry, & early M.D. notification • X-ray +/- resp. techs may need to be notified & activated, but M.D. should see patient prior to their actions • M.D. should be notified of priority of multiple simultaneous patients

11. Patient Evaluation Efficiency Techniques for Physicians • For several near-simultaneous patients : • See 1 or 2 simple cases only requiring exam or single x-ray first, then see a more complex or involved patient, then recheck the x-ray results for the simple cases while awaiting lab, etc. for the complex case • Hold paperwork completion till after all these patients are seen • Lengthy non-resuscitative procedures on patients who are definitely going to be admitted anyway should not delay evaluation & disposition of patients with simple or more minor problems

12. Paperwork Efficiency Techniques for E.D. Physicians • When a patient can be discharged, fill out first the discharge orders & instructions & get the nurses working on the discharge ; then go back & fill out the H&P • Preprint the discharge instructions whenever possible • Can be done during suturing, for instance

13. Additional Efficiency Techniques for E.D. Physicians • Draw & send lab tests early if needed • Pelvic & secondary exams should be done after lab is sent • Hold split urine specimen + extra blood tubes in case secondary tests prove needed • Complete entire physical exam prior to ordering X-rays so all films can be done at once

14. Additional Efficiency Techniques for E.D. Physicians (cont.) • Don't recite entire H&P over the phone to consultant ; just tell him what you need him to do • Verify specific times that labs were sent to know when to check up on them • Once a stable case is turned over to a consultant, don't hover over the patient

15. Suturing Efficiency Techniques for E.D. Physicians • Have equipment obtained & set up while you are doing the H&P • Don't X-ray the wound for foreign bodies if you can explore it directly adequately • Have staff obtain discharge meds & instructions while suturing is being done

16. Charting Efficiency Techniques for E.D. Physicians • Dictate charts whenever free time is available • May split dictation (dictate initial H&P first ; then later add addendum dictation once lab & disposition are known) • Handwrite data prior to dictations as needed to provide "memory jogs" • Leave charts in the locations where they're supposed to be so time is not wasted tracking them down

17. Interactive Efficiency Techniques for E.D. Staff • Don't be rigid about job duty performance • Helping someone else with their job may speed things up a lot • Extra attention should be directed to help the person who is the most busy • Let E.D. staff know your patient care plans so they can anticipate further actions • Have flexible room coverage assignments

18. Improving E.D. Patient Flow Efficiency : Summary • All E.D. staff should take interest & pride in efficient patient flow • Anticipation and cooperation are key • "Mapping out" of short term events is helpful in planning • System should be geared to minimizing time to initial M.D. exam, & to making events simultaneous rather than sequential