Issue 3 : ED Relations with the Rest of the Hospital

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The Problem:

Media:Poster.ppt

Definition
Patient flow between the ED, Radiology, Labs, Inpatient units, and being discharged is not always a smooth, integrated process.


Research

  • Bulk of waiting does not occur in the waiting room, but in the back end
  • Look at input, throughput, and output
  • Quality of communication between ED nurses and techs in other departments can help or hinder patient flow
  • ED overcrowding and effectiveness are determined by internal factors and external pressures. Measuring patient flow can help to detect what these factors are. (Miro 2003)
  • When trying to improve ED operations, one must also look at how the Inpatient Units (IU) are being utilized. Focusing on the IU may have the greater impact. (Kolb 2007)


Measurable Metrics

  • Turn-around time, hours:minutes
  • Length of stay, days
  • Physical distance from ED rooms to other parts of hospital, feet
  • ED bed to initial contact with ED physician, minutes
  • X-Ray Turnaround time (from order to report receipt in ED), minutes
  • Lab Turnaround time (from order to results received in ED), minutes
  • Admission Turnaround time (from admission order written to patient transferred to floor), minutes


Resources
1. Miró Ó, Sánchez, M, Espinosa G, et al. Analysis of patient flow in the emergency department and the effect of an extensive reorganisation. Emerg Med J 2003;20:143–8. link
2. Kolb, E. M., Lee, T., and Peck, J. 2007. Effect of coupling between emergency department and inpatient unit on the overcrowding in emergency department. In Proceedings of the 39th Conference on Winter Simulation: 40 Years! the Best Is Yet To Come (Washington D.C., December 09 - 12, 2007). Winter Simulation Conference. IEEE Press, Piscataway, NJ, 1586-1593.link
3. Blasak, R. E., Starks, D. W., Armel, W. S., and Hayduk, M. C. 2003. Healthcare process analysis: the use of simulation to evaluate hospital operations between the emergency department and a medical telemetry unit. In Proceedings of the 35th Conference on Winter Simulation: Driving innovation (New Orleans, Louisiana, December 07 - 10, 2003). Winter Simulation Conference. Winter Simulation Conference, 1887-1893. link
4. Ruohonen, T., Neittaanmäki, P., and Teittinen, J. 2006. Simulation model for improving the operation of the emergency department of special health care. In Proceedings of the 38th Conference on Winter Simulation (Monterey, California, December 03 - 06, 2006). L. F. Perrone, B. G. Lawson, J. Liu, and F. P. Wieland, Eds. Winter Simulation Conference. Winter Simulation Conference, 453-458. link

Comments:

comment from Marvina (added by Ellen here)

On Issue #3, the metrics you may want to look at are:

1.ED bed to Initial contact with ED physician, minutes

2. X-Ray Turnaround time which would be from order to report receipt in ED., minutes

3. Lab Turnaround time which would be order to results received in ED

4. Admission Turnaround time from admission order written to patient transferred to floor, minutes


COMMENT: Ackerman "Patient flow between the ED, Radiology, Labs, Inpatient units, and being discharged is not always a smooth, integrated process." Why is that a problem? This is equivalent to saying it is hard to shift smoothly from first to second gear. That isn't really a problem if you only want to go 10 miles per hour. From your proposed measures I assume the problem is that patient flow to other units (including lab and radiology) is not a smooth process these delays result in extended waiting times and poor ED throughput. If you think patients not getting to radiology efficently is the cause of extended stays then measure what is actually happening - time from order for x-ray to imaging completed. Unused time on the x-ray or CT scanner, times when patient is waiting and imaging modality is available. One of the postualted delays of getting admitted patients to the floor is "the floor nurse won't take report" - this is measurable. You can look at when the bed is requested and the floor unit/bed is assigned. Then look for time for first attempt to contact the floor nurse, time when the "report" has been completed and time of arrival of patient to the inpatient unit. I worked in one hospital where they documented the problem and eventually we had the ED nurses take the patient's to the floor as soon as the bed was assigned - terrible because the ED nurses would leave the ED for 20 minutes but great because the floor nurses could not hang up, run away, or otherwise hide when our nurse arrived on unit with a patient and our nurses liked it because they spent 20 minutes off unit instead of 30-45 minutes on the phone trying to get someone to pick up AND take report. Another "relation" issue is the content of communications and mode of communication. Phone calls onl;y are a good way to ensure incomplete information transmission.

Comment: Williams Patient flow is such a large issue. I would recommend selecting a department, i.e. Patient flow between ED and Medical Imaging.