Issue 3 : Flow/Throughput

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The Problem

Inefficient ED processes cause multiple bottlenecks, increased patient wait times, and ultimately unnecessary costs.

Discussion

A multitude of studies address this problem head-on, many of which focus on triage and a "lack of integration" (1). Some focus the quality of patient care and others focus on particular procedural interventions to improve performance and efficiency, sometimes a combination of the two as they are in fact related, even if the goal of improved patient care is not stated. Most of the studies have commonalities in the triage process and evaluation, such as automatic ordering of old records, initiating radiology orders by nurse instead of physician(2), or having the attending physician give discharge instructions instead of using a nurse to provide the same information as a separate step (3).

Another area of delay, and a significant one, was simply having beds available in the ER. In triage an area of increased efficiency included teaming a physician with a nurse (4), therefore a system that could help diagnose a patient may increase efficiency in cases where a team is not available. Many referrals from primary care were sent to the ER simply for radiology which raises the question about other sources for that service rather than the ER. Any finally the last study reviewed correlated overcrowding and lack of internal resources as primary problems for patient wait times (5).

Metrics

Most studies focus on time in which a patient waits during certain events or between events, such as waiting to be seen, seen by a physician, or observation. Other attempts to measure efficiency follow patient satisfaction or the number of LWBS patients. One might also be able to measure turnaround time for labs and radiology, which then might allow for faster diagnosis and treatment or admission to hospital should beds be available.

Sources

(1) G. Andersson, I. Karlberg, Health Policy 55 (2001) 187–207 Lack of integration, and seasonal variations in...

(2) K. M. Lee, T. W. Wong, et.al, Accident and Emergency Nursing, 1996, 4, 179-181

(3) Demetrios N Kyriacou et.al, Annals of Emergency Medicine 34:3 September 1999, A5-Year Time Study Analysis of Emergency Department Patient Care Efficiency

(4) F Subash, F Dunn, et.al, 2004;21;542-544 Emerg. Med. J., Team triage improves emergency department

(5) Ò Miró, M Sánchez, G Espinosa, B Coll-Vinent, E Bragulat, J Millá, Emerg Med J 2003;20:143–148 Analysis of patient flow in the emergency department and the effect of an extensive reorganisation

COMMENT: Ackerman Any particular process catch your eye?

COMMENT: NRussell It seems to me that a couple of issues are big or I should say could be focused on due to the amount of time it takes to get from one stage to the next. Mainly, discharge from the ER either to surgery or to home. The other is the "integration" problem where a lab or scan is needed or the results are not available yet to take the next step in treatment. There is another team looking at this problem as well. I am afraid that the problem definition of "throughput" for this topic may have been too large from the outset and when teased apart, many of the problems are being addressed by other teams, such as triage or integration.