Running a More Efficient Emergency Department

Executive Summary

Emergency departments (ED) operate as the gateway to a hospital. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information. Overcrowding is a common occurrence in emergency departments worldwide and causes poor patient satisfaction and inadequate care which leads to poorer patient outcomes. Some of the most frequent complaints presenting to EDs are non-urgent in nature. Hospitals are exploring opportunities to improve efficiency and throughput in the ED. Strategies to enhance efficiency include:

  • Reduce average rate of patient flow through the ED arrival queue
  • Reduce variation in the time between patient arrivals to the ED
  • Reduce variation in service times
  • Increase resource utilization efficiency and capacity

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How to Improve Emergency Department Operations

The key to fixing overcrowding in the ED is to clearly delineate the effects of the different queues and devise appropriate strategies to counteract these effects. These include:

  • Uncouple ED registration and triage, so that registration does not impede the patient’s clinical progress.
  • Reduce average time in triage. Use rapid medical evaluation in triage to redirect low acuity patients away from the emergency department to other care settings.
  • Predict the number of patients who will be admitted to each hospital service and inform that service of the forecasted need for beds. This gives the unit managers more lead time to work out where current patients who can be discharged or transferred from the unit will go and then time to clean, disinfect and prepare the bed for the incoming patients from the emergency. This reduces delays in admitting emergency patients due to the bed not being ready.
  • Keeping vertical patients vertical. Emergency patients who receive intravenous drip treatments stay much longer than patients who receive oral medications. For the same diagnoses, where the drug efficacy is the same, using oral medications gets patients discharged from emergency sooner and avoids the nursing utilization associated with intravenous treatment.
  • Create a 3-24 hour Clinical Decision Unit (CDU) to be used only for patients requiring observation and specific services (eg., GI bleed stabilization, chest pain, transfusion, dialysis, placement). This avoids hospitalization for these individuals.(2)
  • Analyze emergency arrival patterns by time of day and day of week and staff accordingly.
  • Implement a dedicated Emergency Hospitalist program.
  • Implement virtual beds in a result waiting area.
  • Implement triage protocols to start diagnostic orders, specimen collection, and treatment in order to take advantage of delays prior to bed placement.


Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Non-Emergency Use of EDs by Low Acuity Patients

Some of the most frequent complaints presenting to EDs are non-urgent in nature. This low acuity of patients in the ED is supported by US data: In one study, only 15% of ED visits were emergent or urgent, while 34% of visits were non-urgent. Of the remaining 50% of visits, half were non-urgent, meaning that over 50% of ED visits could be treated in a different setting. This trend will continue as health insurance in many countries becomes more expensive and the need for primary care providers widens. In the United States and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast Track or Minor Care units.

These units are for people with non-life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions. In all UK Primary Care Trusts there are out-of-hours doctor services provided by General Practitioners.

Emergency Department Operational Process

Flow through the ED can be thought of as an elaborate system of interconnected queues, comprising three major consecutive queue processes:

1. The Door to Doctor Interval, including Door to Triage and Triage to Bed Assignment

Reduce time from patient arrival to physician consult. This is the most important interval from the patient’s satisfaction perspective. It is dominated by the practice of triage or sorting patients based on their severity of illness or tolerance for waiting for treatment. The goal is to get the patient in front of the physician as soon as possible. This is achieved by uncoupling the triage and registration processes and ensuring that the triage has an appropriate capacity (physicians, nurses, beds) for every hour of the day, relative to demand.

2. Doctor to Disposition Interval

Reduce bottlenecks by evenly distributing clinicians and resources. This deals with the in-emergency department segment of the patient throughput. The ED can be thought of as simply a collection of three servers the patients must navigate--doctors, nurses, and beds. The most commonly perceived problem of most EDs is a lack of beds. The need for beds can be reduced by keeping vertical patients vertical, implementing virtual beds in a result waiting area and optimizing laboratory and radiology turnaround times.

3. The Disposition to Departure Interval

The final interval in the ED is the disposition to departure interval and is one of the most difficult to improve because it involves fixing hospital-wide flows. Emergency departments are often the last department to get a bed assignment. Hospital inpatient units are only more complex queues that must be optimized in order to improve the disposition to departure interval. If inpatient utilization exceeds about 85%, the chances are that the ED is being used to board patients waiting for a bed. Unstaffed, but available inpatient beds are the most common cause of boarding. Boarding patients leads to increased walkouts, poor outcomes for those who walk out, long waits to be seen and increased inpatient mortality for boarded patients. Measures that can alleviate ED boarding include proper demand-capacity matching on the inpatient side, enhancing flow in areas that cause congestion and queuing in the ED, smoothing patient arrivals from operating rooms and intensive care units or boarding patients in the hallways of units to which they will be admitted (the full capacity protocol). In order to reduce flow time through any individual queue, ED departments must do one of the following:

  • Reduce average rate of patient arrivals into an ED queue
  • Reduce variation in the time between arrivals of patients
  • Reduce average physician and nurse service times
  • Reduce variation in service times
  • Add physician, nurse or bed server capacity or change the timing of server capacity.


Fast-Track Units & Overcrowding

Overcrowding occurs when the service providers and their service delivery processes function at a slower rate than the frequency of new patients arriving at the ED. When the supply of resources cannot match the resource demand of resources, patients experience lower quality care, worse health outcomes, and they report poor satisfaction.

To evaluate the efficacy of fast-track (FT) units, a University-affiliated emergency department developed a fast-track area. The goals of the FT unit included reducing patients' length of stay in ED, improving patients' satisfaction, and decreasing ED overcrowding.

The variables investigated included: the length of stay in the emergency department, the rate of patients who left without seeing a practitioner, unscheduled return visits to the emergency department within 72 hours of being seen, and patient satisfaction. During the evaluation period, 5995 patients were seen in the ED fast-track area. The average time patients spent in the emergency department was 4.36 hours. The average time in the room for the FT area was 1.97 hours. The 'left-without-being-seen' rate for this time period in the main emergency department was 7%; the rate for the FT area was 4%. Additionally, 100% of respondents who completed a patient satisfaction survey in the FT area rated the care received by the nurse practitioner (NP) as good or excellent.

Metric Result Comparison: Regular ED → Fast-track ED
Average time spent in ED decreased 4.36 hours → 1.97 hours
Rate of patients leaving without being seen by clinician decreased 7% → 4%
Patient satisfaction rating n/a N/a → 100% of patients rated “good” or “excellent”