Time studies identify interventions to boost patient flow in your ED
December 1, 1999 5 minutes read
Time studies identify interventions to boost patient flow in your ED
What you assume about delays may be incorrect
Would you like to get patients out the door of the ED 25 minutes sooner with one simple intervention — and prove the intervention was responsible for the reduction in delay? By having ED physicians instead of nurses give discharge instructions, then measuring delays before and after the change, researchers were able to do exactly that in a recent study.
When an ED time study was conducted over a five-year period, hard data were obtained to show the effect various interventions had on delays. Overall, median length of stay in the ED decreased from 6.8 hours to 4.6 hours, which was shown to be a result of several interventions.1 (See chart on median total ED length of stay, p. 135, top.)
Conducting a time study in your ED will boost patient flow and efficiency, advises Demetrios Kyriacou, MD, PhD, assistant professor of medicine at the University of California at Los Angeles (UCLA) school of medicine and director of trauma care in the ED at Olive View-UCLA Medical Center in Sylmar, where the study was conducted. "We are being asked to see more and more patients with less and less resources," Kyriacou says. "If we are going to be able to do that and provide good care, then we’ll have to become more efficient."
Time studies are the most effective way to achieve that goal, he stresses.
Constructing a time study allows you to understand all the steps in the process of patient care, says David Talan, MD, FACEP, chairman of the department of emergency medicine at Olive View and professor of medicine at UCLA’s medical school. "Just this exercise can be enlightening and sometimes leads to ideas for changes to improve efficiency," he notes.
A series of seven one-week time studies was conducted over five years at Olive View-UCLA. There were four goals:
• measure the effect of ED and inpatient bed availability on patient flow (see story on linking bed availability to patient flow, p. 136);
• calculate the main ED patient care time intervals to identify areas of inefficiency;
• quantitatively assess the effects of administrative interventions aimed at improving efficiency (see story on using time study results to obtain resources for the ED, p. 137);
• evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician. The chief complaints used in the study were chest pain, abdominal pain, vaginal bleeding, and extremity injury.
Time studies may reveal that your assumptions about what slows down patient flow are incorrect, warns Kyriacou, the study’s principal investigator. "People have general impressions about what slows flow down. But by actually quantifying specific aspects of patient care, you get a better picture, which is more accurate," he says.
Vena Ricketts, MD, FACEP, assistant chief of the department of emergency medicine at Olive View and professor of medicine at the medical school, agrees. "We thought most of delays were in certain areas, and when we actually looked at it, it wasn’t as we perceived," Ricketts says. "The study enabled us to identify areas where improvements were needed and correct some of our misconceptions."
For example, consider lab delays. "We thought the delay was caused by the lab taking a long time, but we found the specimen wasn’t being delivered right away after it was drawn," she says. "Previously, we nursing attendants physically transported it, but we switched to a pneumatic tube system where specimens are delivered directly to the lab."
Identify the best interventions
A time study allows you to track the effect of various interventions to improve efficiency, Talan says. The ED is not a laboratory where you can keep all other variables constant except for the one factor you are changing, he warns. "You also have to take into account changes in census, staffing, and other factors. The time studies can help you to analyze the effect of these factors."
Pinpoint the longest delays and focus your efforts toward the steps that seem to take the longest, he suggests. "Many of our interventions were found to be effective in decreasing specific time intervals. It also allows you to track progress over time."
When time intervals increased, the sources of the delays were pinpointed and used to lobby for increased staff, notes Talan. "As our census increased, we were able to hire more nursing staff and sought approval for a larger remodeled facility."
Four steps to efficiency
Here are some of the changes made in response to the UCLA time study that improved efficiency:
• A link was demonstrated between waiting times and LWBS patients.
The time study showed a connection between the median waiting time to see a physician and the number of LWBS patients. (See graph showing average number of LWBS patients, below left.) "Delays of care were related to the number of patients who left before being seen," Talan notes.
Minimizing LWBS numbers is an important secondary outcome of improving efficiency in the ED, says Pamela Dyne, MD, FACEP, assistant professor of medicine at the medical school and director of the emergency residency program at Olive View. "If patients leave before they get seen because they are frustrated or tired of waiting, then they don’t get the care they need at our ED," she explains.
• Delays from radiology were reduced by pinpointing delay in transport.
The researchers realized that delays in X-ray often were due to lack of communication between the X-ray tech and nursing, notes Dyne. In some cases, for example, the X-ray techs call the ED to say they are ready for a patient. Some one other than the patient’s nurse answers the phone and has to locate that nurse to transport the patient to X-ray, just 50 feet away, she explains. "That wasted much time and was frequently not carried out, so the X-ray would get delayed. Now we have the X-ray techs transport patients themselves, rather than depend on nursing."
• Additional nursing staff are added at triage when needed.
"We realized that too much time was passing from when the patient hit the door to the point when the patient was actually being triaged. So we added a second nurse for triage during busy times," says Dyne.
The researchers documented an increase from three to seven LWBS patients when there were fewer nursing staff. "This helped us to convince administration to hire additional nurses," she notes.
• Physicians give discharge instructions.
The time study revealed a delay in the time when patients were ready to be discharged and when they actually left the ED. "We now have doctors give discharge instructions if patients are going to be sent home," says Kyriacou. "That helps us move patients out a lot faster."
Previously, the nursing attendants gave patients discharge instructions, but they were often overwhelmed with other tasks, Dyne explains. "We made that a physician responsibility. Now it takes less than five minutes to get the patient out the door rather than 30 minutes."
Reference
1. Kyriacou DN, Ricketts V, Dyne PL, et al. A 5-year time study analysis of emergency department patient care efficiency. Ann Emerg Med 1999; 34:326-335.
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