Proposed Actions To Improve Waiting Times At The Emergency Room

In Nova Scotia Hospitals

HESA 4003 & HESA 4020Quality Management and Quality Improvement

Dalhousie University .N.S. winter 2009

Xiomara Arias-Fernandez.

Emergency Room Wait Time Issue. A Need For a Change. According to the Canadian Association of Emergency physicians (CAEP, 2005 )

reducing waiting times is a clear priority at national level established in the document

“A Ten Year Plan to Strength the Healthcare". In effect, from 2004 to 2010, Federal

and Provincial governments have assigned more than 4.5 billion dollars to implement

strategies that aim to accomplish this goal in priority areas. Prolonged waiting times

are also concerning for lack of effectiveness in Canada’s Emergency Departments

(CED). An excess of patients overusing the emergency service impedes their ability to

provide them of effective and timely services. The shortage of beds in hospitals and in

the Intensive Care Unit are the causes of the overload of patients requiring services at

the emergency room. Also, government funding cuts have lead to reduced hospital bed

capacity, generating an overload crisis in emergency departments and this is worsened

by the increasing number of aging users.

(

Emergency Room Wait Time Issue. A Need For A Change

Additionally, patients who require alternate services (alternate level care, or ALC) such as palliative

care, contribute to the overcrowding crisis, because approximately 20% of these patients have to

use beds that should be assigned for acute care. Bed waiting times and patient flow are affected by

in-patients who no longer require acute care (Canadian Institute for Health Information , 2007)

“Most hospitals in Canada currently operate on 95% bed occupancy rates” (CAEP, 2005 p.3) which

means that overcrowding is occurring consistently, deteriorating the service and having harmful

repercussions in health’s patients, ranging from worsening medical conditions to loss of life. The

aim of this presentation is to expose different approaches based on the research of authors . These

approaches could reduce the wait times in ED. Also is presented an hypothetical design based on a

previous successful model put in operation in 2007 at Mary Washington Hospital in VA USA .

The intent of this hypothetical project is to help in making the necessary improvements that lead in

reducing wait times in ED.

Emergency Department Wait Time Issue In The Healthcare System Across Canada

(Canadian Association of Emergency physicians, 2005)

Delays in treatment/Reduction in flow of patients to others wards

Worsened medical condition- Life-threatening

Owercrowding –crisis + overuse of ED service

Ineffective and untimely serviceGovernment funding cut + High # of ALC patients

Beds shortage

Emergency Department (ED) Overuse By ALC Patients

A Brief Look To Part Of The IssueThe Toronto District Health Council defines an ALC patient as one that is “considered a non

acute treatment patient but occupies an acute care bed. This patient is awaiting placement in a chronic

care unit, home for the aged, nursing home, rehabilitation facility, other extend care institution or home

programs etc. The patient is classified as an ALC when the patient’s physician gives an order to change

the level of care from acute care and requests at transfer to another facility.” (GTA Rehab, 2004 , p.3)

In 2007-2008 ALC patients accounted for 14% of hospital days in acute facilities across Canadian

provinces “This means that, on any given day, almost 5,200 beds in acute care hospitals were occupied by

ALC patients.” (Canada Institute for Health Information, 2009 p.3). One of the major clinical

hospitalization categories was mental diseases and disorders -17% of the hospitalizations- (Discharge

Abstract Database, 2007–2008, Canadian Institute for Health Information, 2009 p8).

Discerning The Dynamic of Waiting Times In The E D

Outpatient status Inpatient status

Total ED length of stay

Time to disposition

Initial physician assessment wait time bed-wait time

ED registration triage Initial physician assessment decision to admit leave Ed (move to acute care ward)

The bed wait time is calculated as the time a patient spends waiting in the EDfrom the physician(s) decision to admit them to an inpatient bed to the time that the patient leavesthe ED. (source: Canadian Institute for Health Information ,2007. Access to inpatient beds ,p8 )

Plan Action To Reduce Waiting Times In Emergency Room

Actions To Reduce Owercrowding –Crisis

(strategy based on Karpiel, 2004)

At Inflow process level: To Implement a triage-driven bed placement method (Patients are

taken immediately to a treatment area after triage and quickly registered).

Enforce the use of bedside registration.

At Throughput process level: create a separate "fast-Track” area staffed with mid-level care

providers such as nurse practitioners to care for low-acuity patients. In this way, less critical

patients would be seen quickly and leave ED physicians to focus on critically ill or injured

patients. Create a reasonable not limited access to lab services and diagnostic imaging by having

dedicated radiology and lab technicians assigned to the ED during the busiest hours of operation.

By implementing a point of care satellite laboratory ( Lee-Lewandrowski et al, 2003) the

patient length of stay and turnaround time can be reduced .

At Outflow process level: Use of :Pre-emptive bed requests to allow ED physicians to request a

hospital bed previous authorization patient admission. Perform faxed admission reports, to

eliminate consumed time for ED nurse give call to inpatient nurse .Carry out a capacity

Management System, to replace the floor nurse's role in alerting housekeeping of empty rooms.

(This action improves housekeeping productivity and expedite bed availability).

Plan Action To Reduce Wait Times In Emergency Room

Actions To Decrease Overuse Of ED Service By ALC Patients.

In the case of mental health patients and based on information provided by The

Ontario Partnerships Report, 2008 three alternatives can be used:• Develop a 24/7 Crisis Response System. A comprehensive and coordinated crisis

response system should include the following components: crisis response line, safe beds, mobile teams, direct links to emergency departments, and direct links to community-based case management .

• Support peer support workers involvement in discharge planning to offer support and facilitate transitions from institutional to community care, i.e. social workers.

• Invest in community mental health and addiction services that connect directly with hospitals, to facilitate appropriate diversion from emergency rooms; and support access to the most appropriate community based services and supports

Plan Action To Reduce Wait Times In Emergency Room

Actions To Improve Patient Flow

(strategy based on Jensen and Crane, 2008)

1- To organize a measure of patient demand by hour, and outline a system to manage it. To conform staffing to patient ingress and capacity. To break down ingress by main complaint, triage, emergency medical services arrivals, emergency severity index (ESI) level, and ancillary utilization. (all are calculable). To design a response plan for times when demand unusually spikes (It is critical to match hours of operation to patient demand.)

2- To Justly empower triage processes and systems. Triage is a support, a function to help in the process of reducing waiting times, and is not useful for properly staffing an ED or decide who can wait or who not.

3- To consider using team triage to promptly discharge patients at CTAS level III .This process involves quickly assessing, registering, and processing through team triage, and then allocating or sorting patients CTAS levels I,II,IV and V to either a treatment area or results-waiting area.

4- To appraise ongoing triage protocol By switching to a "see-and-treat“ model, EDs will have one in-process queue, where patients wait just one time for a one-stage assess, treat, and discharge process

5- To use a technician or secretary to follow patients who don't need a bed and their results 6- To prepare and handle a vigorous staff with an eager platform.

Time frames developed in 1998 by CAEP and defined as reasonable times to physician-directed care in person or telephone advice or as care provided by nursing staff in accordance with medical directives agreed to in advance by the physician (Beveridge R. 1998)

Objective: "more accurately define patients' needs for timely care and to allow emergency departments to evaluate their acuity level, resource needs and performance against certain operating 'objectives.' “(Beveridge et al ,1998 p.2). The primary objective of the triage scale is to define the optimal time to see a physician

The Canadian Emergency Department Triage and Acuity Scale (CTAS)

CTAS I: requires resuscitation and includesconditions that are threats to life or imminentrisk of deterioration, requiring immediateaggressive interventions (for example, cardiacarrest, major trauma, or shock states).CTAS II: requires emergent care and includesconditions that are a potential threat to life orlimb function requiring rapid medical interventionor delegated acts (for example, head injury, chest pain,gastrointestinal bleeding, abdominal pain with visceralsymptoms, or neonates with hyperbilirubinemia). CTAS III: requires urgent care and includes conditionsthat could potentially progress to a serious problemrequiring emergency intervention, such as mild moderateasthma or dyspnea, moderate trauma, orvomiting and diarrhoea in patients younger than 2 years. CTAS IV: requires less-urgent care and includesconditions related to patient age, distress, orpotential for deterioration or complications thatwould benefit from intervention or reassurancewithin one to two hours, such as urinary symptoms,mild abdominal pain, or ear ache.CTAS V: requires non-urgent care and includesconditions in which investigations or interventionscould be delayed or referred to other areas of thehospital or health care system, such as a sorethroat, menses, conditions related to chronic problems,or psychiatric complaints with no suicidalideation or attempts.

The Canadian Emergency Department Triage and Acuity Scale (CTAS

Source: Canadian Institute for Health Information ( p.7) 2005

Time to assessmentnurse: 0 min

Physician: 0 min

Time to assessmentNurse:0 min

Physician 15 min.

Time to assessment

Nurse:30 min.Physician: 30 min.

Time of assessment.

Nurse:60 minPhysician:60 min

Time of assessmentNurse: 120

min.Physician: 120

min

The Maximum Efficiency Care Project Hypothetical design based on RATED.ER project ( Crane J, 2007 )

Project developed to improve waiting times and enhance Emergency department service

Xiomara Arias Fernandez

The Maximum Efficiency Care ProjectXiomara Arias Fernandez

( Based on Crane J, 2007 RATED.ER project) The Maximum Efficiency Care Project must be performed in a triage setting at the hospital ED.

This project will be based in the called RATED.ER ( Rapid assessment, Triage, and Efficient Disposition in the

Emergency Department) project performed by Crane Jody at the ED in Mary Washington V.A. USA in 2007.

Crane’s project focus on apply Lean tools to a value stream of Emergency Severity Index (ESI) level 3

patients, instead The Maximum Efficiency Care Project will focus on improve the efficiency through of patients

classified as level III in the CTAS. To set up this project also some Lean tools will be applied , such as Rapid

improvement Teams, (teams who analyzed processes to make quickly improvements) Takt Times, (the time

required to produce a component or set of components to meet a customer demand )and Visual Signals,(use of

indicators and signs to share critical information) among others. In order to provide a comprehensive evaluation,

early treatment and to determinate the bed needs of these type o patients The Maximum Efficiency Care Project

will include a staff comprised of physicians, nurses and medical assistants. It will also be necessary to

implement a waiting area where patients will wait for ancillary test results, and where will be set beds and

treatment/ discharge chairs. These resources will be compiled according the demand presented. To accomplis

TheMaximum Efficiency project when beds are required it will be created an Intake Team System integrated

by

physicians, midlevel ,Register nurses , a paramedic and a Unit secretary with a group of beds behind triage.

One

of the core purpose of this team will be appropriately identify CTAS levels I,II and IV,V patients, so that they

can be seen quickly in Main ED or in a fast track area in order to alleviate potential backlogs.

Goals to be achieved with the creation of “The Maximum Efficiency Care project” in Emergency Department (ED)

• To reduce work in process (patients long waiting at ED ).

• To reduce wait times in Ed.

• Decreasing length of stay(LOS) for fast track patients .This action will allow to see the patients who are sicker.

• To eliminate waste of human time and material resources by decreasing the non -value -added patient processes.

• To accurately determine the quantity of beds needed in the area of emergency.

• To maximized the value of patients by being seen in a primary care setting.

• To improve revenue (funding for the next fiscal year) through enhance throughput and flow of patients.

Strategy to perform The Maximum Efficiency care projectAction Purpose/Targets

1)To create a platform consisting of an expeditious nursing assessment, a brief triage assessment and an intermediate evaluation by the team of providers.

To provide efficient patient flow

2)To create a System Reception where the patient will be received by a ED medical technician, a registration clerk and an Ed nurse ( Pivot nurse).

Pivot nurse will complete a brief sign –in sheet (based on the main patient complain and general appearance) to be delivered to the medical technician and also will assign the patient to Main ED if the patient is an ESI levels I ,II, or to The fast- Track area if patient is IV ,V CTAS levels or to a mini-triage. Then to the intake team if patient is a CTAS level III or some IV level . The Pivot nurse also places patients in the waiting and results waiting area. The registration clerk will perform a quick registration

3) To calculate takt times (based on patient demand)

To allow staffing the Intake team system and to identify bed needs a s well as to complete initial nurse and physician assessment

4) To Perform a limited initial assessment To meet criteria that satisfy the need to assign an ESI triage level as well as not to delay further progress of the patient through the system

5) To set up a treatment area with treatment beds , nurses and techs.

To eliminate backlogs by providing quickly and efficient service

6) To update physicians periodically as to the patients' status and t he status of ancillary test resulting

To advise physicians come to discharge or to admit the patients (continue the flow). To provide quickly and efficient service. To eliminate waste of resources

The Maximum Efficiency Care Project

Patient at the Reception team

(Quick Pre-

assessment by Pivot nurse

and registration by clerk ) 10min

Main ED (levels I,II )

Mini-triage process .Vital signs, main complain,

allergies, pain scales 13 min

To complete assessment , initiate treatment, testing

and bed decision needs 20 min

Fast Track (levels IV, V) Performed by Intake team system

ESI level assigned

Level III

Intake Team System Flow

Patient

Sent to ancillary services

Laboratory/ Radiology (No bed needed. Levels 3,4,5)

Main ED. (Bed needed-Levels 1,2 )

Discharged at home

Sent to a treatment area

Iv Fluids

medications

Waiting area

Virtual bed

Conclusions The shortage of beds in hospitals and in Intensive Care Unit, the

overcrowding originated by an increasing number of ALC patients using E.D beds, and the consequent low flow produced, seem to be the main causes of prolonged wait times at the emergency room . There does not appear to be a single solution to address the issue of overcrowding and shortage of beds in the E.D, causes that lead to inefficiency in the service. Several factors should be taken in account when strategies are implemented to help reduce the time patients spend in the E.D, for example, type of hospital, day of the week etc. However, the success of these strategies also will depend upon the cooperation of other hospital departments as well as the involvement of top management. The strategic areas to improve wait times must be focused mainly on E.D overcrowding management, E.D ,ALC patients overusing management, and E.D patient underflow management. Improving the access to primary health care and community-based services also can be a measure used to reduce the unnecessary visits to E.D by ACL patients. Recurrent visits to the E.D could be curtailed if opportune community discharge plans are aligned the first time.

Conclusions

A significant percentage of emergency visits by individuals could be more

appropriately served through alternative programs and services, i.e. visits to

family doctor, crisis counsellors, etc. Implementation of triage systems with

fast-track areas has been shown to improve throughput and reduce waiting

times (mainly for patients with CTAS IV and CTAS V levels ). This arise as an

answer to diminish overcrowding in E.D in these group of patients. Additional

staff in the areas of laboratory, radiology and others support diagnosis during

the busiest hours in E.D, is going to cover part of the needs of patients with

CTAS III level. By implementing a design that incorporate the use of Lean

Tools on CTAS III level patients, length of stay could be reduced in ED. The

expected reduction in time at the different stages of this model is going to

depend on the patient demand in each institution. To successfully set up the

project data should be analyzed and Takt Times should be calculated.

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