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“If you try to improve flow by only focusing on the ED in isolation, you will put a Band-Aid on a portion of the problem.”
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Improving Patient Flow: Enduring Issues, New Challenges

By Jill Duncan | Thursday, July 2, 2015

In this interview, IHI Executive Director Jill Duncan describes the need to use a multidisciplinary approach to address flow, and to avoid letting an overemphasis on patient satisfaction scores distract from quality and safety.

JillDuncan

How would you compare the challenges of improving the flow of patients through the emergency department a decade ago to the challenges of today? 

As was the case 10 years ago, work continues on addressing bottlenecks in the ED, the ICU, and the OR. Hospitals continue to work on flow at the system level because they can’t move people through the ED if they don’t have a place to transfer them. Essentially, many of the same issues continue to drive ED flow challenges, but what’s different from 10 years ago is volume; the volume of patients has grown and volume impacts flow. It sounds rather simple, but of course the rising number of visits to emergency departments is a symptom of very complex health and health care system problems resulting in difficulty getting access to care in the right place and at the right time. In many communities, people now use emergency departments for chronic care management as well as non-emergent health care issues. As a result, many emergency departments still have to go on bypass or diversion periodically.

In a recent survey in HealthLeaders Media, respondents rated patient flow as their number one challenge in the ED. What are some of the opportunities for improvement?

Some of the best opportunities to improve ED flow relate to front-end and back-end flow. Front-end refers to triage, admission, and intake or demographic data gathering. Back-end refers to the use of some specialists, and getting patients to where they need to be. 

Information exchange is one of the big levers for organizations trying to improve their flow. For example, since an increasing number of people using emergency departments have complex medical histories, the ability to access their medical information quickly is important. Some of this focuses on electronic medical records because the ability to pull data across systems is a real opportunity for improving efficiency, accuracy, timeliness, and overall care. 

Hospital Flow Professional Development Program | May 6–10, 2019, Boston, MA

Another opportunity is subspecialty management. An ED physician is the first person to attend to a patient and may require input from an orthopedic surgeon, endocrinologist, or infectious disease physician, for example. It’s important to get subspecialists to see the patients in a timely manner, give input into care decisions, and then provide support and continued management for the patient. This creates a big communication challenge, and it’s also a systems challenge because subspecialists are not primary providers in the emergency department. They’re primarily consultants to the ED, so they’re not necessarily available to the ED 24/7. They might be at home. They might be in their office. They might be seeing patients in a clinic. They might be in a hospital seeing patients on the ward, but that’s less likely, so the challenge is how to get access to them. Organizations have made strides in this area by doing things like using ED-call schedules for subspecialists and adapting staff and subspecialty staffing for day-to-day and seasonal variation. Finally, there are opportunities for well-coordinated systems to consider bypassing the ED for selected patients via protocol such as stroke, ST segment elevation myocardial infarction (STEMI), or heart attack.

Improving triage is another opportunity since triage is where we first assess patients. Rethinking triage may involve everything from analyzing the best time to get a patient into triage to redesigning the flow of people in and out of triage. Some organizations are starting to merge triage right into the emergency department’s direct care, almost doing away with traditional triage since it’s sometimes a potential bottleneck. Often the ED team can identify likely admissions. To improve flow, there is an opportunity to start to locate inpatient beds on ED admission versus completion of ED work up and the “formal” decision to admit a patient to inpatient care.

How does the increasing emphasis on patient satisfaction scores influence the efforts to address flow issues?

A recent article in The Atlantic raised some troubling issues about how some hospitals’ overemphasis on patient satisfaction scores may be distracting organizations from improving the quality and safety of their care. When organizations place such heavy emphasis around one component of quality care, they risk not seeing the larger picture. But it’s easy to understand why health care organizations focus so heavily on the patients’ expectations because they get rewarded for getting high patient satisfaction scores.

Having said that, the focus on patient satisfaction can also tell us a lot about the bottlenecks, backups, and other problems with flow. Getting input from patients is important, but it is only one piece of a bigger systems-level view that helps us understand the many factors that impact quality and safety in an emergency department.

The 2014 AHRQ guide, Improving Patient Flow and Reducing Emergency Department Crowding, made the case for the importance of forming a multidisciplinary patient flow team. Would you comment on that?

IHI recommends that a multidisciplinary improvement team includes a clinical leader, technical expert, a day-to-day leader, and a project sponsor. Additionally, the AHRQ guide recommends paying particular attention to the roles played by registrars, clerks, and technicians, as well as other ED support personnel. They offer important perspectives that many overlook.

For day-to-day care, nursing leaders play a pivotal system navigator role in emergency flow. The emergency department is a place where multiple care providers typically tend to the patient, so a nurse can create continuity as part of a multidisciplinary team approach. Nurses can be an advocate and educator, but also the coordinator of care.

Putting too much responsibility on just nursing, however, has potential challenges because of staffing. When various demands pull nurses in too many directions, if they’re playing the coordinator role for the patient and they’re not available, the system slows down. That’s why it’s important to have multidisciplinary team responsibility instead of individual responsibility.

How can improving flow in the ED potentially contribute to efforts to reduce unnecessary readmissions?

By improving ED flow, there is a real opportunity to help reduce avoidable readmissions. If you look at the data, some of the biggest users of emergency departments are very often frail elders, people with chronic conditions, or behavioral health challenges. Organizations making an impact on admissions and readmissions of these patients have formed collaborative partnerships with mental health agencies, skilled nursing facilities, and primary care practices in their communities. Similarly, some organizations are starting to look at unique team designs within their emergency departments to ensure access to the right people – mental health professionals, social workers, and community resource experts, for example – to help ensure that patients in the ED system get the special care they may need in a timely manner and to help transition patients to the most appropriate setting, such as hospice or psychiatric care or a nursing home.

Supporting those community components of care is a big part of reducing avoidable readmissions as well as improving population health. How can we help people avoid the crisis situations that may bring them to the ED? This applies to a person with behavioral health issues and also to someone with asthma.

How can hospitals better engage patients in the process of improving flow?

Ask patients about their experience beyond the typical satisfaction surveys. For example, shadowing patients through the system is one of the best methods providers can use to understand what their system looks like from the patient’s perspective. As clinicians, we can make a lot of assumptions about how the system works, but there’s probably no better source of information than actually following a patient from entry to discharge to really understand the opportunities and challenges within an organization’s system. Patients will tell you what is working and what is not efficient or even safe. With patient input, frontline care teams are better able to design potential changes or improvements. You can then engage patients in testing these changes.

What role does rebuilding or renovating the ED physical environment play in improving flow?

Sometimes renovation of the building space that physically houses the ED can be part of systems improvement, such as creating an area within the ED for extended observation of patients who don’t meet the acuity criteria for admission, but do need some extended support. However, before embarking on building or renovating, organizations really need to rethink their systems from front-end to back-end because flow issues are bigger than the emergency department. How does flow work across departments? With radiology? With the lab? With pharmacy? What is the flow between the ED and the ICUs, the medical units, the step-down units, and the OR? The emergency department interconnects with so many departments within an organization. If you try to improve flow by only focusing on the ED in isolation, you will put a Band-Aid on a portion of the problem without understanding and addressing what is a very complex system for patients and staff.

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