Patient Flow Efficiency

1
Patient Flow Efficiency Techniques in
the Emergency Department
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health
Sciences Clinical Professor of Emergency
Medicine George Washington University Bethesda,
Maryland, U.S.A.

2
Goals of Trying to Maximize Patient Flow
Efficiency in the E.D.

• Improve patient care
• Improve patient satisfaction with care
• Lessen stress on E.D. staff
• Limit financial costs to hospital
• Allow more available staff time for teaching

3
What Does Maximizing Patient Flow in the E.D.
Really Mean ?

• Limiting as much as possible the time intervals
  between each sequential event that is necessary
  for patient care
• Maintaining quality, safety, completeness,
  empathy, and personal attention in patient care

4
Fundamental Principles Behind Improving Patient
Flow Efficiency

• Anything that delays evaluation by the emergency
  physician is detrimental
• Everyone in the department must be committed to
  cooperative with efficiency efforts
• Provision of emergent care procedures always
  takes precedence
• Making events simultaneous rather than sequential
  increases efficiency

5
Items for Everyone to Keep in Mind to Enhance
Efficiency

• Starting patient care does not depend on the
  paperwork being ready
• Maintaining efficiency and speed are important
  even when the E.D. is not busy, because this
  enables the E.D. to better handle a sudden,
  unexpected influx of patients

6
Nursing Triage Background Aspects Related to
Efficiency

• COBRA / EMTALA require that all patients be
  medically evaluated prior to being asked to
  register
• Triage should take lt 3 minutes maximum per
  patient
• Space seating allowance necessary for multiple
  simultaneous presenting patients

7
What Exactly Constitutes Proper Efficient Nursing
Triage ?

• Immediate "experienced eyeball" assessment of the
  patient's condition
• "One line" chief complaint
• Vital signs
• Pulse
• BP
• Resp. rate
• Temp.
• Current meds allergies

8
Patient Disposition Options for the Triage Nurse

• Take patient immediately back to emergency care
  area
• Send patient to E.D. registration
• Send patient to a "nonemergent" care area
• Send patient to X-ray or laboratory prior to
  being sent into E.D.
• By preapproved written protocol based on chief
  complaint

9
Time-Saving Techniques at Registration

• If others accompany the patient, have them
  register the patient while triage and initial
  E.D. care are started
• If patient is preregistered in hospital system,
  only record new or changed info
• Utilize bedside registration as much as possible
• Automatically obtain patient's recent E.D. chart
  to accompany current chart

10
Standard Efficiency Criteria for Initial Patient
Care

• For any potentially unstable patient, nursing
  should go ahead with O2, monitor, IV, blood draw,
  EKG, pulse oximetry, early M.D. notification
• X-ray /- resp. techs may need to be notified
  activated, but M.D. should see patient prior to
  their actions
• M.D. should be notified of priority of multiple
  simultaneous patients

11
Patient Evaluation Efficiency Techniques for
Physicians

• For several near-simultaneous patients
• See 1 or 2 simple cases only requiring exam or
  single x-ray first, then see a more complex or
  involved patient, then recheck the x-ray results
  for the simple cases while awaiting lab, etc. for
  the complex case
• Hold paperwork completion till after all these
  patients are seen
• Lengthy non-resuscitative procedures on patients
  who are definitely going to be admitted anyway
  should not delay evaluation disposition of
  patients with simple or more minor problems

12
Paperwork Efficiency Techniques for E.D.
Physicians

• When a patient can be discharged, fill out first
  the discharge orders instructions get the
  nurses working on the discharge then go back
  fill out the HP
• Preprint the discharge instructions whenever
  possible
• Can be done during suturing, for instance

13
Additional Efficiency Techniques for E.D.
Physicians

• Draw send lab tests early if needed
• Pelvic secondary exams should be done after lab
  is sent
• Hold split urine specimen extra blood tubes in
  case secondary tests prove needed
• Complete entire physical exam prior to ordering
  X-rays so all films can be done at once

14
Additional Efficiency Techniques for E.D.
Physicians (cont.)

• Don't recite entire HP over the phone to
  consultant just tell him what you need him to
  do
• Verify specific times that labs were sent to know
  when to check up on them
• Once a stable case is turned over to a
  consultant, don't hover over the patient

15
Suturing Efficiency Techniques for E.D. Physicians

• Have equipment obtained set up while you are
  doing the HP
• Don't X-ray the wound for foreign bodies if you
  can explore it directly adequately
• Have staff obtain discharge meds instructions
  while suturing is being done

16
Charting Efficiency Techniques for E.D. Physicians

• Dictate charts whenever free time is available
• May split dictation (dictate initial HP first
  then later add addendum dictation once lab
  disposition are known)
• Handwrite data prior to dictations as needed to
  provide "memory jogs"
• Leave charts in the locations where they're
  supposed to be so time is not wasted tracking
  them down

17
Interactive Efficiency Techniques for E.D. Staff

• Don't be rigid about job duty performance
• Helping someone else with their job may speed
  things up a lot
• Extra attention should be directed to help the
  person who is the most busy
• Let E.D. staff know your patient care plans so
  they can anticipate further actions
• Have flexible room coverage assignments

18
Improving E.D. Patient Flow Efficiency Summary

• All E.D. staff should take interest pride in
  efficient patient flow
• Anticipation and cooperation are key
• "Mapping out" of short term events is helpful in
  planning
• System should be geared to minimizing time to
  initial M.D. exam, to making events
  simultaneous rather than sequential