Across America, hospital emergency departments (EDs) are in crisis. For many communities, the local hospital ED has become the linchpin of their health care safety net. With a legal obligation to see patients at all times and with more people than ever seeking their services, EDs nationwide are bursting at the seams.
From 1992 to 2002, the number of annual ED visits increased 23 percent in the United States, while the number of operating EDs decreased by about 15 percent, due to hospitals either closing their EDs or going out of business.1 Many EDs are overwhelmed by the number of patients needing their services, with 62 percent of the nation's EDs reporting they that are “at” or “over” operating capacity.2 Almost daily, newspaper headlines across the country relay stories about patients waiting for hours in the ED before being seen and tales of ambulances being diverted from one hospital to the next because of overcrowding. While much of the blame for this situation has been placed on broader social issues—such as increasing numbers of uninsured Americans and increasing reliance on the ED by those who are uninsured—3many hospitals have done little to address the patient flow obstacles that lead to overcrowded EDs.
The Urgent Matters program, a national initiative of the Robert Wood Johnson Foundation, worked intensively to try to find solutions to this problem that could be applicable nationwide.As part of the program, 10 hospitals were selected to participate in a year-long Learning Network to develop a series of practical management tools to address issues related to ED overcrowding. As the initiative evolved, hospitals participating in the Learning Network developed a variety of strategies designed to improve patient flow and reduce ED crowding, and in the process created their own best practices. While each of the Learning Network hospitals decided which strategies to implement within their own organization, a number of common overarching themes for success quickly became apparent.
Critical Success Factors:
The program used an input/throughput/output (I/T/O) model as a framework for understanding why patient flow breaks down. Creating a hospital-wide team to participate in decisions and changes to patient flow was a critical factor for success.
Core MetricsThe program identified 17 key performance indicators (KPIs) designed to evaluate each hospital's patient flow performance. Information systems varied greatly among the Learning Network hospitals. Many hospitals had to implement manual systems to capture the required data, although collecting the necessary data was sometimes eased by using data sampling strategies.
Web-Based Project Management SystemLearning Network hospitals accessed the Urgent Matters toolkit of available materials via the program's Web site and also posted action plans, monthly project reports and “Celebrating Success” stories. The Web-based management system both spurred collaboration among hospitals while fostering healthy competition.
Sample Strategies and Innovations
Patient Flow Coordination and Facilitation
Boarding and Inpatient Bed Assignment
Diversion Management and Reduction
Tracking ChangeTracking dozens of changes that are being implemented at one time in a single hospital can be a huge challenge. Yet, to properly identify achievements or successes as outcomes of a specific change, each change must be closely tracked and monitored. To streamline the process, a number of Learning Network hospitals developed a rapid cycle testing (RCT) tracking worksheet to record all of the changes made, allowing them to maintain momentum while providing a redesign audit trail.
RCT Tracking Worksheet
Met with Pharmacy to develop par level and add Td to current EC PYXIS. Td was removed some time back because of a national shortage. Shortage has improved, but Td is expensive and often wasted. Td protocol added to standing orders for EC.
For this RCT, a registration specialist will be designated to register all Pediatric and PA triage patients. During the RCT, nursing staff in triage will be asked to put triaged patients' charts in a bin designated for Pediatric and PA triage patients. This will ensure that these patient charts will not be included with other EC charts during the RCT. The designated specialist will be continuously monitoring the bin. Registration will be done continuously without delay due to other charts.
Source: University Hospital in San Antonio
Short reports of effective and promising interventions demonstrated through the work of RWJF grantmaking. These products include summaries of interventions and "how-to" guides for improving care, summaries of major issues in health care, and video and audio files that further illustrate these ideas.View all