Our Journey: Decreasing Time From Decision-to-Admit to ED Departure

Purpose:
The purpose of this project was to optimize patient flow, decrease time from decision to admit to Emergency Department (ED) departure, and reduce ED diversion hours by engaging a whole hospital response to facilitate pulling admitted patients from the ED and placing them in inpatient (IP) beds.

Relevance/Significance:
Based on the principles of Lean/Six Sigma, an Operational Excellence project titled Status Indicator and Back-up Plan was begun in 2012. Improving patient flow metrics involved Emergency Nursing and Medicine Directors, Diagnostic Imaging Safety Officer, ED Physician and Representatives from 38 departments. This project demonstrates how nursing and involvment from 38 hospital departments can connect quality, safety and staffing to improve admit to ED departure and reduce ED diversion hours.

Strategy and Implementation:
Key tools that were developed and implemented in September 2012 included a status indicator grid, status alerts, and status alert standard work. Using an alert color scheme, the status indicator grid defines capacity management based on identified standard work. Status is determined by combining data from the ED saturation calculation and daily assessments of inpatient capacity, critical care beds, OR and procedural area operations. Nursing Supervisors are authorized to coordinate efforts that support activation of the status indicator grids, disseminating cascading communications that indicate hospital capacity and initiate Throughput Huddles. Census capacity communications are sent at routine intervals. Throughput Huddles include representation departments who have established actions to each status alert. Huddles take 15 minutes and have goals of identifying resources needed to expedite discharges, ensure adequate resources are triaged and improve inpatient bed capacity.

Evaluation:
There is now a leveled methodology to improve flow and accomodate surge. These metrics are monitored through the Patient Flow Steering Committee. The admit decision to ED departure has improved from 2011 before the project was implemented when it took 140 minutes to 2014 when it took 102 minutes. Diversion hours decreased from 667.39 in fiscal year 2011 to 5.60 in fiscal year 2014.

Implications for Practice:
Decision to admit (IP) to ED departure management is dynamic. It is important to have hospital processes and supporting tools to continuously evaluate and allow for real time changes. Sharing this nurse driven best practice will assist other hospitals improve their patient flow metrics.