Pull Don't Push - A Paradigm Shift for Patient Throughput

Purpose:
Discover an innovation addressing patient flow as a hospital-wide improvement. The flow of the ED is effectively addressed and improved by treating it as a hospital-wide process instead of an ED problem. This presentation describes the processes, outcomes and impact of a Full Capacity Protocol.

Relevance/Significance:
ED overcrowding is associated with decreased quality of care, higher morbidity/mortality, decreased satisfaction, increased costs, diversion, increased patients who leave without being seen and delayed care with longer lengths of stay. Overall high census within the hospital has a downstream effect on the ED and impacts patient care.

Strategy and Implementation:
Full Capacity Protocol(FCP),a hospital-wide response plan for managing patient flow during extreme hospital volumes was created to promote the provision of safe, efficient care for the most complex cases by enhancing throughput and reducing diversion. FCP is effective in reducing LWBS, diversion, and accommodating increased admissions while allowing for significant increase in ED volume. Instead of the ED “pushing” patients up, resources respond to help facilitate the interventions needed to “pull” patients to disposition. This includes housekeeping, transport, flow coordinators and leadership. The cornerstone of this program includes the establishment of an ED Flow Coordinator; an experienced emergency nurse whose sole responsibility is to facilitate the flow into and out of the ED combined with the implementation of a Full Capacity response plan. Our “all hands on deck” approach changes throughput from an ED issue to a house-wide response.

Evaluation:
Data regarding diversion hours (ED and hospital), and patient throughput were collected. The analysis showed a 7.4% increase in ED encounters (p<0.001) and an 11.9% increase in ED admissions (p<0.001) compared to the corresponding time period. The ED also saw a 10.2% decrease in LWBS (p=0.29), an increase in LOS of 34 minutes (p<0.001), and a 92% decrease in ambulance diversion (111 fewer hours).

Implications for Practice:
A FCP is effective in reducing LWBS and diversion, while allowing for an increase in ED volume and accommodating increased hospital admissions. This indicates that a multidisciplinary approach can generate substantial improvements in a hospital's ability to address ED overcrowding and throughput.