Due to overcrowding and hospital closures, wait times at emergency rooms across the country are soaring. About 65,000 patients visited the Torrance Memorial Emergency Department (ED) last year. So it’s no surprise that like most EDs in Southern California, it too suffered from overcrowding.
Having spent hours in the ED during previous visits with her three small children, Jacqueline Renfrow of Redondo Beach fully expected to endure a similar experience when she visited Torrance Memorial in December with her 10-month-old, Amelie. After leaving her kitchen briefly that evening, she heard a loud thud and returned to find her daughter and her highchair had toppled onto the floor.
“I heard a snap and didn’t know if it was her head or the high chair bumping into something. After a few minutes of tears, she seemed fine and had just a red mark on her cheek. But I had heard that children under 1 year old should visit the ER for any kind of head trauma, so I decided to err on the side of caution,” Renfrow says.
While Jacqueline filled out paperwork, Amelie’s vitals were tested upon arrival. Sent back to the waiting room, she braced herself for a long wait. To her surprise, within 10 minutes they received a bed and also a visit from Emergency Department physician Gretchen Lent, MD.
Renfrow is the beneficiary of a program recently implemented to streamline efficiency and reduce ED wait times. Torrance Memorial’s ED nurses were aware that, in addition to being frustrating for the patient, long wait times also increase the risk of poor patient outcomes. They proposed forming awork group to address this challenge.
“We knew that long wait times were a serious problem from the standpoint of patient safety and satisfaction,” says Don Andrews, RN, ED manager. “When patients visit the ED, you can only appease them for so long before they are able to see a doctor. So it can also be a tough environment for the nurse and the patient when, in addition to not feeling well, the patient is already upset at first contact from having waited so long.”
A team composed of ED nurses, registration staff and physicians convened in mid-2013 and assessed that the long waits were stemming from three factors—one geographic and two organizational. First, the physical layout of Torrance Memorial’s ED is linear. As a result, an emergency physician would spend significant time walking back and forth through the department evaluating patients scattered across its length and searching for the appropriate staff members assigned to a patient’s care team.
It was not uncommon for physicians to share patients with every nurse and tech in the ED. It was also typical for nursing assignments to change mid-shift.
TAKING A LEAN APPROACH
The team used principles of Lean methodology, Toyota’s model for process improvement, to develop a new approach to patient flow. The geography of the approximately 45-bed ED was broken down into four, 10-bed units known as pods and one five-bed unit for ambulatory patients with minor problems.
The new pod system went live in October 2013. Each pod is staffed by a stable team of one emergency physician, three nurses and one ED tech for the duration of the physician’s shift.
“Our goal was to move staff closer to their patients and minimize the necessity for anyone to leave the pod,” Andrews says. “Previously we had certain areas devoted to specific issues such as gynecology or lacerations. Now each pod is equipped to handle all types of patients.”
Within the pod, one nurse acts as the team coordinator and is responsible for patient flow through the pod. Patient volume data is tracked to determine staffing needs hour-by-hour— resulting in a scheme where the ED expands and contracts between a minimum of one and a maximum of five pods over the course of the day.
When a patient checks into the ED, he or she receives a pod assignment. An electronic tracking system allows each pod team coordinator to identify which patients in the ED waiting room have been assigned to their pod, effectively splitting the main ED waiting room into five separate waiting rooms.
According to ED physician Brian Miura, MD, the team’s assessment also revealed that on average, 25% of ED patients don’t require a bed.
To further improve patient safety and efficiency, emergency physicians were mandated to perform a medical screening examination within one hour of patient arrival. During that process, the medical stability of each patient is assessed, and appropriate diagnostic studies are initiated.
“Stable patients can undergo blood work, CT scans, ultrasounds and other testing from the waiting room lobby without ever having to occupy a bed. This enables us to maintain bed availability for unstable or critically ill patients,” Miura says.
Once their workup is complete, the patient is either admitted to the hospital or discharged to go home.
Since the program’s implementation, benchmarks have improved in all areas. Data shows an average decrease in door-todoctor evaluation time (amount of time from when a patient enters the ED to the time he/she is seen by a physician) from 74 minutes to 39 minutes year-over-year. Median length of stay decreased by one hour and 18 minutes. Patient satisfaction also improved 51% within two months*.
With no visible bumps or scratches, Dr. Lent advised Renfrow that X-rays probably weren’t necessary for Amelie and that they could safely return home.
“The entire visit took less than an hour and a half,” Renfrow says. “I was so impressed by how efficient and nice everyone was. While Amelie was still getting dressed, someone came in with a computer and printed out our paperwork, and we were all set to go. Everyone seemed to have a very specific job, knew their role and got it done quickly.”
IMPROVING PATIENTS OUTCOMES
While efficiency is important to Miura and Andrews, so are better patient outcomes.
“The stable configuration of personnel over the course of the shift fosters improved communication and accountability among pod team members and minimizes potential for medical errors by reducing the number of patient care transfers,” Miura says.
Since the Lean method by definition means a system of continuous improvement in quality, the staff will continue to refine its pod structure. But the team is confident that with this new structure in place, it is much better equipped for the future.
“The improvement is quite dramatic. We are now much better prepared to handle surges in patient volume we had previously struggled with, and our waiting room is rarely full,” Miura says.