This article is the second of a four-part series of articles focusing on emergency department improvement. Subsequent articles will deal with “The ED Performance Scorecard” and ” The Multidisciplinary ED Performance Improvement Team.”

In the emergency department, minutes are critical. In a minute, a life can be saved, in a minute, a parent relieved. But what happens when minutes turn into hours, many hours, sometimes days? What effect does this have on patients and their families? What happens to the confidence of the community that entrust their emergency care in an emergency department that is always crowded, always takes to long and seems to always be in crisis, no matter what time of day or night?

The answers to all these questions will not surprise you. Patients complain, communities complain, and hospital administrators struggle to find answers. According to the Centers for Disease Control and Prevention (Advance Data No. 372, June 23, 2006), on average in 2004, patients spent about 3.3 hours in the emergency department – from arrival to discharge. Almost 400,000 patients waited 24 hours or more; patients admitted to the hospital or referred for drug or alcohol treatment were in the emergency department about 6 hours on average. Press Ganey Associates assessed average waits across the U.S. in 2005, and found Iowa had the briefest waits (138.3 minutes) and Arizona had the longest waits (297.3 minutes).

So in a sea of overcrowding, complaints and struggles to find solutions, where should improvement efforts begin? Where should process improvement efforts be focused? What key processes should we evaluate, improve and monitor to make the biggest impact? To find these answers, lets look at the two most basic needs of any emergency department; How to get patients in for treatment (Front Door) and get them out to appropriate dispositions (Back Door)

Front Door Issues

Thinking in terms of supply and demand, the demand for emergency care is high, while the availability of emergency departments continues to shrink. According to the American College of Emergency Physicians, Emergency department visits in 2004 rose to 110.2 million, up from 93.4 million in 1993 – an 18 percent increase. At the same time, the number of emergency departments decreased by 12.4 percent resulting in dramatic increases in patient volumes and waiting times at the remaining facilities. U.S. hospitals over the past 10 years closed more than 100,000 inpatient beds and nearly 8,000 intensive care beds in an effort to control costs. The majority of the nation’s 4,000 hospital emergency departments report that they are operating “at” or “over” critical capacity.

While these issues are real, so is the need to improve accessibility for those that seek emergency care. So how do emergency departments get these patients into their front door efficiently while the department is already overcrowded?

Relief Valves

Everyone arrives at the same door, everyone talks to the same receptionist, and everyone has to see the single triage nurse and so on. Sound familiar? This single file process sets up the first in a series of “natural bottlenecks” that prevent efficiencies. As the waiting room fills, there should be a series of pressure relief mechanisms to prevent acute patients from getting to care, to prevent excessive wait time for non critical patients and to avoid the frustration of overburdened physicians and staff as they struggle to care for everyone.

While all EDs are different in physical structure, numbers of beds, staffing patterns, etc., most still have capacity to make front door improvements. Numbers of registration clerks, numbers of triage nurses, fast tracks or quick cares are just a few. Other considerations include use of midlevel practitioners (PA or ARNP), physician triage, or accelerated MSE (Medical Screening Exam).

With improved efforts to get patients into the ED, there must be a concurrent focus on getting them out of the ED.

Back Door Issues

Once inside the ED, the clock starts ticking again. “How long will I be here”, I have been admitted, when will I get a bed”? Common questions from waiting patients. Does your emergency department give the standard cliché answers or does it really have a plan to decrease the time it takes to send patients to their next destination i.e. home, inpatient bed, or another facility?

There are many factors that effect moving patients from the ED. Hospital capacity during peak times, availability of on call physicians, availability of local resources for drug and alcohol treatment, etc. But within these factors are two that stand out as a must improve:

1. Discharged patients must be discharged timely>br /> 2. Boarding patients must be minimized

Timely Discharge

Patients that have been cared for and are awaiting the “discharge process” are taking up precious bed space for sometimes an hour or more. This seems to be a no brainer, but not so fast. There are legitimate reasons why some patients can’t be pushed out of an ED once their care is complete. Nursing home patients waiting for transportation, elderly patients waiting for caregivers to arrive, etc. But some of the delays are the results of an overworked staff trying to catch up and care for other patients. Some nurses have stated, “the discharged patient is a low priority” or “If I discharge one, I get another one and I am already overwhelmed.” Giving support and incentive to moving patients and not hording them can help improve overall patient turn around times.

Boarding Patients

According to the American College of Emergency Physicians (ACEP), hundreds of emergency departments have closed in the United States. At the same time, the number of emergency department visits increased to 110.2 million in 2004 (up from 107.5 million in 2001). Many of the remaining hospitals lack capacity, which means critically ill or injured patients may have extended stays in the emergency department until hospital beds become available. This practice is known as “boarding,” and it is a major factor in overcrowding Boarding also contributes to ambulance diversion and limits a hospital’s ability to meet periodic surges in demand, such as those from disasters.

Certainly this issue is complicated and each facility must examine the issue closely and determine the best improvement strategies. The practice of leaving admitted patients in the emergency department for extended periods creates a hardship not only for patients waiting to get into the department, but for the admitted patients that require complicated care, for staff that has to prioritize care and sometimes leaving things undone, and for ED physicians that must now compete with admitting physicians for “nursing care time.”

Another factor influencing ED boarding is the facilities internal competitors for inpatient beds. The ER, OR, the cath lab, direct admissions, all competitors for inpatient beds. Often the priority of bed control is to “leave them in the ED because they are receiving care” or, “we can’t back up the PACU because we may delay surgery.” This practice coupled with internal ED and hospital inefficiencies create another bottleneck to ED flow. Are you prepared to stop elective surgeries? Are you prepared to stop elective admission? Questions that must be asked and answered to effectively address ED boarding.

So which is the bigger problem, front door or back door? Well both are certainly high on the list of must focus on for ED improvements. According to simple physics, you can only get more into a funnel if you let an equal or greater amount out the other end. As with emergency departments, focusing on the entire process, which includes the constant balance of inflow and output, will improve overall efficiency and patient, physician and staff satisfaction.