For anyone who has visited an emergency department (ED) at a hospital, the time spent anxiously waiting to be seen by a physician doesn’t just feel like hours – often, it literally takes hours to be seen and diagnosed.
Cindy Boily, Chief Nursing Officer at Broward General Medical Center, made it her mission to improve the processes that led to long waits in the ED.“I realized that these delays experienced by patients undermined patient safety, reduced access and, ultimately, led to increased costs for Broward General,” said Boily. “Not only does this delay care and cause anxiety for patients, there is a multidimensional economic impact. There is the immediate loss of patients who are unwilling to wait, and leave before being seen. Additionally, it results in a future loss of business to the hospital.”
To improve patient flow, Boily, who joined the staff of Broward General Medical Center 2008, created a multidisciplinary team called the Patient Flow Committee. Its purpose: to alleviate overcrowding and patient “gridlock” in the ED. More specifically, the team’s was to cut the time for a patient to be admitted to the hospital through the ED from the current average of 9 1/2 hours, or 569 minutes, to the national benchmark of 300 minutes in the first phase.
The team agreed that the program had to be more than a standard initiative; it was established as a pillar for the hospital’s overall strategic plan. “The ED could no longer be thought of as an isolated unit inside four walls,” said Boily. “The project’s success depended on challenging the current practices of staff and caregivers. Each employee in each department has a direct impact on patient throughput. Our job was to show each and every employee that the ED was not just a room – it’s a process that affects every aspect of the hospital.”
The first phase of the project included performance assessment and data capturing. Each department and process was assessed in order to identify key holdups. Next, a policy and procedure patient flow guideline was crafted. Changes were defined for each department. A key element of the process included an anticipatory practice called “Be A Bed Ahead”, or “BABA”. Additional changes included the development of pull strategies, revising the discharge medication process, addressing culture change, educating environmental service on the importance of prompt bed preparation, and evaluating transportation and turnaround time. Finally, the nursing and medical staff leadership led the hospital-wide transition to the new patient flow structure.
A chief goal was to take the surprise out of patient admissions. Throughout the process, the nursing leadership team met several times a day around the clock to evaluate the program’s effectiveness, handling patient placement challenges in real time when necessary.
The patient flow process has achieved several milestones since its implementation. Laboratory CBC turnaround time improved 72%. Patients leaving the ED without being seen improved 57%. Admission orders to exit from the ED improved by an impressive 81%. Also, patient transfers between departments were streamlined, a process that ensures the availability of resources when patients are ready. There were noteworthy cost savings to the hospital, too. Overtime in the PACU and the ED were reduced by a combined $800,000; ICU days were reduced by 300 (with no boarding for the last 18 months), and the average length of stay was reduced by 20%, a savings of $1.16 million in 2010.
The patient flow initiative was not without challenges. There was an anticipated resistance initially in the process change. But the benefits to the hospital and its patients made the challenge worthwhile. Dr. Nabil El Sanadi, Chief of Emergency Services, has been pleased by the results of the program. “The efficiencies achieved by the team have placed our hospital at the highest level of elite national performers,” said Dr. Sanadi.
