436 - Improving Emergency Department Flow through Model of Care Changes

Poster Number: 436
Publication Number: 436.2897

Background: Emergency Department (ED) overcrowding is a national crisis associated with decreased quality and significant patient safety concerns.(1) With decreased physical capacity due to boarding and ongoing staffing challenges, EDs need to adapt to meet the needs of increasing patient volume.

Objective: Our objective was to re-design an ED model of care (MOC) to improve patient flow.

Design/Methods: We conducted a multi-day, interdisciplinary workshop to re-design our MOC using Lean principles. The initial model used four existing double-entry ED rooms combined with elements of provider-in-triage, supertrack, vertical patient flow, a results waiting lobby, and reimagined nurse roles for Lobby Sort and Flow. This model runs 15 hours/day and is staffed by a PEM physician, an APP/senior resident, two RNs and an ED tech. Through the completion of iterative Plan-Do-Study-Act cycles using tabletop and in-person simulation, and a 4-day patient trial, we refined processes needed for the new MOC. Outcome measures include left without being seen (LWBS) rates, ED length of stay (LOS), and time to see a licensed provider. A process measure was time to vital signs. A balancing measure was 72 hour return rates. Initial results were compared to results from an equivalent time period in 2022 with similar patient volumes (Sept 2022). Run charts, statistical process charts (SPC) and non-parametric paired comparison are also planned.

Results: Beginning in early October, 2023, we went live with the new MOC. Initial results after the first 4 weeks of implementation demonstrate a decrease in LWBS rate (2.6% vs 0.7%), decrease in ED average LOS for discharged patients (259 min vs 225 min), and decrease average time to provider for all patients (54.8 min vs 42 min) as compared to patients from September 2022. A run chart of cases is shown in Image 1. Initial SPC charts for LWBS rates and ED LOS for all discharged patients are shown in Images 2 and 3. Process and balancing measure evaluation is in process.

Conclusion(s): We instituted a new MOC that after the first 4 weeks of implementation has decreased LWBS rates, time to a licensed provider and ED LOS which is contributing to decreased ED overcrowding and does not require additional staff, physical space or equipment resources. We believe that lessons from this model are generalizable to other EDs.

Reference: (1) Kelen GD, Wolfe R, D’Onofrio G, et al. Emergency Department Crowding: The Canary in the Health Care System. NEJM Catalyst. September 28, 2021. Accessed 10/31/2023.