Comprehensive Bundle of Strategies Improves Emergency Department

Turnaround Time, Reduces Boarding Time and Patients Leaving

Without Being Treated
(January 2011)

Lakeland Regional Medical Center implemented a comprehensive bundle of strategies to

improve emergency department throughput, including reorganizing space into pods, making
staffing changes to facilitate patient flow, requiring emergency medical service personnel to
provide advance notice of ambulance arrivals so that a bed can be preassigned, and having a
multidisciplinary team develop and use care plans for non-emergent patients who repeatedly
present with chronic pain issues. Together, these initiatives significantly improved patient
turnaround time (in part by reducing visits from non-emergent patients with chronic pain),
which in turn has led to fewer patients leaving before being treated and fewer patients boarding
in the emergency department while awaiting an inpatient bed assignment.
The evidence consists of pre and post-implementation comparisons of key outcomes measures,
including patient turnaround time, the percentage of patients leaving without treatment, and the
number of patients boarding in the ED awaiting bed assignment.

Problem Addressed
Many emergency departments (EDs) in urban areas routinely experience overcrowded
conditions, resulting in long waits for patients, ambulance diversions, patient boarding in
hallways, and patients leaving without being treated.
A common problem: Between 1996 and 2006, the annual number of ED visits in the
United States increased by roughly 32 percent, from 90.3 million to 119.2 million.
During this time, the number of U.S. hospitals operating EDs declined, dropping from
5,000 in 1991 to fewer than 4,000 in 2006. As a result, ED overcrowding has become
quite common,1 with 90 percent of large hospitals (300 or more beds) that operate EDs
reporting consistently functioning at or above capacity.
Driven by multiple factors: Multiple factors account for ED overcrowding in urban
areas, including inefficient patient flow, patients coming to the ED with conditions that
are not emergencies, and uncontrollable fluctuations in demand related to trauma visits.
Leading to long turnaround time, related problems: Patients often wait a long time
before being treated and discharged from the ED. Before implementation of this
program at Lakeland Regional Medical Center, ED patients routinely waited 4 to 5 hours
(and sometimes up to 10 hours) before being treated and discharged. Together, ED
overcrowding and associated long wait times can cause other related problems as well,
including "boarding" of patients in hallways, diversion of ambulances to other facilities,
patients leaving the ED before being treated, and patients generally being dissatisfied
with ED services. For example, before implementation of this program, the long wait
times at Lakeland led 4 percent of ED patients to leave without seeing a doctor.

Description of the Innovative Activity

Lakeland Regional Medical Center implemented a comprehensive bundle of strategies to
improve ED throughput, including reorganizing space into pods, making staffing changes to
facilitate patient flow, requiring emergency medical service (EMS) personnel to provide
advanced notice of ambulance arrivals so that a bed can be preassigned, and having a
multidisciplinary team develop and use care plans for nonemergent patients who repeatedly
present with chronic pain issues. Key strategies include the following:
Reorganizing space into pods: Previously, the Lakeland Regional ED had two
designated patient care areas: one for critical care patients and a second for noncritical
patients. As part of this improvement strategy, the ED staff decided to no longer divide
patients by acuity according to these designated areas and instead grouped rooms into
nine pods: one for triage, six that serve adults, one that serves children, and one for
"fast-track" patients.
Triage pod: A nurse supervisor and three registered nurses (RNs) (increasing to
five RNs as arrival patterns peak) staff the triage pod, assessing patients as they
come to the ED and assigning them to other pods as appropriate. Because beds
are not earmarked for specific types of patients as was done previously, the triage
nurse supervisor can assign patients to maximize use of available capacity.
Adult and pediatric pods: Each of the 6 adult and pediatric pods has 12 beds,
including 2 designated for critical care patients. One physician and four RNs
provide direct patient care on each of these pods (although only four of them are
staffed between 1:00 a.m. and 8:00 a.m.). A nurse supervisor monitors and
manages patient flow for these pods during regular work hours (see sub-bullet
under Staffing for more details).
Fast-track pod: Staffed by a physician, nurse supervisor, and four RNs, the fasttrack pod includes five recliner chairs for low-acuity, mobile patients. The fasttrack pod serves as an efficient place to serve patients who do not require a bed,
allowing clinicians to quickly treat and discharge patients with relatively minor
conditions.
Staffing to facilitate patient flow: The following staffing-related strategies were put in
place to facilitate patient throughput:
Bed traffic controller: An RN serves as a "bed traffic controller" for the triage
pod, assigning patients to the adult pods. The RN rotates patient assignments to
the adult pods so that clinicians do not become overwhelmed with multiple
patients at once. When the RN assigns a critical care patient to a pod, she will
delay new assignments to that pod for 20 minutes so that the staff has sufficient
time to attend to the patient's immediate needs.
Nurse supervisor to monitor, manage patient flow: Each adult and pediatric pod
has a nurse supervisor who monitors patient flow and identifies and addresses any
delays in care. For example, the nurse supervisor may follow up on a diagnostic
test that has not been performed or on results that have not been received, remind
the physician that laboratory test results have arrived, resolve difficulties in
reaching a consulting physician, move a teenager from the pediatric pod to an

adult pod if the pediatric pod is full, and prompt physician decisions related to
hospital admission or ED discharge.
Throughput coordinator during off-hours: Because pods do not have nurse
managers present regularly during off-hours and weekends, an RN throughput
coordinator assumes responsibility for monitoring and addressing workflow
issues and delays across all pods at night and on weekends.
Assessment-Care-Treatment (ACT) Team: When pods are at full capacity, the bed
traffic controller can activate a small group of nurses for the triage pod, known as
the ACT team. Led by the triage nurse supervisor on the shift, this team
implements protocols approved by ED physicians to initiate laboratory testing
and other needed services. The goal is to begin care before bed assignment,
thereby reducing delays. The ACT team is typically activated when a patient has
waited for 15 or 20 minutes after triage for a bed assignment.
Prenotification from EMS personnel: EMS personnel notify the bed traffic controller
about all patients coming to the ED by ambulance, providing information about their
medical history, condition, and severity of illness. The bed traffic controller uses this
information to assign these patients to pods before their arrival. After arriving at the ED,
EMS personnel view a tracking board at the EMS entrance to learn the patient's bed
assignment and then deliver the patient directly to that bed.
Care plan for frequent visitors with chronic pain: A multidisciplinary pain
management team (including a palliative care pharmacist, pain management pharmacist,
hospitalist, the ED medical director, and the ED manager) develops individualized care
plans for patients with chronic pain who frequently visit the ED. The care plan is
initially developed when an ED physician notifies the team about a patient who has
presented with chronic pain issues multiple times over the past 3 months. The team
meets periodically to review the records of referred patients and develop individualized
care plans, including a strategy for managing medications. This plan becomes part of the
electronic medical record. If the patient comes to the ED again complaining of chronic
pain, the triage nurse receives an electronic alert that a medical management plan for
chronic pain has been developed for this patient and reminds the ED physicians that a
care plan is present. The ED physician then assesses the patient and discusses the plan,
self-management strategies, and care settings that can be used in the future instead of the
ED.