Robert Hitchcock, M.D., FACEP, is VP and CMIO, T-System Inc. For more on T-System: T-System Inc.

Workflow and process optimization go hand in hand when improving throughput to accommodate a high volume of patients through the crowded emergency department (ED). In a worst-case scenario, patients could suffer for hours in the waiting room before they are treated. Those weary of waiting are walking out sans treatment, potentially putting their safety at risk. ED physician and nursing workflow, recognized as a driver of efficiency, can drastically slow patient flow and throughput if left broken and unattended.

Studies have documented that low throughput has severe negative implications for EDs and hospitals. Lost revenue opportunities include, for example: each patient leaving without being seen costs the hospital $300 to $500; each ambulance diverted due to no available beds costs the hospital more than $3,000; and for every 75 out of 100 unsatisfied patients, expect that they will share their unhappy experience with 465 potential patients who may choose a different provider.

To resolve this concern that is universally plaguing the U.S. emergency care system, three hospital organizations varying in size have implemented the T SystemEV ED information system (EDIS). Each provider has embraced the technology to provide more timely and higher quality ED care to its respective communities.

Hardin Memorial Health

A 300-bed not-for-profit institution, Hardin Memorial Health is a collection of health facilities in Hardin, LaRue, Meade and Nelson counties in Kentucky. Its Hardin Memorial Hospital in Elizabethtown serves a 10-county area with a population of 350,000.

Though the Hardin Memorial Hospital ED’s patient volume is expected to exceed 58,000 this year – which was well beyond its intended patient capacity – administrators were determined to improve throughput processes at every care point to enhance the experience of its patients. According to monthly figures, up to 5 percent of patients left the ED without seeking treatment. The door-to-room time averaged 40 to 50 minutes. Average ED door-to-provider time approached 71 minutes, and average length of stay for discharged ED patients was calculated at 216 minutes. 

To quickly relieve overcrowding and other emergency care concerns, Hardin Memorial implemented an EDIS this past summer and saw a dramatic improvement in its patient flow metrics.

Getting 100 percent of physicians adopting the EDIS within nine weeks of activation on June 5 was the first step helping instigate major change. Hardin Memorial Hospital’s ED was able to decrease its average patient door-to-room time by 22 percent, from 45 minutes to 35 minutes, and its average length of stay for discharged patients by 13 percent, from 216 minutes to 187 minutes.

“High patient volumes in the ED can adversely affect patient care and safety,” says Tom Carrico, vice president, Hardin Memorial Hospital. “Our EDIS put us on the right track to resolving throughput issues so we can provide more timely care to our community’s most critically ill and injured patients, as well as the growing number of non-urgent patients.”

Hardin Memorial also used the EDIS to streamline processes affecting patient safety and provider efficiency. Caregivers now travel with mobile computer carts room to room, documenting care and entering orders at the patient’s bedside. Bedside computers were also installed in all ED patient treatment rooms (excluding the psychiatric room and hallway beds), which increased clinicians’ access to real-time data. Since the EDIS’ patient tracking and status board can be viewed from any computer, this new feature helped nurses and staff communicate about a patient’s care more quickly and easily.

“Since we are markedly challenged by space, our EDIS has dramatically impacted our awareness of patient flow,” says Carrico, explaining the real-time ED data depicts inflow, throughput and departmental outflow. “The ED director reviews this data numerous times throughout the day and even while off duty to predict and manage staffing needs.”

Dosher Memorial Hospital

Approximately one mile from Cape Fear, Dosher Memorial Hospital is located in the coastal historic town of Southport, N.C., in Brunswick County.

With 25 staffed beds and 64 licensed skilled nursing center beds, the critical access community hospital converted its emergent care paper-based charting to electronic documentation in April 2011. It wanted to qualify for meaningful-use funds, optimize patient care and improve workflow, care coordination and communication.

“The hospital tried multiple times to create electronic forms for nurses, but the project was eventually dropped due to the difficulty reading printed forms, clinician resistance to utilization and a perceptible increase in flow issues,” says JoAnn Turzer-Commesso, R.N., MSN, director of emergency services, Dosher Memorial Hospital. “As patient safety questions escalated with the need to convert to CPOE and a well-integrated care program, the conversion to electronic records made sense.”  

Fortunately, the hospital ED found the organized e-chart an invaluable tool for meeting regulatory needs and collecting data points, performance indicators and metrics. “There is so much data that can be pulled to improve care and also to compare performance,” says Turzer-Commesso.

Thorough electronic documentation is helping to easily monitor many time intervals, such as door-to-room time and room-to-doctor time. These throughput metrics can assist in identifying areas for improvement and individual performance metrics. One such metric was a decrease in patients foregoing care from 2.45 to 2.18 percent.

Dosher Memorial credits the EDIS for supporting new ED physician and nursing workflow changes that are also influencing process improvements, such as stronger clinician-staff alignment. “Flow processes are definitely improved,” says Turzer-Commesso. “Everyone knows what is going on throughout the entire department, including the triage and waiting room areas. This instant knowledge helps prepare us for incoming patients.”

Moreover, the hospital ED’s work efficiencies and patient safety efforts are benefiting from the EDIS’ computerized provider order entry (CPOE) and patient tracking board functions. “By having CPOE, the staff has found it easier to read and verify orders,” Turzer-Commesso says. “There is more unification with everyone on the same page.”  

MedWest Health System

MedWest Health System serves 160,000 people in western North Carolina, providing quality healthcare in Haywood, Jackson, Swain, Macon and Graham counties. Affiliated with Carolinas HealthCare, the organization employs more than 230 physicians and 2,100 employees who work across three main campuses: MedWest-Haywood, MedWest-Harris and MedWest-Swain. 

At MedWest-Haywood, the not-for-profit public hospital licensed for 189 beds cares for 50,000 patients annually and 27,000 ED visits. For five years, Haywood’s ED used a cumbersome legacy system for nursing and physician documentation, which was literally built one page at a time.

Roger Coward, R.N., MedWest Health System assistant vice president, emergency services, recalls: “The worst part of the system for the staff was moving through the documentation. As you documented, you had to move in a linear fashion; there were no tabs, and if you went in to the system five pages, you had to back out five pages. Documentation was very time consuming.”

Coward, who was hired in 2008 to re-engineer ED operations, noted that an analysis of the system’s homegrown charge capture revealed documentation of a significant amount of care services rendered were missing; and a discharged patient’s average length of stay (ALOS) in the ED averaged close to four hours, while an admitted patient’s ALOS hovered at seven hours.

Haywood implemented its EDIS in 2010, and process improvement in patient documentation was “realized almost overnight.” A discharged patient’s ALOS in the ED decreased 27 percent to 2.8 hours. An admitted patient’s ALOS decreased 29 percent, from seven hours to less than five hours. Patients’ satisfaction improved when their time was shortened and when given new, easy-to-understand discharge instructions.

Regulatory compliance also improved considerably. Haywood ED employees used to spend long hours identifying new changes in Centers for Medicaid & Medicare Services (CMS) and The Joint Commission regulations and then manually implementing them. Today, the EDIS vendor monitors regulatory changes and accordingly updates the system to keep the hospital ED current with compliance issues. Recently, CMS visited twice to address a complaint and found no deficiencies in documentation after reviewing 50 ED patient records.

In addition to the EDIS implementation, computers were moved to patient rooms to enhance workflow, and tablets were given to nurses and physicians to assist with EHR portability. Bedside registration and point-of-care testing were instituted for faster turnaround of lab and radiology results.

The improved documentation and charge capture inevitably supported hospital revenue growth, as did MedWest’s ability to accommodate a 15 percent increase in patient volume as a result of improving throughput. In fact, Haywood increased its revenue 9.5 percent, a net increase exceeding $3 million from 2011 to 2012.

Patient flow strategies that incorporate ED automation can have a powerful impact on the hospital.

As hospital administrators grapple with overcrowding, tightened budgets and numerous other regulatory challenges, improved throughput can help increase capacity, capturing lost revenue and reducing risk. The data provided by an EDIS is critical in identifying opportunities for improvement and implementing process change.