(A122) Using Focused Operations Management Tools to Analyze and Alleviate Emergency Department Overcrowding

IntroductionEmergency department overcrowding plagues departments worldwide with grave implications on patient comfort and care quality. Many standard approaches have been introduced without widespread success. A new approach is required. Focused Operations Management (FM) integrates novel managerial theories and practical tools into a systematic approach to complex systems, promoting insight and improving performance. It has allowed systems in the industry and service sectors to radically improve throughput and quality with no or little additional cost. The implementation of the FM in the emergency department setting to alleviate overcrowding has never been attempted, and it could revolutionize emergency department operations management.MethodsEmergency department patient flow data affecting factors and outcomes from a large tertiary medical center, exclusively utilizing electronic patient records, will be collected. Root causes and influencing variables of emergency department overcrowding will be mapped and analyzed using FM tools. Later, alleviating measures will be developed and evaluated. During phase two, data will be collected from two additional emergency departments, measuring the impact of implementation of FM operational changes on emergency department flow parameters such as length of stay, wait times, clinical outcomes, and patient and staff satisfaction.ResultsData collection and analysis of phase one of the study will be completed by March 2011 and presented at the conference. The authors speculate that the FM tools will allow better understanding of the root causes and affecting variables of emergency department overcrowding and help plan and later implement efficient interventions.DiscussionThe implementation of the novel management strategies of FM has revolutionized operations in many industries and services, helping them to drastically improve performance. The emergency department is a perfect candidate for the use of these tools, due to the overwhelming current operational difficulties (with overcrowding as a prominent symptom) and its complex high volume and high acuity patient flow.

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The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department

Open Access Emergency Medicine ◽

10.2147/oaem.s228291 ◽

2020 ◽

Vol Volume 12 ◽

pp. 13-18

Author(s):

Asher L Mandel ◽

Thomas Bove ◽

Amisha D Parekh ◽

Paris Datillo ◽

Joseph Bove Jr ◽

...

Keyword(s):

Emergency Department ◽

Patient Flow ◽

The Impact ◽

Urban Emergency Department

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Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow

Canadian Association of Radiologists Journal ◽

10.1177/08465371211023861 ◽

2021 ◽

pp. 084653712110238

Author(s):

Francesco Macri ◽

Bonnie T. Niu ◽

Shannon Erdelyi ◽

John R. Mayo ◽

Faisal Khosa ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Patient Flow ◽

Interrupted Time Series ◽

Trauma Patients ◽

Linear Regression Models ◽

High Acuity ◽

Time Series Approach ◽

Comparison Series ◽

The Impact

Purpose: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Methods: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. Results: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. Conclusions: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

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Validating the primary provider theory in emergency medicine

Leadership in Health Services ◽

10.1108/17511870810870565 ◽

2008 ◽

Vol 21 (2) ◽

pp. 120-130 ◽

Cited By ~ 2

Author(s):

Joseph S. Guarisco ◽

Stefoni A. Bavin

Keyword(s):

Emergency Department ◽

Patient Satisfaction ◽

Pay For Performance ◽

Medical Center ◽

Waiting Times ◽

Emergency Department Visits ◽

Business Success ◽

Content Type ◽

The Impact

PurposeThe purpose of this paper is to provide a case study testing the Primary Provider Theory proposed by Aragon that states that: disproportionate to any other variables, patient satisfaction is distinctly and primarily linked to physician behaviors and secondarily to waiting times.Design/methodology/approachThe case study began by creating incentives motivating physicians to reflect and improve behaviors (patient interactions) and practice patterns (workflow efficiency). The Press Ganey Emergency Department Survey was then utilized to track the impact of the incentive programs and to ascertain any relationship between patient satisfaction with the provider and global patient satisfaction with emergency department visits by measuring patient satisfaction over an eight quarter period.FindingsThe findings were two‐fold: firstly, the concept of “pay for performance” as a tool for physician motivation was valid; and secondly, the impact on global patient satisfaction by increases in patient satisfaction with the primary provider was significant and highly correlated, as proposed by Aragon.Practical implicationsThese findings can encourage hospitals and physician groups to place a high value on the performance of primary providers of patient care, provide incentives for appropriate provider behaviors through “pay for performance” programs and promote physician understanding of the links between global patient satisfaction with physician behaviors and business growth, malpractice reduction, and other key measures of business success.Originality/valueThere are no other case studies prior to this project validating the Primary Provider Theory in an urban medical center; this project adds to the validity and credibility of the theory in this setting.

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845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.1040 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S513-S513

Author(s):

Elizabeth A Aguilera ◽

Gilhen Rodriguez ◽

Gabriela P Del Bianco ◽

Gloria Heresi ◽

James Murphy ◽

...

Keyword(s):

Emergency Department ◽

Screening Program ◽

Medical Center ◽

Hiv Infections ◽

Hiv Screening ◽

Opt Out ◽

Number Of Patients ◽

Confirmatory Tests ◽

Routine Hiv Screening ◽

The Impact

Abstract Background The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown. Methods The Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared. Results 72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals. Conclusion The COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic. Disclosures All Authors: No reported disclosures

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The impact of medical specialist staffing on emergency department patient flow and satisfaction

European Journal of Emergency Medicine ◽

10.1097/mej.0000000000000487 ◽

2019 ◽

Vol 26 (1) ◽

pp. 47-52 ◽

Cited By ~ 5

Author(s):

M. Christien van der Linden ◽

Roeline A.Y. de Beaufort ◽

Sven A.G. Meylaerts ◽

Crispijn L. van den Brand ◽

Naomi van der Linden

Keyword(s):

Emergency Department ◽

Patient Flow ◽

Emergency Department Patient ◽

Medical Specialist ◽

The Impact

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Inhaled methoxyflurane for the reduction of acute anterior shoulder dislocation in the emergency department

CJEM ◽

10.1017/cem.2018.493 ◽

2019 ◽

Vol 21 (4) ◽

pp. 468-472 ◽

Cited By ~ 3

Author(s):

Etimbuk Umana ◽

Josephine Hannah Kelliher ◽

Christiaan Johannes Blom ◽

Brian McNicholl

Keyword(s):

Emergency Department ◽

Shoulder Dislocation ◽

Recovery Time ◽

Patient Flow ◽

Hospital Setting ◽

Anterior Shoulder Dislocation ◽

Fracture Dislocations ◽

Record Review ◽

The Impact ◽

Successful Reduction

ABSTRACTObjectivesMethoxyflurane is an inhalation analgesic used in the emergency department (ED) but also has minimal sedative properties. The major aim of this study was to evaluate the success rate of methoxyflurane for acute anterior shoulder dislocation (ASD) reduction. The secondary aim was to assess the impact of methoxyflurane on ED patient flow compared to propofol.MethodsA health record review was performed for all patients presenting with ASD who underwent reduction with either methoxyflurane or propofol over a 13-month period (December 2016 – December 2017). The primary outcome was reduction success for methoxyflurane, while secondary outcomes such as recovery time and ED length of stay (LOS) were also assessed compared to propofol. Patients with fracture dislocations, polytrauma, intravenous, or intramuscular opioids in the pre-hospital setting, no sedation for reduction, and alternative techniques of sedation or analgesia for reduction were excluded.ResultsA total of 151 patients presented with ASD during the study period. Eighty-two patients fulfilled our inclusion criteria. Fifty-two patients had ASD reduction with propofol while 30 patients had methoxyflurane. Successful reduction was achieved in 80% (95% CI 65.69% to 94.31%) patients who used methoxyflurane. The median recovery time and ED LOS were 30 minutes [19.3-44] and 70.5 minutes [49.3-105], which was found to be shorter for the methoxyflurane group, who had successful reductions compared to sedation with propofol.ConclusionMethoxyflurane was used successfully in 30% of the 82 patients undergoing reduction for ASD, while potentially improving ED efficiency.

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The impact of a multimodal intervention on emergency department crowding and patient flow

International Journal of Emergency Medicine ◽

10.1186/s12245-019-0238-7 ◽

2019 ◽

Vol 12 (1) ◽

Cited By ~ 4

Author(s):

M. C. (Christien) van der Linden ◽

◽

H. M. E. (Jet) van Ufford ◽

N. (Naomi) van der Linden

Keyword(s):

Emergency Department ◽

Patient Flow ◽

Emergency Department Crowding ◽

Multimodal Intervention ◽

The Impact

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Multi-objective optimization for simultaneous operating room and nursing unit scheduling

International Journal of Engineering Business Management ◽

10.1177/1847979019891022 ◽

2019 ◽

Vol 11 ◽

pp. 184797901989102 ◽

Cited By ~ 2

Author(s):

An Jen Chiang ◽

Angus Jeang ◽

Po Cheng Chiang ◽

Po Sheng Chiang ◽

Chien-Ping Chung

Keyword(s):

Quality Improvement ◽

Operations Management ◽

Health Care Quality ◽

Patient Flow ◽

Care Quality ◽

Multi Objective Optimization ◽

Labor Costs ◽

Nursing Unit ◽

Multi Objective ◽

Time Scheduling

The managerial aspect of providing quality, cost-effective health services to hospital patients is becoming increasingly important. However, merely focusing on cost reduction and quality improvement may jeopardize personnel satisfaction. Therefore, a balanced approach based on multiple considerations is necessary. Operating rooms (ORs) account for almost 33% of a hospital’s budget, and nursing labor costs represent more than 40% of a hospital’s budget. The concerns around health-care quality, personnel motivation, staff satisfaction, patient length of stay, and patient flow rate are greatly influenced by these two units with regard to day-to-day operations management. A possible approach is to look into the related essential problems, such as the nursing staff time scheduling in nursing units, and the doctor time scheduling in ORs. After surgery in the OR, patients stay in the subsequent ward for a period of time. This causes loading interdependency between the anterior OR and the posterior ward nursing unit; as a result, an attempt to schedule these two departments simultaneously is necessary for operation efficiency enhancement, service quality improvement, hospital budget reduction, and personnel satisfaction. In order to achieve the multiple objectives describing the conflicting priorities and differing preferences within nursing units and ORs, a compromise programming is adopted in this study as a balancing tool for multi-objective optimization to realize improved OR and nursing unit scheduling.

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The impact of computerized provider order entry on emergency department flow

CJEM ◽

10.1017/cem.2016.11 ◽

2016 ◽

Vol 18 (4) ◽

pp. 264-269 ◽

Cited By ~ 4

Author(s):

Andrew Gray ◽

Christopher M.B. Fernandes ◽

Kristine Van Aarsen ◽

Melanie Columbus

Keyword(s):

Emergency Department ◽

Patient Safety ◽

Improve Patient Safety ◽

Patient Flow ◽

Wait Time ◽

Order Entry ◽

Computerized Provider Order Entry ◽

Left Without Being Seen ◽

Before And After ◽

The Impact

AbstractObjectivesComputerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).MethodsWe conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.ResultsA significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.ConclusionsCPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

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