Hard wiring a hospital for competitive performance

Mar 17
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The facts:

  • The emergency department is the main gateway to the hospital
  • The emergency department typically accounts for:
    • 50% of inpatient admissions
    • 75% of plain radiographs
    • 50% of CT scans and ultrasounds in the entire hospital
  • In addition, as the ‘front door’ to the hospital, the emergency department not only drives flow, but it drives the patients’ perception of flow

Prolonged waiting times and delays in the emergency department are a whole of hospital issue, not just the ED. Timely access to appropriate care is prevented by operational inefficiencies, negatively impacting patient experience and increasing patient dissatisfaction.

Though many hospitals understand this problem, few have strategies to address it in a consistent and reliable manner. Instead, many are forced to throw more people at the problem without much improvement.

Operational inefficiency is challenging. Hardwiring the hospital transitions of care will result in improved operational performance without overloading front line teams.

It is important though, to remember that improving something doesn’t mean it’s easy to sustain.  Process improvement is an ongoing endeavour. It requires a culture and mindset of consistent attention.

Fast track

In an emergency department with 30,000 presentations per year or more, Category 4 & 5 patients constitute up to 55% of presentations.

The majority of these patients are low acuity and can be seen in Fast Track.  They have minor injuries that require simple investigations, e.g. ankle x-ray or no lab work at all.

Those patients can be seen quickly and discharged from the ED, thus improving efficiency. Nurse Practitioners work very well in this area.

ED – Inpatient conflict resolution

Emergency Medicine physicians and inpatient specialists are charged with the same goals, to provide the best care for their patients at all times.

However it is not uncommon to find the two groups working antagonistically due to conflicting priorities.

To beat the 4-hour rule, the ED needs to move the patients through rapidly while the inpatient team would like to manage their inpatient LOS respectively. 

The fundamental answer to this ED/Inpatient conflict is seeing the issue from each other’s perspective. A well-coordinated and collaborative approach will help resolve the conflicts and improve patient care.

Jointly develop guidelines for specific areas of concern

One of the most contentious points in the ED/Inpatient relationship is the decision on when patients leave the ED and where they will go.

NEAT aims at either discharging, transferring or admitting patients within 4 hours – an important Key Performance Indicator.

Inpatient specialists have a different perspective: seeing patients early in the day to discharge them before noon, to have beds available for new patients coming from the ED.

Some pushback is expected from the inpatient specialists as they find themselves trapped between seeing existing patients, discharging them as soon as medically appropriate and being informed there are new patients for admission in the ED, especially when they haven’t completed their ward rounds.

Not forgetting that inpatient specialists can disrupt negotiations.

The solution lies in establishing jointly developed guidelines and protocols. Leaders from inpatient and ED teams must come together and determine the criteria for Direct Admission Policies.

Criterion’s series of Health conferences cover topics including Patient Flow, Emergency Departments, Infection Prevention, Hospital Safety & Security and more. View upcoming events here.

Health conferences

Submitted by Augustus Kigotho

Augustus Kigotho

Dr Augustus Kigotho is the Director of Emergency Medicine at Albury Wodonga Health and a Senior Lecturer at the University of New South Wales.

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