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Improving Emergency Department Patient Flow

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Improving Emergency Department Patient Flow

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© © All Rights Reserved
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Clin Exp Emerg Med 2016;3(2):63-68

http://dx.doi.org/10.15441/ceem.16.127

Review Article
Improving emergency department eISSN: 2383-4625

patient flow
Paul Richard Edwin Jarvis
Emergency Department, Calderdale & Huddersfield NHS Foundation Trust, West Yorkshire, UK

Emergency departments (ED) face significant challenges in delivering high quality and timely Received: 15 February 2016
patient care on an ever-present background of increasing patient numbers and limited hospital Revised: 2 March 2016
resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads Accepted: 2 March 2016
to poor patient flow and departmental crowding. These are associated with reduction in the
Correspondence to:
quality of the care delivered and poor patient outcomes. A literature review was performed to
Paul Richard Edwin Jarvis
identify evidence-based strategies to reduce the amount of time patients spend in the ED in or-
Emergency Department, Calderdale
der to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid as- Royal Hospital, Dryclough Lane, Halifax,
sessment, streaming and the co-location of a primary care clinician in the ED have all been West Yorkshire HX3 0PW, UK
shown to improve patient flow. In addition, when used effectively point of care testing has been E-mail: paul.jarvis@cht.nhs.uk
shown to reduce patient time in the ED. Patient flow and departmental crowding can be im-
proved by implementing new patterns of working and introducing new technologies such as
point of care testing in the ED.
Keywords Emergency department; Patient flow; Improvement

What is already known How to cite this article:


Published literature on improving patient flow in the emergency department is Jarvis RE. Improving emergency department
often contradictory. patient flow. Clin Exp Emerg Med
2016;3(2):63-68.

What is new in the current study


This study identifies those factors that have been shown to improve patient
This is an Open Access article distributed
flow within the emergency department.
under the terms of the Creative Commons
Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/4.0/).

Copyright © 2016 The Korean Society of Emergency Medicine 63


Improving emergency department patient flow

INTRODUCTION shown to be associated with earlier diagnosis, shorter waiting


times and faster patient throughput in the ED.22-24 For this system
Across the world emergency departments (EDs) are facing incre­ to be effective there has to be a robust training programme, pro-
asing challenges due to growing patient numbers and an inability tocols and a standardised approach to investigation.
to flex capacity to meet demand. This is on a background of de-   Doctor-led triage is often cited as a possible solution to poor
creasing hospital resources. Consequently, ED crowding has be- ED flow.5 It is important to differentiate having a doctor embed-
come an ubiquitous, international phenomenon. Approximately ded in the triage process from other models of ED working such
half of all EDs report operating near or above maximum capacity.1 as ‘see and treat’ (or ‘fast-track’). Triage is the initial assessment
Several studies have presented evidence that ED crowding con- of undifferentiated patients, whereas see and treat identifies pa-
tributes to a reduction in the quality of patient care,2-8 delays in tients without serious illness or injury who are likely to have the
commencement of treatment9,10 and that adherence with recog- potential for prompt discharge.
nised guidelines worsens.11 The link between ED crowding and   Rowe et al.5 evaluated the impact of having a doctor, of any
mortality is increasingly being recognised.12,13 Another symptom grade, assisting the triage process. They demonstrated that a phy-
of overcrowding is patients leaving without their care being com- sician in triage is an effective intervention to alleviate the effects
pleted. In the United States this accounts for 2% of all ED visits.14 of ED crowding. Triage performed specifically by a senior doctor
  Crowding occurs when demands placed on the ED are greater has been proposed as a way of accelerating patient flow through
than the entire hospitals capacity to ensure timely care in the ED. the ED, reducing admissions and improving the time to key deci-
The factors that contribute to poor ED performance can be classi- sion making.2 This is done by initiating prompt patient assessment,
fied as being either intrinsic or extrinsic to the ED.3 Departmental appropriate diagnostic testing and initiating treatment earlier in
layout and staffing levels are examples of intrinsic factors that the patient’s journey. This includes the identification of definite
influence patient flow, whereas exit block related to the lack of admissions and expediting swifter and safer discharge of patients
inpatient bed availability and surges in patient demand are fac- not requiring further investigation or treatment.
tors extrinsic to the ED that influence patient flow. The impact   A review confirmed that having a senior doctor in triage im-
that the wider hospital system has on patient flow in the ED should pacted positively upon many ED metrics and concluded that it
not be underestimated. Blom et al.15 showed that the probability offers a valuable solution to ED crowding.25 Another systematic
of a patient being admitted from the ED is negatively correlated review found senior doctors, working individually at the front door
to inpatient bed occupancy. of the ED or as part of a wider triage team is associated with a
  Improving patient flow within the ED is ultimately achieved by reduction in overall ED patient journey time and the length of
reducing the amount of time patients spend in the ED, thereby time from the patient arriving to them being assessed by a doc-
reducing departmental crowding. Shorter patient journey times tor.5 Although it appears, as a model of working, doctor triage is
are associated with improved patient satisfaction16 and reduc- beneficial to patient flow in the ED, the heterogeneous nature of
tions in mortality and morbidity.17,18 the role of the doctor in these studies means it is difficult to de-
  The aim of this article is to review the evidence relating to strat- termine the most efficient and effective model for senior doctor
egies to reduce the amount of time patients spend in the ED in triage.
order to improve patient throughput in the ED.
RAPID ASSESSMENT MODELS
DOCTOR TRIAGE
Rapid assessment is the assessment, investigation, and initial treat-
Triage is a brief intervention that should occur ideally within 15 ment of patients as soon as they arrive in the ED. This model uti-
minutes of the patient’s arrival in the ED.4,19 The aim of triage is lises the principle of single piece flow more commonly found in
to risk stratify patient presentations and prioritise them accord- the automotive manufacturing industry.26 Essentially early assess-
ingly as a way of allocating limited resources, such as staff and ment and investigation coupled with prompt initiation of treat-
physical space based on their clinical need.5 Nurse-led triage is ment aims to reduce the amount of waiting time that occurs be-
currently the international standard triage model throughout the tween each of these steps in the traditional model. Typically these
world20,21 and there is insufficient evidence of any one triage scale are patients that do not require resuscitation room or high de-
being more effective than another.6 Utilising the triage nurse to pendency unit treatment.27
request investigations, such as blood tests and X-rays, has been   A review article demonstrated that utilising a rapid assessment

64 www.ceemjournal.org
Paul Richard Edwin Jarvis

model reduces the overall journey time of patients in the ED. This pared with emergency physicians. However, there is some evidence
review article also demonstrated that the length of time it takes to suggest there is a potential for cost savings as general practi-
for patients to be seen by a doctor is reduced when a rapid as- tioners tend to order fewer tests and fewer admissions31,32 whilst
sessment model is utilised.27 patient satisfaction was increased.32 The waiting time for ED pa-
  The costs of implementing such system is often cited as a bar- tients in hospitals with a co­located general practitioner service
rier to its introduction. However there is evidence that altering was on average 19% less than patients attending EDs without a
the existing work pattern within the ED and introducing a rapid primary care service.33
assessment model within the confines of existing departmental
resources is associated with improved patient flow.28 POINT-OF-CARE TESTING

STREAMING Point-of-care testing (POCT) provides clinicians with rapid results


for commonly ordered investigations. Moving laboratory standard
Streaming is the process of allocating similar patients (with re- testing into the ED could increase the speed of diagnosis. Numer-
gards to disease severity or nature of complaint) to a particular ous reports have highlighted a reduction in turnaround times for
work stream. Typically, patients in each work stream are assessed investigation results utilising POCT in an emergency setting.22,34-37
by dedicated staff in a specific geographical area within the ED. A systematic review performed in 2011 showed that the introduc-
For example, ‘see and treat’ is a form of streaming where patients tion of POCT in the ED may reduce the total patient journey time
with less severe illnesses are allocated to a dedicated clinical area in the ED.22 More recent studies have demonstrated a similar mod-
and receive assessment and treatment from a clinical team only est reduction in the amount of time a patient spends in the ED
seeing ‘see and treat’ patients. By its nature, triage leads to a build before a disposition decision is reached when POCT is utilised.36,37
up of relatively well patients in the ED as critically ill patients are   Norgaard and Mogensen38 compared laboratory turnaround
seen preferentially. However, streaming ensures less urgent pa- times when utilising POCT in the ED with centralised laboratory
tients continue to be seen in a timely manner. The individual pa- testing with an air-tube transport system for the rapid transport
tient work streams in the ED can be staffed by senior doctors, of blood samples. They showed that in this setting POCT yielded
nurse practitioners, physician’s assistants or a combination of all results on average 46 minutes earlier than from the central labo-
of these.22 ratory.
  There is little evidence to support the use of streaming patients   A multicentre randomised controlled study performed in the
according to their triage categories as a means of redirecting pa- United Kingdom evaluated the performance of POCT in the ED
tients from hospital EDs to other clinical settings outside of the examining cardiac biomarkers in patients with suspected myo-
hospital, such as primary care.3 cardial infarction.39 This study demonstrated a discharge rate
  There is evidence that dividing ED patients into work streams which was 20% greater in patients who had blood analysed by
results in reduced waiting times and shorter ED journey times POCT. Interestingly, this study demonstrated a greater effect in
when compared with a non-streamed ED model.22 The effective- district general hospitals rather when compared with large uni-
ness of this strategy is likely to be dependent upon how patients versity-affiliated teaching hospitals. This phenomenon has been
are signposted towards the different streams within the ED and demonstrated by other authors.40 Interestingly, recent evidence
whether there is appropriate staffing and physical space to meet suggests that POCT can add value when used in the prehospital
the patient demand of each individual work stream.29 setting and may reduce the number of patients brought to the
  There is limited evidence that dividing patients entirely based ED.41-43
upon whether they are likely to be admitted or not has any bene-   Blood sample POCT is most commonly performed by nursing
fit on ED patient flow.22 staff in the ED.44 To ensure quality assurance there needs to be a
robust training programme in place reinforced with regular recer-
PRIMARY CARE CO-LOCATED IN THE ED tification. This places an additional burden on members of staff
who already have heavy workloads. However, improvements in
Two reviews have evaluated the effectiveness of utilising primary patient flow seen within the ED as a result of the introduction of
care clinicians within the ED setting for patients with less urgent POCT are likely to reduce staff workload.44
clinical problems.30,31 There was insufficient evidence comparing   The cost of a single test performed utilising POCT is higher than
the safety of care provided by general practitioners in the ED com- the cost of a similar test performed in a centralised laboratory.36

Clin Exp Emerg Med 2016;3(2):63-68 65


Improving emergency department patient flow

However, Rooney and Schilling44 state that the time saved elimi- CONFLICT OF INTEREST
nating steps when POCT is introduced, such as the sample trans-
portation, registration of the sample in the laboratory and time No potential conflict of interest relevant to this article was re-
spent retrieving results, means the cost of utilising POCT seldom ported.
exceeds those of analysis in a centralised laboratory. An Austra-
lian study performed in 2014 concluded that each hour of patient REFERENCES
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