Direct-to-Room: One Department's Approach to Improving ED Throughput

doi:10.1016/j.jen.2006.09.018

Journal of Emergency Nursing

Volume 33, Issue 1, February 2007, Pages 26-30

https://doi.org/10.1016/j.jen.2006.09.018 Get rights and content

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University of Pittsburgh Medical Center–Presbyterian

The University of Pittsburgh Medical Center–Presbyterian (UPMC Presbyterian) is a 720-bed academic medical center located in the Oakland section of the city of Pittsburgh, Pennsylvania. UPMC Presbyterian is the primary teaching facility of the University of Pittsburgh Schools of Medicine, Nursing, and Health Related Professions. The UPMC Presbyterian emergency department consists of 31 beds and averages 47,000 visits per year. The emergency department plays an integral role as a level I trauma

The Old Way

The process for admitting a patient to the UPMC Presbyterian emergency department historically involved several steps. The patient presented to triage, where an ED patient care technician (PCT), who is an unlicensed ED employee (EMT or paramedic), would greet him or her. The PCT would ask the patient 5 questions consisting of name, age, social security number, allergies, and chief complaint. The PCT would then escort the patient to the triage desk where the registered nurse (RN) would begin the

Direct-to-Room

It was decided that the same process that called for patients to be brought directly to a room when presented by medics could be utilized for walk-in patients. The new direct-to-room (DTR) approach (named by our chief of emergency services) to ED care would be in place as long as there was one empty bed within the department. Patients who presented either with a medic unit or as a walk-in would be taken directly to an ED bed by the triage PCT under the direction of the triage RN. Registration

Results

The average LOS for admitted patients for the first 3 quarters of fiscal year 2005 (prior to initiation of the DTR process) was 259 minutes. The average LOS 90 days after DTR implementation (May-July 2005) was 239 minutes. This was a decrease of 20 minutes for admitted patients, for an improvement of 7.7%. Not only did the LOS decrease by 7.7%, but night shift nurses routinely noted a decrease in department crowding as evidenced by overflow patients in stretchers and chairs in the hallways at

Strengths

Along with the improved throughput times, other positive effects were noted after the implementation of DTR, including patient satisfaction scores (as measured by Press Ganey) and a decrease in discharged LOS. Overall, patient satisfaction scores did not change significantly (our scores were relatively high in comparison with peer hospitals), but improvement was noted by the comments written by our patients on their surveys. Patients perceived that their evaluation and treatment started upon

Barriers

The main barrier we encountered with DTR was staff acceptance. With any new process, there is a potential resistance to change. Historically, triage was a step in the admissions process and a location, not a verb. The well-known definition of triage is to sort. The view of the ED Leadership Team was that when the department has a number of available beds, there is no need to sort. This new definition of triage was met with resistance. The ED Leadership Team realized that to make this change

Summary

The new triage system, DTR, has been a success. The average LOS for both admitted as well as discharged patients has dropped 7.7%. This drop in LOS has been achieved through the cooperation of multiple layers of hospital leadership and by their acceptance of ED throughput as a hospital-wide problem, not strictly an ED problem. The staff of the emergency department has worked hard to incorporate DTR into their daily practice. They all have accepted change—some reluctantly, but they have accepted

Acknowledgment

The authors wish to thank Theodore R. Delbridge, MD, MPH, former chief of emergency services UPMC Presbyterian, whose vision and perseverance made this project a success.

David A. Bertoty, ENA Chapter 061, is Unit Director, Emergency Department, University of Pittsburgh Medical Center–Presbyterian, Pittsburgh, Pa.

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References (2)

B Pate et al.
Solving emergency department overcrowding: successful approaches to a chronic problem
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Workflow planning and ED design should anticipate this trend, with flexibility for any low-resource split flow space to serve the needs of sicker patients should the future needs of the ED require it. A second major development in recent years has been the adoption of immediate bedding (also known as “direct bedding,” “pull-’till-full,” or “closing the waiting room”), wherein patients are taken immediately to an ED room or treatment space on check-in, and are triaged, registered, and evaluated in the treatment space.17–20 There may be design implications from this process model, in that there is potentially less need for triage evaluation rooms.
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In an urban academic emergency department (ED), a front-end split-flow model, which entailed deployment of an attending-physician intake model, implementation of a 16-bed clinic decision unit, expanded point-of-care (POC) testing, and dedicated ED transportation services, was created.
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During the six-month pre- (July 2012–December 2012) and postimplementation (July 2013–December 2013) periods, there were 17,307 and 27,443, respectively, walk-in encounters during the intake times. Despite this 59% increase and a 35% increase in overall ED patient census, implementation of the innovative novel process redesign resulted in a clinically meaningful reduction (median minutes pre vs. post and one-year post) in (1) overall length of stay (LOS) for all walk-ins (220 vs. 175 and 140), discharged (216 vs. 170 and 140), and inpatient admissions (249 vs. 217 and 181); (2) door-to-physician time (minutes) (54 vs. 15 and 12); and (3) left without being seen (LWBS) rates (5.5% vs. 0.5% and 0.0%). The left before visit complete (LBVC) rates were 0.8% vs. 1.1% and 0.6%. The average total relative value unit (RVU) per patient discharged from intake was 2.31. During the pre-post analysis periods, no significant increase in reported safety events were identified (10 vs. 9 per 1,000 patient encounters).
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In more traditional models, these processes occurred sequentially. Today, however, more and more EDs are adopting a process referred to as “immediate bedding” whereby these same steps are performed, either sequentially or simultaneously, in patient care rooms rather than in triage rooms (6–11). On November 1, 2011, we implemented a new immediate bedding process in our ED.
Immediate bedding has been shown to increase efficiency in general emergency departments (EDs), but little has been published regarding its use in pediatric emergency medicine.
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The median DTP decreased from 44 min in the pre period to 25 min in the post period (Cohen's r value = 0.29; p < 0.001). The percent DTP < 30 min also significantly improved (pre: 31.8%, post: 58.2%, odds ratio = 2.99; 95% confidence interval 2.87–3.12; p < 0.001). For the benchmark satisfaction question of “likelihood to recommend,” there was also an improvement in the mean responses (pre: 89.0, post: 92.7, Cohen's r value = 0.10; p = 0.03). There were no significant differences in the balancing measures of nurse practitioner productivity and compliance with two nurse-initiated protocols. There was a weak inverse correlation between throughput times and satisfaction scores (Spearman's rank correlation −0.18; p < 0.001).
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This study reports on clinicians' perspectives on reasons for delay in the ED care of psychiatric patients. In other settings, input from the ED frontline staff has contributed to innovations such as the “Direct to Room” alternative to traditional triage when an ED bed is available [24]. The results from this study demonstrate an association between clinician identified reasons for delay and actual increases in ED wait times for their patients.
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Immediate bedding requires bedside registration. Although the converse is not obligatory, many published reports26-31 discuss the implementation of both simultaneously as a process improvement strategy. “Bedside registration” typically involves an initial (“quick”) registration capturing the basic patient demographic information (eg, patient name, date of birth, social security number, and chief complaint) needed to generate an ED chart.
As administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), “front-end” operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated “fast track” service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology (“smart cards”) have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.

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David A. Bertoty, ENA Chapter 061, is Unit Director, Emergency Department, University of Pittsburgh Medical Center–Presbyterian, Pittsburgh, Pa.

Michele L. Kuszajewski, ENA Chapter 061, is Emergency Clinical Nurse Specialist, University of Pittsburgh Medical Center–Presbyterian, Pittsburgh, Pa.

Eric E. Marsh, ENA Chapter 061, is Director of Emergency Services, University of Pittsburgh Medical Center–Presbyterian, Pittsburgh, Pa.

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ClinicalDirect-to-Room: One Department's Approach to Improving ED Throughput