Focusing on front end initiatives for ED performance improvement

Emergency department process design – begin with the front end

Authored by: 

Bill Briggs, MSN, RN, CEN, TCRN, NEA-BC, FAEN

Vice President and Managing Partner

Most emergency departments (EDs) face periodic crowding and for many this is a constant state. There are two common misconceptions held by ED staff and leaders that prevent them from redesigning the front end (arrival, triage, and early intervention) first. The first is blaming the problem on the inability to get inpatient beds. While this is a major consideration in ED throughput, most ED patients are not admitted. Considering the 70 – 90% who will be discharged and cutting a few minutes off their ED length of stay will provide a significant improvement on the total length of stay.

The second is the concept that shortening the length of time patients spend in the front end will only make the interior of the ED more crowded. In some cases that may be true, however, decreasing any interval in the ED visit shortens the entire visit. Also, most EDs have capacity early in the day and getting patients in and out will make the ED beds available for patients at peak hours.

The major reasons for starting an ED performance improvement project on the front end are:

Use of space: Reducing the total ED length of stay has a net impact of allowing more patients to be treated in a shorter time. Reducing your door to provider time is a major patient satisfier and decreases the time to disposition.

Patients who are left in the waiting room because they have not been triaged when there is capacity in the ED is wasting resources and extending their length of stay. Cutting 20 minutes of a three-hour length of stay in a 20-bed ED has the effect of adding 12.5% more capacity.

Patient experience: Numerous factors account for the patient’s experience in the ED. Long waiting time acts as a multiplier. A patient seen in 30 minutes of arrival is far more likely to give the ED a positive review than one who has waited six hours. After a certain point, the best and most personal care will be outweighed by the long wait. Patients also want to perceive that their care is progressing, such as the provider talking to them, being moved to an inside waiting room, or having diagnostic studies or treatment started.

Risk reduction: Patients who leave without being seen (LWBS) are at risk of deterioration. Even the patient with vague symptoms or triaged as a low priority may have a hidden condition. A seriously ill patient may take one look at the waiting room and decide to leave.

LWBS equal lost revenue: Patients who leave the ED without being seen include patients who could have been treated and released and patients who could have been admitted. If you look at the average collected revenue rate inclusive of both discharged patients and admitted patients, the revenue going out of the door often amounts to $1000 each. An ED with 60,000 annual visits and a 6.5% LWBS rate that reduced its LWBS rate to 2.5% could realize an increase in actual revenue of $2.4 million.

It is important to note two misconceptions about LWBS. First, patients that leave the ED did not need to be there or are uninsured. Patients with the means are likely to go somewhere else for treatment. Uninsured patients are more likely to wait. The second misconception is that sicker patients are more likely to stay. Apart from those patients with acute life threatening (triaged as ESI-1), patients tend to leave without being seen at the same acuity rate they arrive.

When you start an ED process redesign or process improvement project, you have a choice where to start, i.e. front end, ED process, or discharge or disposition. Starting on the front end and concentrating on the patients who will be discharged is generally within the control of the ED team. Focusing on the front end is not only an effective strategy to reduce total throughput times but can also be “low hanging fruit” that is a quick and easy processes to implement.