At Admin EM, we believe that data analytics provide a critical tool in understanding the impediments to patient flow. This case is one example of how understanding your data can lead to better decision making. 
At this emergency department, daily volume follows a stereo-typical curve. There is significant variability between days of the week but the pattern is predictable. Similarly, the ED is struggling with high numbers of patients leaving before being seen by a provider (LWBS). The department has collected the data and the leadership team is contemplating several options to combat the issue, but there is disagreement regarding the root cause of the problem. Suggested strategies include:

  • Adding nurses to the emergency department: Hospital capacity and increased volumes suggest that more nurses are required, especially on high volume days. A request has been made to provide additional staffing to see the higher volumes of patients waiting to be seen. 
  • Adding physical space or alternative treatment areas: Medical staff has suggested adding treatment areas in order to increase the capacity of the department. Considerations include building an addition, expansion of the ED into a nearby hallway, addition of vertical spaces, and utilization of a “care in progress” lounge. 
  • Adding providers: Increasing volumes on Mondays, Tuesdays and Fridays along with increasing walkouts suggest the need for more providers. It has been suggested that one or more providers in triage would lower walkouts, or at least address the number of patients leaving before being seen by a provider. Providers have suggested that this only addresses half the equation and are concerned about not having sufficient space to treat patients. 
  • Diversion of EMS patients: The increase in volume with reduced capacity has led to increased days of EMS diversion. It has been suggested that diversion threshold might be reduced in order to reduce incoming EMS volume. 
  • Reducing Boarding: The hospital is at capacity frequently. Focus has been on ED patient flow, however, boarding of inpatients has increased in the past 2 years. Leadership team members have suggested that boarding is responsible for the reduced ED capacity and that alleviation of this issue would restore the ED to its normal function. 

All of these suggestions have the possibility of improving patient flow and reducing patients leaving without being seen by a provider. When faced with so many alternatives, how can a team agree on what steps to take, and in what order? 
The multivariable analysis of EM Analytics clarified a few things for the team, and provided the following insights: 

  • Diversion: Although this is a common pressure release for emergency departments, this department had almost level EMS arrivals. Variability averaged 9 patients. Diversion would yield minimal impact as a long term strategy and would only incur relations with local EMS providers. 
  • Daily volume fluctuations are significant. Mondays bring the highest volume to the ED, and Tuesday, Thursday, and Friday have almost equal volumes. Weekends showed a dramatic decrease in volume. 
  • The most patients left without seeing a provider on Monday, Tuesday, and Sundays. This seemed counter to what the team members expected as it did not correlate perfectly with volume. In fact, Tuesday showed the highest number of patients leaving without being seen, and yet it was not the highest volume day. 
  • Boarding hours in the ED are quite significant. On all days except Sunday, the number of boarding hours correlates highest with patients leaving without being seen.  

After reviewing the data and visualizations with the team, we recommended priorities for improvement follow this order:

  • Boarding: given the highest degree of correlation, this problem showed the highest potential for significant impact in patient flow and LWBS reduction. We recommended reducing boarding hours as much as possible by utilizing this same data driven approach to analyze why patients were boarding. 
  • In order to reduce patient walkouts, we recommend an interim plan to be utilized solely while boarding alleviation processes are being put in place. 
    • Vary provider staffing based on weekday, increasing staffing on Mondays. 
    • Vary nursing staffing based on weekday, increasing staffing on Mondays. 
    • Account for nursing positions devoted to boarding patients in the ED financial plan.

In an ideal scenario, all resources and efforts would be utilized to address the root cause of the problem. However, we also recognize the immediate need to address the emergency medical condition of patients walking out without being seen. This requires a temporary solution. A dual focus yields the greatest improvement, allowing this hospital to maximize its return on investment while safely addressing the needs of patients. Utilizing data analysis and visualization improves communication and decision making by simplifying the complex variables involved in busy emergency departments. 

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