1. Preceptorship Teaching Project Jennifer Nagy Auburn University School of Nursing

2. Objectives Make staff aware of the importance of good patient flow through Emergency Departments (EDs) Make staff aware of potential adverse effects associated with prolonged waiting times before being taken to a room, time before being seen by a doctor, and length of stay (LOS) Provide education on common causes of delayed patient flow and reasons for increased waiting times Provide education on several strategies to improve patient flow

3. Introduction Although EDs are intended for emergencies, many patients use hospital emergency services to obtain non-emergent care ED visits increased 38% between 1997 and 2007. This increase has put a huge strain on hospital facilities and budgets The lack of access to primary care providers, lack of insurance, and lack of information about when to use the ED have contributed to their overcrowding Adding more staff and spending capital to expand the ED are not viable options for most hospitals, so EDs must improve efficiency and effectiveness through low-cost process improvement efforts

4. Importance Overcrowding has created longer than usual wait times and an increased number of persons who leave without being seen by a doctor ED overcrowding and LOS has been linked with morbidity, mortality, extended inpatient LOS, and increased readmission and ED re-attendance ED overcrowding is associated with a 30% relative increase in mortality by Days 2 and 7 for patients requiring admission from ED

5. Possible Causes of Delayed Patient Flow Increased complexity and acuity of patients in the ED Overall increase in patient volume More patients needing intensive therapy prior to discharge Delays in radiology, lab, and other ancillary services Shortage of nurses, doctors, and clerical staff Delays in, and lack of, senior ED or specialty consultation Lack of space in EDs Increased medical record documentation requirements Language and cultural barriers Difficulties arranging follow-up care

6. Reasons for Increased Waiting Times and LOS ED doctor yet to commence assessment ED assessment/treatment in progress Waiting for investigation to be performed Waiting for results of investigations Awaiting review by subspecialty team Awaiting bed allocation (no beds or beds not ready) Awaiting transport

7. “Wastes” of Time and Potential Solutions Upon arrival patient signs a log book, sits down, is called to register, sits down again, and then is called to triage Solution: bring patient into triage immediately, if room is free, and doing registration during the triage process No standardized call to pull a patient to an empty room Solution: standardize work flow; for example, always fill an empty room unless it is being reserved for incoming ambulance patients Delay in starting the initial nursing workup, which leads to delay in getting doctor to room Solution: page overhead when a new patient arrives in a room; all available staff will then go to that room to help with the new patient, greatly reducing the workup process time

8. UAB Strategies “Pull-til-full”: bring patients in from the waiting rooms if there are beds available. This will decrease the length of time the patient spends waiting to see a doctor and will decrease the number of patients who leave without being seen Results pending: UAB implemented the utilization of results pending (RP), which is two rooms, staffed by a nurse and patient care tech, where a patient can wait comfortably for lab results if no further treatment is anticipated Improved coordination and teamwork: staff working together to get patients discharged or transported, prompt cleaning of rooms, and notification of triage nurse when rooms are clean and ready for the next patient

9. Another Possible Strategy Staffing of satellite areas in order to decrease patient waiting times and number of patients leaving without being seen

10. References Chan, A., Arendts, G., & Wong, S. (2008). Causes of constraints to patient flow in emergency departments: A comparison between staff perceptions and findings from the Patient Flow Study. Emergency Medicine Australia, 20,234-240. doi: 10.1111/j.1742- 6723.2008.01079.x Johnson, M., Sensei, L., & Capasso, V. (2012). Improving patient flow through the emergency department. Journal of Healthcare Management, 57(4), 236-243. Popovich, M. A., Boyd, C., Dachenhaus, T., & Kusler, D. (2012). Improving stable patient flow through the emergency department by utilizing evidence-based practice: One hospital’s journey. Journal of Emergency Nursing, 38(5), 474-478. doi: 10.1016/j.jen/2011.03.006