The physician contact is now very early in the ED encounter, and lab testing is initiated at triage. The physician can decide which zone is most appropriate for the patient, but the PFC assigns the room.
The PFC is a role that is growing in popularity, especially in emergency departments seeing more than 50,000 visits per year. The PFC manages incoming ambulances and has the 30,000-foot view of the workload in each area. As emergency departments get busy with increased numbers of geographic zones, an overview is lost unless someone is dedicated to monitoring and managing flow. This role works best when it is in addition to the charge nurse role, which was becoming unmanageable in terms of scope of duties. The charge nurse and PFC work as a team and are in constant communication (cellphones with speed dial) to share information for flow management. The charge nurse now focuses on one area with attention to outflow, admissions, and discharges. The charge nurse can inform the PFC as to workload in the back, the status of patients, and which patient is likely to be moving next. Together, they manage overall patient flow.
Patients were grouped according to acuity and resources needed. This allowed for the realization of new efficiencies, and many fast-track patients were turned around in under an hour! Housekeeping fine-tuned its processes to decrease the downtime of most rooms.
The results were astonishing and unequivocal. After four rapid-cycle tests of change, the leaders and stakeholders had ironed out the bugs and were ready to turn on their new ED processes for good. Compare their results where they were underperforming relative to the Academy of Administrators in Academic Emergency Medicine and Emergency Department Benchmarking Alliance cohorts before and are now top performers (see Table 1).
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Table 1: Miriam’s Performance Before and After Intervention
Compared to Benchmark Data
Definitions: PPD, patients per day; D2D, door-to-doctor time; LOS, length of stay; LBTC, left before treatment complete; LWBS, left without being seen; AAAEM, Academy of Administrators in Academic Emergency Medicine; EDBA, Emergency Department Benchmarking Alliance
There are some take-home messages that are important to all ED leaders and managers reading this story. You will need to change your processes as your volumes grow. In particular, as you jump a volume band, what has worked before no longer works at the increased volumes. Parallel processing, patient streams that segment patients according to the time and resources they will need, and pushing the provider to the front of the encounter are all forward-thinking ED flow strategies. For The Miriam Hospital emergency department, this change package helped get its mojo back! Once again, the ED members are top performers in their system. From now on, they will continue moving their patients fast forward and achieving higher levels of performance and great success!
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