Thesis Results Presentation

The Effect of Implementing a

Flow Coordinator on

Emergency Department

Throughput

Susan Flaming

CSULB, Dept of Nursing

Spring 2015

Problem

• ED overcrowding is a nation-wide, growing

problem

• ED demand far exceeds capacity

• Prolonged wait times affect patient safety, patient

satisfaction, staff morale and hospital financial

performance

Recap of Project

• Flow coordinator was implemented to improve the efficiency of the throughput process in the ED

• An experienced RN focused on “pushing” patients through the process by communicating test results, following up on delays, moving patients, updating patients and caregivers on status

• Measures:

• Discharge Length of Stay (DCLOS): registration to dischgarge (minutes)

• Left Without Being Seen (LWBS): leaving without being seen by a provider (%)

• Elopement: leaving prior to official discharge (%)

Common ED Throughput

Interventions in the Literature

• Split-flow by acuity or patient type (fast track)

• Rapid Triage/Team Triage (parallel processes)

• PIT model (Provider in Triage)

• Flow Expeditor (Tech, RN, NP/PA, Paramedic)

• Technology (POC, Utz in ED, mapping software)

Conceptual Model

Study Design

• Retrospective, comparative study

• Pre & Post groups (“Pre FC” and “Post FC”)

• Data analysis was blind to any patient specific information

• No consents required because no human subjects were tested; no patient-specific information was seen/used by researcher

• Data extracted from existing reports by hospital analyst, blinded and released to researcher

Setting

• Urban ED in a diverse community; median annual salary is $48,000

• 46% white, 13% black, 13% Asian and nearly 40% of Hispanic

descent

• Academic teaching hospital

• Specialty center

• STEMI

• Stroke Center

• EmergencyDept Approved for Pediatrics

• Base Station for the city

• 21 acute care beds, 5 urgent care beds (plus chairs, hallway gurneys)

• 145 patients daily; 55,000 patient annually

Sample Selection

• All ED patients who completed registration

process for both the Pre FC group and Post FC

groups

• Pre FC= 26,386

• Post FC= 26,765

• Female 54%, Male 46%

Flow Coordinator JD

Requirement: RN (at least three years experience)

Hours: 6:30am-7:00pm; 6:30pm-1:00am (until Rapid Triage side closes)

• Facilitates the flow of patients from arrival, through registration, Rapid Triage, to internal waiting room and to main waiting room when needed.

• Communicates collaboratively with ED charge nurse to progress patients through the process toward disposition with emphasis on Rapid Triage patients that need to be moved to the acute side for evaluation

• Maintains updated location of all patients on the tracking board

• Checks charts for order completion and assists with handoffs between providers

• Works proactively to alleviate bottlenecks by moving patients, assisting staff with tasks and interventions and completes triage and discharge when available

• Monitors laboratory and other diagnostic results and notifies providers

• Updates patients on their plan of care by rounding frequently

• Night shift Flow Coordinator ensures handoff of all patients to the acute site prior to Rapid Triage closing

Hypotheses

1. The length of stay in minutes for patients discharged (DCLOS) from the emergency department will be lower in the experimental group after the implementation of the flow coordinator role.

2. The percentage of patients who left without being seen (LWBS) by a provider will be lower in the experimental group after the implementation of the flow coordinator role.

3. The percentage of patients who elope from the emergency department will be lower in the experimental group after the implementation of the flow coordinator role.

Results

…not as hoped for regarding throughput

efficiency, but important insights did emerge

from analysis of age, gender and patient

satisfaction

Distribution of DCLOS

Discharge Length of Stay

0

50

100

150

200

250

300

Pre FC Post FC

Min

ute

s

Discharge Length of Stay (DCLOS)

n= 26765n= 26386

p < 0.001

(187 min; SD = 43)

(216 min; SD = 58)


greater by 29 minutes in

Post FC group

LWBS

0

0.5

1

1.5

2

2.5

3

Pre FC Post FC

Per

cen

tage

of

LW

BS

Left Without Being Seen (LWBS)

n= 26765n= 26386

p < 0.001

(1.34%; SD = .11)

(1.94%; SD = .14)

Left Without Being Seen

greater by nearly 50% in

Post FC group

Eloped

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Pre FC Post FC

Per

cen

tage

of

Elo

pem

ent

Eloped

n= 26386 n= 26765

p = 0.238

(3.75%; SD = .19)

(3.95%; SD = .19)

Difference in Post FC

group for Eloped not

statistically significant

Age & Gender Effect

• Age and gender were analyzed for each

throughput metric to uncover patient-type trends

• The idea behind this analysis is to determine what

patient types are high risk for an extended

DCLOS, LWBS or elopement

• Example: 20-40 yr old male patients are HIGH RISK

• Identifying these patient types can help caregivers

to focus interventions to improve throughput

Gender on DCLOS

190

195

200

205

210

215

Female Male

Min

ute

s

Gender Effect on DCLOS

n= 28668 n= 24483

p = 0.001(211 min; SD = 10)

(198 min; SD = 11)

Female patients stayed in

the ED 13 minutes longer

than males on average

Gender on LWBS

0

0.5

1

1.5

2

2.5

3

Female Male

Per

cen

tage

of

LW

BS

Gender Effect on LWBS

n= 24483n= 28668

p = 0.001

(1.43%; SD = .11)

(1.88%; SD = .14)

Males 32% more likely to

LWBS than females

Gender on Eloped

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Female Male

Per

cen

tage

of

Elo

pem

ent

Gender Effect on Eloped

n= 24483n= 28668

p = 0.001

(3.63%; SD = .19)

(4.12%; SD = .19)

Males 14% more likely to

Elope than females

Age on DCLOS

0

50

100

150

200

250

300

< 20 y.o. 20-40 y.o. > 40 y.o.

Min

ute

s

Age Effect on DCLOS

n= 11559 n= 17826 n= 23766

p = 0.001

(146 min; SD = 41)

(199 min; SD = 2)

(239 min; SD = 5)


increased by age with the

> 40 y.o. group staying

longest in the ED

Age on LWBS

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

<20 y.o. 20-40 y.o. > 40 y.o.

Per

cen

tag

e o

f L

WB

S

Age Effect on LWBS

n= 28668n= 17826n= 11559

p = 0.001

(1.44%; SD = .11)

(1.76%; SD = .11) (1.65%; SD = .13)

Left Without Being Seen

was highest in the 20-40

y.o. group

Age on Eloped

0

1

2

3

4

5

6

<20 y.o. 20-40 y.o. > 40 y.o.

Per

cen

tag

e o

f E

lop

emen

t

Age Effect on Eloped

n= 11559 n= 17826 n= 23766

p = 0.001

(3.29%; SD = .21)

(4.52%; SD = .19)

(3.07%; SD = .11)

Eloped was highest in the

20-40 y.o. group

Patient Satisfaction

“Given my medical condition, I did not have to wait

long”

• Pre FC: 83.2% answered “always”

• Post FC: 84% answered “always”

• p= .08324

“My health condition was checked immediately when

I got to Emergency”

• Pre FC: 85% answered “always”

• Post FC: 86.7% answered “always”

• p= .5326

Patient Satisfaction

“The Emergency staff kept me comfortable while I

waited to see the physician”



• p= .8404

“The Emergency staff took my problem seriously and

responded quickly to help me”



• p= .3172

Summary of Results

• DCLOS & LWBS were higher (worse) in Post FC group

• Flow coordinator had neutral effect on Elopement

• Age & Gender were significant for all three metrics

• Men had LOWER DCLOS but HIGHER LWBS & Elopement

• Women had HIGHER DCLOS but LOWER LWBS & Elopement

• 20-40 y.o. group had highest LWBS & Elopement

• Patient Satisfaction improved, despite worse DCLOS & LWBS

Discussion

• Electronic Medical Record had a much larger

impact on length of stay than anticipated

• 4-5 min increase in registration/triage alone

• All ED operations slowed down and lasted > 6

months

Discussion

0

50

100

150

200

250

300

350

400

450

500

Min

ute

s

May-

13Jun-13 Jul-13

Aug-

13

Sep-

13

Oct-

13

Nov-

13

Dec-

13Jan-14

Feb-

14

Mar-

14

Apr-

14

May-

14

ALOS 340 322 325 376 335 324 362 371 434 423 382 385 397

DCLOS 126 139 130 170 192 188 177 207 202 191 193 216 201

Patient Length of Stay

May 2013-May 2014

Data Source: ER Monthly Metrics- 5/2013 - 5/2014 ALOS- Admission Length of Stay DCLOS= Discharge Length of Stay

Implications

• Confirmed what the literature has established with

results of age & gender effect on throughput

metrics

• Confirmed what the literature has established that

technological implementations add value but often

slow processes for months after implementation

• Patient satisfaction and patient safety

Recommendations

• Implement the flow coordinator using different

clinical roles- EMT, LVN, MA

• Study FC impact on other areas of throughput:

Left Without Being Registered, Admit LOS,

ambulance diversion

• Analyze impact on patient satisfaction and patient

safety

• Analyze impact on employee satisfaction (staff

now see the flow coordinator role as

indispensable)

Thank you

• Committee members

• Dr. McGuire

• Ann Kim

• Gail Daly

Slaying the beast (me vs.

thesis)

Documents

Thesis Results Presentation