In an emergency department (ED) spanning 50,000 square feet and serving more than 100,000 patients each year, improving patient throughput is no small task. When Grady Health System in Atlanta - one of the Southeast's largest public health systems - was awarded an Urgent Matters grant, the team set a goal for reducing throughput by 25 percent.

"The literature references average ED throughput of two to three hours, but these are the averages across all EDs in the country, many of which are considerably smaller than Grady's," said Leon L. Haley, Jr., MD, MHSA, deputy senior vice president, Medical Affairs, chief of emergency medicine and vice chairman, Clinical Affairs, Grady Health System, who helped lead implementation of a new, centralized order entry system. "Nobody seems to have a good handle on how long it takes to get patients through a 100,000+ volume ED. We started with an average patient throughput of 6.8 hours. We knew that we couldn't achieve the 'mythical' three hours in one year, but reducing the time by 25 percent seemed like a good start."

Members of Grady's ED Leadership Council, which included department leaders, the trauma coordinator and the administrative manager responsible for managing clerical staff, decided to aggressively tackle one of the key components that slowed down patient throughput - the time it took for processing physician orders.

Under Grady's existing system, physicians' orders for everything from labs to x-rays were dropped into a box for the nurse in charge of that patient care area. Each of these nurses would have up to six patients in his or her care, yet all orders for patients had to be processed by this nurse.

"As a physician, you placed your order into the box. If the nurse was standing right there, great. If not, the order sat there until he or she returned," explained Dr. Haley. "Many times, nurses would be working with patients and not even know that physician orders were waiting to be processed."

Frequently as many as three or four orders would be awaiting a nurse's attention, which required the nurse taking time to prioritize each one, leaving some orders to wait even longer. It was clear that a more centralized way of doing things may help save time in moving patients through the ED.

Pilot Testing and Implementation

Using rapid cycle testing techniques, implementation started with a two phase pilot of centralized order entry. The data gathered during Phase One was based on the existing decentralized order entry system and was used as a basis for comparison. In Phase Two, all patient charts with orders were instead placed in a rack on the unit clerk's desk. Unit clerks, rather than several busy nurses, were then responsible for order entry.

In both phases, the data tracked included the times at which:

• the order was written;
• the order chart was placed on the rack;
• the unit clerk entered the order into the computer; and
• the order was completed.

Impact on Staff

"We were lucky that our department is big enough to test changes like these before they're implemented," said Dr. Haley. "We didn't have to just drop the change on staff."

As with most systemic changes, however, hospital staff had mixed emotions. Physicians were in full support of the new protocol since orders for all patients were placed in one area, which saved them time. Nurses were initially skeptical that they would lose autonomy. Not surprisingly, clerks were hesitant because for them, the protocol meant increased responsibilities.

"We went from a process that was taking two hours per order to a new centralized process that typically takes 30 minutes," said Dr. Haley. "But if you're the clerk who has 10 orders to process, this may not feel like such an improvement."

Lessons Learned

While the ED's Leadership Council did include the administrative manager, since the new protocol had such a profound impact on the clerical staff, Dr. Haley would recommend that other hospitals looking to implement such a system involve this group earlier. "We should have involved them earlier than everyone else," he said. "And now, we're looking at better ways to help a clerk who may subsequently become overwhelmed with too many orders."

Since ED flow can vary according to the time of day, Dr. Haley and his team have been working on ensuring the system works no matter what the time of day and regardless of the staffing situation. "Any well-designed system should work at 2:00 in the morning just as well as it works at 2:00 in the afternoon. It should also work when you're fully staffed and when you're short - 1 person, or 5 people."

Dr. Haley and his team are constantly looking for ways to improve the new system, hoping one day to get down to the mythical three hours for throughput time. "You can't change what you can't measure," he said. "We continue to give physicians measurements and ask them to report back the results. That's the only way to continue to identify ways to improve."

Click here to download a presentation of rapid cycle testing done at Grady Memorial Hospital.

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Leon Haley, Jr., M.D., M.H.S.A
Deputy Senior Vice President, Medical Affairs
Chief of Emergency Medicine and Vice Chairman, Clinical Affairs
Grady Health System
Atlanta, GA