As a part of the Urgent Matters project's resources, each site has been provided with training and education relevant to emergency department (ED) efficiency and throughput. Using rapid cycle testing (RCT) methods, Dr. Hnatow's team has implemented a number of small changes to their protocols, procedures and patient discharge processes to achieve greater efficiency. Rapid cycle testing involves change on a small scale. Not only is staff resistance less likely, but staff input is highly encouraged. Also, results from each RCT inform decisions to either adjust the RCT or implement the RCT on a larger scale. This process allocates resources more efficiently, while still contributing to innovation and change. To measure success, the Urgent Matters program developed Key Performance Indicators, or KPIs, to track patient flow progress.

See Urgent Matters KPIs

Implementation

The first observations for improved efficiency came from the housekeeping staff. "Sometimes the 'worker bees' have the best ideas about how things should run," said. Dr. Hnatow. The idea was proposed to place two jars at the nurse's station to represent clean and dirty beds. Once a patient checks out, the nurse should put a bright red slip of paper with the room number into one of the jars. Once housekeeping staff have finished preparing the room, they are to remove the red slip and replace it with a green slip. This reminds the clerk that there is an open bed that can be filled.

As a result of their "two slips of paper" RCT, the average inpatient bed turnaround time decreased from 167 minutes to 58 minutes in just three weeks. Recently, they have been able to reduce that time to as little as 40 minutes, according to Dr. Hnatow. But in addition to the apparent time reduction, several more "subtle" lessons were learned. Previously housekeeping staff were prohibited from removing sheets from certain beds due to an outdated policy created to avoid staff being jabbed by stray needles in bedding. However, the hospital had long since moved to a needleless system. The new policy change has helped staff perform their tasks with higher efficiency.

Impact

By eliminating housekeeping inconsistencies, and affecting small changes through the RCT process, the team was able to decrease bed turn-around time significantly.

"Those minutes add up," Dr. Hnatow said, citing the incredible advantages of a reduced bed turn-around time, including the significant reduction in ED overcrowding.

Although the throughput time of the ED has remained the same, Dr. Hnatow reported that the ED has increased its capacity by approximately 500 patients a month. "Although patients are spending the same amount of time here, we are able to see more patients," Dr. Hnatow said. His team's next goal is to decrease their patient throughput time.

"In the past, it's been hard to get buy-in from everybody," he said. "The rapid cycle testing allows us to try something for a little while to see if it improves our situation, and then decide if we want to continue." He also said that the RCT process enables the staff to take action, instead of simply planning to eventually make changes.

See sample RCT tracking tool.

The positive results have led to many more initiatives to improve patient flow. "We had a goal of getting 30 percent of our patients out by 11:00 a.m.," said Dr. Hnatow. "So we created rewards for the members if the surgical team who made it in by 7:00 a.m." He confessed that the 'rewards' were meal tickets for residents, but the plan has helped improve throughput time. They have also begun examining their discharge process, and created a Discharge Lounge in a further effort to decrease throughput time.

"Small changes can have a huge impact on efficiency," he added. "Make sure someone owns the process, but don't overburden people with big changes." Dr. Hnatow's team has implemented one RCT change a week, and recommends the same process for other hospitals. "Once you have buy-in, and everybody is working together, you can have big impact with a series of small steps," he said.

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David Hnatow, M.D., F.A.C.E.P.
Division Chief for Emergency Medicine
University of Texas Health Sciences Center
San Antonio, TX