Saving Time in the ER, Even When It’s Not Life and Death

In the ER, we celebrate small improvements. After all, we work in a place where a few minutes saved could mean the difference between life and death. In other cases, shaving a few minutes off a process here or a protocol there may result in somewhat less dramatic payoff.

Take our recent Kaizen project at Meritus Medical Center to reduce the time from when a doctor decides to admit a patient, to when the patient leaves the ER. Historically it had taken about 200 minutes for the patient to be admitted, but after a top to bottom analysis and a few small but significant process improvements, we have brought this time to consistently below 140 minutes.

It may not be life or death, but it’s a thousand small improvements like these that are going to help fix our healthcare system, both saving money and improving patient care. Guided by the LEAN system of identifying pain points, creating “standard” work, and making other “right work” easier to do, we identified several areas for improvement:

• Historically doctors would often decide to admit patients without changing the patient’s status in the ER’s tracking system. The physician would decide in their head but often neglect to change the patient’s status to “decide admit” in the computer. This created a problem for the hospital’s patient care manager, who uses the tracking system to decide whether admissions are appropriate. Ensuring doctors used the system properly was the first step. A checklist we created for admitting patients includes this step to help remind them.

• Next came fixing the information flow around bed assignment. Before we began to work on this issue, the person at the hospital with responsibility for making bed assignments was doing so with incomplete information about the patient, for example what level of care was needed. The issue was that the Administrative Nursing Supervisor, who had that information delivered to them through a computer alert, wasn’t sharing it with patient registration. Furthermore, we discovered a mysterious 8-minute delay from the time the admission request was sent from the ER to the time it showed up as an alert in the hospital. We worked with the hospital’s IT department to fix both these issues, the latter of which required the installation of a new server.

• Finally, we examined the actual transfer of care between the ER nursing staff and the hospital staff. Before, the ER nurse and the floor nurse in the hospital essentially had to have their stars align and find a time to communicate effectively about the patient being transferred. Anyone who has tried to schedule a phone call in a busy work environment knows how hard this can be. To improve the situation, we created a system that populated a report with information about patients such that any ER nurse at any time could deliver the necessary information to the floor nurse. That way, when the floor nurse calls, any available nurse in the ER can communicate the patient’s information.

These changes were just a start to improving this process, but they have had dramatic effect in a very short period. Implemented in the middle of March, these improvements and others were able to bring down the time from when a doctor makes the admit decision to when the patient is given a bed by approximately an hour. That can make a huge difference.