How IT Can Help Emergency Department Flow?

Nawanan Theera-Ampornpunt, M.D., Ph.D.

Health Informatics Division, Faculty of Medicine Ramathibodi Hospital January 28, 2013 http://www.SlideShare.Net/Nawanan

The Mission

Ideal Process in ED

Input

Process

Output

Emergency Patients

Urgent Care

Treated Patients

Ideal ED Characteristics
Predictable patient arrivals All patients are truly emergency patients Staff & resources match demands Little or no wait times Good patient outcomes & satisfaction Efficient use of resources

The Unfortunate Truth

Real Process in ED

Input

Process

Output

Emergency & NonEmergency Patients

Urgent & Non-Urgent Care

Treated Patients

Real ED Characteristics
Unpredictable patient arrivals Mixture of urgent & non-urgent patients Staff & resources dont match demands Looooooooong wait times Poor patient outcomes & satisfaction Inefficient use of resources

A Closer Look
ED Emergency Patients Triage Investigations Non-Emergency Patients

Observation

Treatment

Disposition

Conceptual Model of ED Crowding

Asplin et al (2003)

Simplified Model
Demand
Input

Supply
Process Output

Emergency & NonEmergency Patients

Urgent & Non-Urgent Care

Treated Patients

Process Improvements
Operations Management
The science of understanding and improving business processes (Soremekun et al., 2011)

Close linkage to
Operations Research Industrial Engineering Business Process Reengineering/Redesign/ Improvement/Management Quality Improvement (e.g. Lean Management)

How IT Can Help ED Operations?

Delivers information at point of care
Timely access to useful information Prevention of potential adverse events Such as
Past history Drug allergies Medication list Problem list

IT Role: Timely Access to Information

E-mail

Postal Mail (Snail Mail)

How IT Can Help ED Operations?

Enables improvement of business processes Changes workflow
More efficient More effective Parallel processes (not serial) Concurrent access

Business process redesign/reengineering (BPR) facilitated by IT

IT Role: Facilitates Workflow Redesign

Key To Leveraging IT for ED

Think of IT as operations management tools Recognize values of IT in
Facilitating Patient Flow Controlling Information Flow

How these two flows can be optimized & aligned?

Operations Management Strategies

Increasing Capacity Eliminating Waste Reducing Variability Increasing Flexibility

Soremekun et al. (2011)

Key Operations Management Concepts

Flow Time
Total time spent by a flow unit within process boundaries

Flow Rate
Number of flow units that flow through a specific point in the process per unit of time

Inventory
Total number of flow units present within process boundaries

Throughput or Arrival Rate

Average number of flow units that flow through (into and out of) the process per unit of time
Modified from Anupindi et al. (2006)

A Simplified ED Process
Process

Input

Output Time

Flow Time (hours)

Throughput = # of Flow Units Per Time

= Flow Unit (Patient)

Crowded ED means too much inventory

Littles Law

Average Inventory = Arrival Rate x Average Flow Time

I = RxT
Modified from Anupindi et al. (2006)

Littles Law: Manipulating Process

Average Inventory = Arrival Rate x Average Flow Time

I = RxT
What We Want to Reduce What Needs to Be Reduced
Modified from Anupindi et al. (2006)

Fixing ED Crowding

I = RxT
Reducing inventory through
Reduction in ED arrival rate Reduction in flow time

Strategies to Reduce ED Arrival Rate

Ambulance diversion
Communications & situational awareness among EDs & dispatch

Non-urgent referrals Improved primary care access & insurance coverage Patient education & counseling Telephone triage

Strategies to Reduce ED Arrival Rate

Preventing repeated ED arrivals
Reducing Leave Without Being Seen Improving post-ED ambulatory follow-up care Predicting high risk patients and intervene before ED visits

Fixing ED Crowding

I = RxT
Reducing inventory through
Reduction in ED arrival rate Reduction in flow time

Critical Path
The longest path in the process flowchart
(Anupindi et al., 2006)
B E

Start

G 80%

Finish

D 20% G

A A

C B

F E

Time

Critical Paths Time

Reducing Flow Time

Shorten length of critical paths (bottlenecks) by
Eliminate work of critical activities
Eliminate non-value added work (work smarter) Reduce repetitions of activity (do it right the first time) Increase speed (work faster)

Work in parallel

Anupindi et al. (2006)

Reducing Flow Time

A

C C BF D D GF F E G G

Total Time
Eliminate Non-Value Added Work (Work Smarter)

B Work In Parallel

Start

D Work Faster C C D 20% 3% F

G 80% 97%

Finish

Do It Right The First Time

Time

Strategies to Reduce ED Flow Time

Work Smarter
Provider in Triage/Team Triage RFID Location Tracking
Patients Equipment Charts Personnel

Strategies to Reduce ED Flow Time

Work In Parallel
Bedside registration
Role of mobile devices

Bedside triage
Role of mobile devices

Prehospital data transmission Self-registration kiosk

Strategies to Reduce ED Flow Time

Work Faster
Fast access to patient information
Electronic Health Records (from hospitals) Personal Health Records (from patients) Well-designed user interface

Advanced order sets

Paper or Computerized

Effective provider communications (mobile, pager, etc.) Reducing lab/imaging turnaround time
LIS/PACS Point of care testing of certain lab tests

Tracking/Monitoring of Patient Status (Online Dashboards)

Strategies to Increase Capacity

Indirectly reduce flow time through increase in throughput or capacity of bottleneck activities
Add more resources (e.g. staff, space, equipment) Increase availability of bottleneck resources (e.g. 24-hr. MRI, reducing equipment breakdowns through preventive maintenance) Reducing wasting setup time

Strategies to Increase Capacity

Dealing with ED Boarding of Inpatients
Full-capacity Protocol Better inpatient discharge planning Faster discharge procedures More efficient use of beds (e.g. bed pooling) Comprehensive bed occupancy status monitoring Bed Czars

Strategies to Reduce ED Variability

Dedicated fast-track non-urgent care Standardized protocols
Practice guidelines Order sets Clinical Decision Support Systems (CDSS)

Surgical schedule smoothing Ambulance diversion

Strategies to Increase Flexibility

Avoid high utilization rates (degree to which a resource is working, not idle, compared to full capacity) Predictive modeling & forecasting Full-capacity protocols Cancellation of elective cases Flow flexibility (e.g. dynamic bed management & treatment location depending on needs)

Summary
Operations management approach is critical to solving ED crowding problems IT can play various roles in improving ED patient flow, but key is in process redesign and finding operations management solutions Success will depend on context Be careful of unintended consequences of poor implementation

References
Anupindi R, Chopra S, Deshmukh SD, Van Mieghem JA, Zemel E. Managing business process flows: principles of operations management. 2nd ed. Upper Saddle River (NJ): Pearson Prentice Hall; c2006. 340 p. Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003 Aug;42(2):173-80. Handle D, Epstein S, Khare R, Abernethy D, Klauer K, Pilgrim R, Soremekun O, Sayan O. Interventions to improve the timeliness of emergency care. Acad Emerg Med. 2011 Dec;18(12):1295-302. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008 Aug;52(2):126-36. Pines JM, McCarthy ML. Executive summary: interventions to improve quality in the crowded emergency department. Acad Emerg Med. 2011 Dec;18(12):1229-33. Soremekun OA, Terwiesch C, Pines JM. Emergency medicine: an operations management view. Acad Emerg Med. 2011 Dec;18(12):1262-8. Wiler JL, Gentle C, Halfpenny JM, Heins A, Mehrotra A, Mikhail MG, Fite D. Optimizing emergency department front-end operations. Ann Emerg Med. 2010 Feb;55(2):142-160.