09 May 2007

Moving the Meat

In our ED, it’s all about throughput. We have a smaller ED than we might in an ideal world, and as a result, we need to eat, sleep, and bleed efficiency. We are not alone in that on a routine basis the demand for our services exceeds capacity. In fact, the Institute of Medicine released a groundbreaking report last year called “Emergency Care: at the Breaking Point.” In that report, a bleak picture was painted of the overall state of Emergency Departments nationwide. The trend is towards increased demand and reduced capacity – ED visits have increased by 20% over the past decade to 110 million visits annually, nationwide; there has been a net loss of hospitals and EDs with a net loss of about 10% of national capacity. The result is that in most EDs nationwide, the same scenario plays out on a daily basis: overcrowding, patients with extended stays in the waiting room, patients being treated in the hallways, etc. It is not just at academic and county hospitals any more – the problem has spread out even to relatively affluent community hospitals. This is not just a customer service issue; at every facility at which I have worked, there have been cases of patients dying while waiting to be seen. It is impossible to know certainly on an individual basis, but the inescapable conclusion from a systems management point of view is that these are preventable deaths, and we as a specialty need to take ownership of the issue and develop solutions.

In our ED, we are limited by external factors. We cannot increase the physical size of our ED, at least not in the short term. We cannot do anything about the nursing staffing levels, which are determined by larger market forces. All we can do to decompress the waiting room is to embrace the religion of throughput and strive to maximize the operational capacity of our department. The way to do that is by reducing length of stay.

It makes sense, if you look at it in a quantifiable way. Each ED bed is good, theoretically, for 60 patient-minutes per hour. In a hypothetical ED with 45 beds there is a theoretical capacity of 2700 patient-minutes per hour. If the average length of stay is 180 minutes, the expected throughput rate is 15 patients per hour. If the average length of stay can be reduced to 150 minutes, the effective throughput rate rises to 18 patients per hour, and the effective size of your department has been increased by 20%.

This has to be a team sport. Our efficiencies have been captured in large part in partnership with the hospital. Other service lines, like lab and housekeeping and central supply, have been engaged and have worked on improving the rapid turnover of ED services. The administration has worked to create “express admission units” and staffed admission facilitators in the ED to move admitted patients upstairs in a more expeditions fashion. These are essential elements of any efficiency program. But the ED physician remains the quarterback of this particular team, and without a motivated and effective leadership presence from the ED physicians, the initiative is unlikely to gain much traction.

Thus, over the next few days (weeks?) I will be running a series of posts on the topic of efficiency from the perspective of the ED physician. I started to write it as a single post, but it started getting too long, and longer yet as I started fleshing out ideas, tips, and tricks to generating rapid turnover in the ED. So I will break it down into a series of shorter posts. Stay tuned.


  1. I'm really looking forward to hearing your tips. we have increased our patient volume 30% per month but the hospital, while demanding us to see more patients and have less LWOBS, have not given us any tools to make it so. I would love to have some ideas to present at the next ECC meeting.

  2. Gotta have inpatient beds available. And if you don't, gotta have an agreement that admitted patients get wheeled to the inpatient halls, and not languish in the ED. (We're still working on this one).

  3. 110 million visits in a year. Wow. Aren't there only something like 300 million Americans?

    How many of these visits would not happen if the 40 million Americans without insurance had insurance? I would assume some fraction of the visits are that, either substitute for GP or the result of not seeing a GP.

  4. jimii,
    This has been studied. I don't recall the numbers, but it was clear that a large chunk of the people who went to the ER a lot were the same people who clogged up clinics. There are high-users or care and low-users, and getting people clinic doctors doesn't help as much as you'd think to keep them out of the ER. I'll see if I can find the study.


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