How IT Can Help Emergency Department Flow?

Nawanan Theera-Ampornpunt, M.D., Ph.D.Health Informatics Division, Faculty of Medicine Ramathibodi HospitalJanuary 28, 2013http://www.SlideShare.Net/Nawanan

The Mission

Ideal Process in ED

Urgent CareEmergency Patients

Input Process Output

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

Urgent & Non-Urgent

Care

Emergency & Non-

Emergency Patients

Input Process Output

Treated Patients

Real ED Characteristics

• Unpredictable patient arrivals• Mixture of urgent & non-urgent patients• Staff & resources don’t match demands• Looooooooong wait times• Poor patient outcomes & satisfaction• Inefficient use of resources

A Closer LookED

Emergency Patients

Non-Emergency Patients

Triage

Treatment

Investigations

Observation

Disposition

Conceptual Model of ED Crowding

Asplin et al (2003)

Simplified Model

Urgent & Non-Urgent

Care

Emergency & Non-

Emergency Patients

Input Process Output

Treated Patients

Demand Supply

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

Input

= Flow Unit (Patient)

Process

Output

TimeFlow Time (hours)

Crowded ED means too much

inventory

Throughput = # of Flow Units Per Time

Little’s Law

Average Inventory = Arrival Rate x Average Flow Time

I = R Tx

Modified from Anupindi et al. (2006)

Little’s Law: Manipulating Process

Average Inventory = Arrival Rate x Average Flow Time

Modified from Anupindi et al. (2006)

I = R TxWhat Needs to Be ReducedWhat We

Want to Reduce

Fixing ED Crowding

• Reducing inventory through– Reduction in ED arrival rate– Reduction in flow time

I = R Tx

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

• Reducing inventory through– Reduction in ED arrival rate– Reduction in flow time

I = R Tx

Critical Path

• “The longest path in the process flowchart” (Anupindi et al., 2006)

C

Start

B

G

E

D F

AFinish

Time20%

80%

Critical Path’s TimeA B E G

A C D F G

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

C

Start

B

G

E

D F

AFinish

Time20%

80%

Eliminate Non-Value Added Work (Work Smarter)

20% 3%

80% 97%

Do It Right The First Time

C

Work Faster

D

Work In Parallel

Total TimeA B E GD FC GGD FC GFC

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.