The emergency door flood gates: Is that a bottleneck in your patient flow?


The emergency room (ER) represents the largest portal of entry into hospitals, accounting for 65 per cent of admissions to acute care beds each year – The Canadian Institute for Health Information (CIHI) identified in their 2007 report that 68 per cent of patients admitted in the ER required acute care medical beds. The ER represents a key area that operates at a fast-pace with high turnover of patients and can respond to, at any given time to patients requiring priority or emergent care. Once a patient has been admitted into the hospital system through this portal, a bottleneck can occur quickly, thereby impeding its staff member’s abilities to attend to its emergent patients. The need for a timely transfer of patients to an inpatient care unit must be coordinated for a safe, seamless and transparent process that involves each unit leader.

Managing the flow of patients into, and across organizations efficiently and effectively requires a consistent, flexible and integrated plan that is utilized and equally well understood across the organization. A supply chain management approach facilitates the identification of risk, redundancy and bottlenecks within the flow of patients and information needed for the safe transfer of a patient’s care. Paired with an intuitive software program or Enterprise Resource Planning (ERP) program will provide a useful dashboard to quickly identify and monitor ready-for-discharge patients (RFD) to determine the appropriate use of acute care beds and to identify appropriate patients for immediate discharge during a pandemic or crisis.

The current research literature largely reflects our US counterparts. Canadian research on effective bed utilization and its effect on patient flow is largely in its infancy. In private sector business organizations, it is not uncommon to find supply chain management for not only materials, but services and information as a source of competitive strength, providing a distinction among saturated markets. We are now in a time where Ontario hospitals must also identify gaps in how patients access timely acute care services and links within the chain that are risky or inefficient. An organization is only as strong as its weakest link. Implementing such a system will result in improved patient and staff satisfaction and patients that receive the right care, by the right provider, in the right bed, at the right time.

Both bed capacity and human resources are critical – nurses and physicians have a direct impact on an organization’s ability to meet patient needs in a timely and effective manner. Confidential information exchange must be accurate and timely, prior to taking over patient care to effectively provide quality care in a safe environment. Information management is a critical component to patient care safety. Transparency and communication with stakeholders is important to establish, maintain, and develop relationships. As Ontario hospitals transition to improve transparency, improved bi-directional communication must take place in order to improve the public’s awareness about the organization when entering the hospital system. Ontario hospitals have already begun to report ER wait times on hospital websites. Data from the beginning of 2009 indicated an average wait time in ER ranging from 5-13.6 hours, with a Ministry set target of 8 hours. This is an excellent first step in the overall patient flow management process and can be utilized as one indicator for the patient care experience and can set the stage for further data and knowledge management. While many hospitals have their own form of a quick fix or band-aid solution, an integrated software program can provide real-time data, would reflect the organization’s overall strategy and its values with the ability to predict and respond to patient volumes vs. a reactionary nature.

There are both variable and invariable factors that must be considered when considering how patient care needs are met and how this may represent a barrier to accessibility of services. Variability in admissions can be forecasted to a large degree considering historical data on seasonality, changes in health-care services in the community (such as the closure of walk-in clinics or retirement of family physicians), outbreaks in alternate care facilities, and media, particularly on communicable diseases. Planned admissions include surgeries and repatriations. There is often a disconnect with planned surgeries in terms of days of the week and availability of beds and staff, largely related to a surgeon’s booked OR times, and advanced bookings. Other factors for consideration in planning are the percentage of alternate level of care (ALC) beds as part of an organization’s acute care beds, which represent bottlenecks outside of the hospital environment.

Across Ontario, nursing shortages and disengaged staff lead to a high turnover and sick time, reducing the organization’s ability to respond to patient care levels effectively and costly overtime demands resulting in higher operational costs and increased risk to the safety of both staff and patients. Nursing staff are at the forefront of meeting these increased workload demands, mitigating increased infection control risks, increasingly acute patients, and stringent documentation practices needed for the protection of their own licensed practice, communication across the multi-disciplinary team and organizational requirements.

Risks include surgical cancellations, the inability to accommodate out-of-county patients in other facilities who are away from family and friends, patients not receiving level of expertise they would if in the right bed at the right time, patient anxiety related to not knowing when a bed will be available, sharing a patient room with the opposite gender due to cohortation to accommodate as many patients as possible, an absence of a quiet and restorative environment due to being held in ER, patients experiencing delays in ER due to lack of room availability and staff resources being utilized with held patients awaiting transfer. CritiCall’s services are reserved for exceptional and complex patient cases when the nearest hospitals do not have the resources to meet the patient’s health-care needs. Patients may be transferred to facilities outside the province or country resulting in significant costs to the health-care system and the time needed to find and transport such patients to these organizations places them at a higher risk for undesirable outcomes such as discomfort, additional worry, and potentially higher mortality and increased costs.

Key hospital practices that can reduce risk, contribute to staff engagement, and accommodate a smoother patient flow into hospitals:

• Policies and procedures that are integrated into the overall strategy of the organization, engaging all staff and physicians

• Incorporate patient communication tools (at admission, signage in ER to identify transitions to and from hospital admission)

• Bringing in a Patient Flow Specialist to specifically manage the portfolio of Central Registry department and bed facilitator to identify areas for improvement within the supply chain and facilitate communication across the organization and with key external partners in alignment with the values of the organization

• Identify targets, set metrics and report them. Examples include established targets for discharges each day or estimated length of stays based on best practices or CIHI. Include key findings in ER wait time reports to provide informative information to stakeholders

• Acknowledge increased ARO status of patients and create plans to minimize exposure to other patients through a planned cohortation of patients and effective infection control practices such as hand hygiene, patient and family education for isolation needs and practices

• Create a community of practice across regions to establish processes and practices and benchmarks to develop strong infrastructure

Smoother flow results in better patient care, as patients receive the right care in the right bed at the right time. The ER department will be able to respond and function as it was designed – to focus on treating the episodic events of the patient in their department and releasing those that do not require admission.

Removing redundancy, delays and other activities that do not create value, hospitals can improve their ability for patients to access care and increase patient and staff satisfaction through improving the patient care experience. Aligning with the Lean philosophy, an organization that can predict an event, can prevent it. Fluctuating volumes of patients moving into an organization does not need to create gaps or variability in the patient care experience. Now that’s money well-spent.