Our hospital is a large pediatric hospital located in the mid-Atlantic area of the United States.
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Background
Our hospital is a large pediatric hospital located in the mid-Atlantic area of the United States. It is part of a larger children’s health system with primary and specialty services in the Northeast and in Florida. It includes the only Level I pediatric emergency department (ED) and Level I pediatric trauma center in the state, which typically provide services for more than 60,000 patients over the course of a year and offer care to the most vulnerable patients and families. Critical for patient care, the flow of patients through the emergency department is also vitally important for access to care, affecting the patient experience and the nursing practice environment.1,2 Organizational data indicated an increase in the number of patients being held in the emergency department as a barrier to patient disposition across the continuum of care. As noted in January 2019, 61.1% of our patients did not reach the inpatient units within 60 minutes of being ready for transfer. Between January and December of 2019, before implementation of improvement interventions, the mean time from patient readiness to arrival on the unit was 122.49 minutes. A lack of a standardized process was noted as the main barrier to meeting our target.
Problem Identification
Patients at our pediatric hospital can access care at multiple locations, including the emergency department. Our department has prioritized flow within the department, as well as during patient disposition. Our ED flow consists of patient arrival, initial assessment, treatment, reassessment, and disposition. These processes contribute to satisfaction and overall successful patient care outcomes. When demand exceeds capacity, patients determined to need admission occupy ED space and flow is interrupted, leading to dissatisfaction and the inability to serve other patients requiring emergent care.1,3,4 Patients who are unable to progress through to the intended admission location are then held within the emergency department to continue care, which is not ideal for patients or their providers. An evidence-based process was needed to assure a seamless transition for patients admitted from the emergency department.
Review of current protocols and creation of best practices for ED flow were included in the consideration of the emergency department’s ability to transfer patients for continued care. Communication and data documentation were extremely important starting points. During daily management huddle, emergency clinical nurses and other emergency care team members raised concerns regarding the ED front-end process and control over the patient care they provide. With the emergency department being a high-volume, high-acuity, fast-paced care environment, multiple competing processes may cause poor patient flow. This results in the inability to consistently locate patients for “next steps” in care and for staff to have control over the environment where they provide care. Multiple patient arrivals at the same time caused bottlenecks resulting in unnecessary patient movement and potential obstruction to disposition decisions.5
In 2015, the ED team introduced the concept of immediate rooming when rooms are available and revamped the front-end process for when rooms are not available, with a goal to have patients in rooms and the bedside care team and support staff interacting with the patient within 15 minutes of arrival.4,6 Other goals, which were achieved, included reducing patient travel from a maximum of 9 stopping points to 6 when no rooms in the emergency department were available (Table 1), finding the correct patient in the ED waiting room 100% of the time, and limiting duplicative staff interaction with the primary care team. Achieving these goals streamlined communication, improving care for the patient/family while increasing efficiency of staff. The percentage of patients placed in rooms within 15 minutes increased from 59% to 85% overall and increased to 95% when a room was readily available.
Management of the internal ED patient flow led to the next challenge of improving flow to inpatient areas of the hospital, which was the emphasis for this quality improvement (QI) project. We considered acuity of illness, risk of deterioration in status, and opportunity to provide inpatient and specialty services. This important goal was incorporated in the Nursing Strategic Plan, with an initial goal of decreasing the length of stay (LOS) within the emergency department but to then improve the overall satisfaction of patients and families across the continuum of care. A primary strategic goal alignment was for 65% of patients arriving on the inpatient units within 60 minutes from their baseline time of “patient ready” in the hospital electronic health record. Determining methods to succeed with this process was the problem identified and addressed through QI methodology.
Available Knowledge
The Centers for Disease Control and Prevention reports a total of 130 million ED visits per year, with 12.4% of these resulting in hospital admission.7 In both adult and pediatric hospitals, approximately 70% of hospital admissions come from the emergency department. In pediatric hospitals, 10% of all ED visits result in admission.8 In 2018, the national median time interval from decision to admit to hospital admission across all EDs reporting was 116 minutes, but this represents only a small percentage of emergency departments and does not differentiate hospital type, patient characteristics, or geographical locations, especially urban versus rural.8
A substantial percentage of patients admitted to inpatient units come from the emergency department, which means patient flow within the emergency department and outside of the emergency department is extremely important, but there are no universal guidelines nor benchmarks available to gauge patient movement across hospital areas.2,9 Models to improve throughput in the emergency department itself, especially from the waiting room to initial care, and to streamline admission to critical care units across all populations have been published.9-13 Communication, as a critical part of handoff, and the ability of the ED staff to recognize and predict acute and critically ill patients are other aspects of study.14 However, we were unable to find data that present appropriate or recommended timing of ED patients admitted to inpatient areas. In most cases, this concept is measured by family satisfaction with ED care and access to care, specifically.15
Patient handoff is a comprehensive process associated with ED LOS and an important component to guarantee an efficient inpatient admission.9,14,16 Communication is key to smooth transfer from one unit to another, especially for ED patients who are admitted with various levels of complexity.17 One hospital used a conference call approach to disseminate information for pediatric patients who were moving from the emergency department.14 An electronic version of Situation, Background, Assessment, Recommendation was used by an emergency department for the inpatient nurse to view patient data and then call the emergency department for additional details.18 Wolak et al9 published results of changing handoff processes, also using Situation, Background, Assessment, Recommendation, for patients admitted to inpatient areas. This adult-focused study noted an average LOS of 154 minutes from time to admit decision.
Prediction of ED patient risks for admission and for deterioration in status has been studied, but primarily focused on individual hospitals/organizations.10,11,19,20 Patient acuity on admission from the emergency department is another discussion point. Nadeau et al11 conducted a retrospective review of pediatric patients admitted to 1 inpatient unit and then transferred to an intensive care unit (ICU) within 24 hours. Of 82,397 admitted patients, 1% were transferred to the ICU. Another study in a large Canadian hospital attempted to decrease the incidence of rapid response calls that required transfer to the ICU. The study focused on adult patients admitted to inpatient units from the emergency department within 24 hours. The authors used a Modified Early Warning Score along with other patient characteristics such as presence of a Foley catheter to predict risk at time of admission.13 These studies reinforce the need for patient risk identification and admission to an appropriate unit in a timely manner from the emergency department. Barak-Corren et al21 presented a multivariate prediction model that along with specific patient characteristics, including previous admissions, current medications, and ED risk acuity scoring, can predict the need for hospitalization of patients arriving to the emergency department as early as 10 minutes from check-in. This type of prediction assists in getting patients to the correct level and environment of care and is also helpful for the purpose of admission planning and decreasing the total LOS in the emergency department.21 Rowland et al22 described a similar predictive model for children admitted to nonspecialist hospitals in England, called the Pediatric Admission Guidance in the ED score, which assists in determining risk for admission. Similar to other published prediction models, this one also used a quantifying method to document potential for admission. An adult model focused on improving discharge times of inpatients to have available beds for ED admissions.12 Obviously, providing health care in an efficient manner in any setting is important, but care in the emergency department is unique given that many patients presenting there are not previously known by providers or staff, acuity can change momentarily, and decisions for disposition can take extended periods of time.
Despite the availability of rapid access to care in the emergency department and accurate patient acuity evaluation, attention to timing of transfer to inpatient units has not been a priority in research. However, it is essential to improve access for patients waiting in the emergency department for continuation of care, considering the lack of resources ED providers have to provide inpatient care. Streamlining admission from the emergency department to the ICU or a medical-surgical unit is critical.10,23
Methods
To address the throughput in the emergency department and from the emergency department, a patient flow process improvement event was held using continuous improvement efforts. A continuous improvement event uses a QI structure that does not require institutional review board approval, given that it does not include development, testing, or evaluation involving human subjects. However, a query was submitted to the institutional review board at our institution, and they concluded that the project was not research. The data obtained for this project were de-identified and aggregate, and the results are not considered generalizable. This event emphasized the need to align with previous ED improvement efforts.
An interprofessional team with emergency clinical nurse participation completed an analysis of the flow of patients to the inpatient units, noting barriers within this environment, which included lack of a standard process, absence of visual indicators, and fragmented communication between teams. Process mapping was the tool used to outline results with the goal of disposition of patients within 60 minutes of the decision to admit, and an admission model (Table 2) was created to include specific steps to support improving patient flow on admission. Once the new process was implemented, barriers were discussed daily at the Patient Care Services huddle to improve communication, using daily visual data metrics and huddle discussion to monitor success and to escalate noted opportunities. High inpatient volume throughout the hospital limited the initial success of the admission model. Teams were encouraged to escalate barriers in real time. The most common barrier that was escalated was related to bed availability because of high inpatient census. Daily metrics were provided for nursing leadership and ED clinical teams to assess and measure success and to document trends in barriers. Trending issues allowed the team to identify ongoing issues, such as extended length of time for inpatient room turnover.
Once the potential new process was outlined, a unit known as 4 West, a fast-paced, short-stay unit, was chosen as the pilot unit to implement the new emergency department to inpatient model. The 4 West patient flow supervisor, a designated lead and expert nurse, had the task of collaborating with the interdisciplinary team to coordinate patient flow and adjust resources to ensure optimal care delivery and continuum of care. The patient flow supervisor played a vital role in the process of admitting and discharging patients, ultimately guiding throughput of patients admitted from the emergency department. Direct communication between the emergency department and the receiving unit was instrumental in early identification and planning for patients. Given that our short-stay area is a fast-paced unit, with continuous admission and discharge expectations, it proved the best place to pilot the change with the end goal of rolling out the tested admission goal and admission process to the remainder of the medical-surgical inpatient units.
Efficiency added to the quality outcomes of this admission model; therefore, patients arriving from the emergency department were given a “reservation” or pull time when “ED ready to admit” was identified through the electronic health record. The emergency department and unit-based nurses determined a time when they would endorse handoff at the patient bedside in the emergency department to exchange this information. Although bedside handoff is a standard within our organization, completing the handoff in the emergency department was a new outcome as a result of this project. The nurses met in the ED patient room, and the medical-surgical nurse received a standardized report, performed a safety check with Pediatric Early Warning Score24 assessment, and transported the patient back to the floor. The Pediatric Early Warning Score is a severity of illness score developed for hospitalized children, which provides objective patient criteria and allows for early identification of patients at risk for cardiopulmonary arrest.24 Completing this assessment decreased the frequency of unnecessary rapid response team calls and transfer of newly admitted patients to an ICU within our organization.
Evaluation of the pilot for transition of pediatric ED patients revealed that, in 2019, 59.75% of patients were admitted within 60 minutes. Once we successfully and efficiently placed patients in ED rooms and demonstrated a decrease in inpatient admission timing, the QI group decided to introduce this model to other units within the hospital, with the intention of all units participating in the same admission process as ED patients.
Assumptions included the fact that streamlined inpatient care can decrease incidents, flawless communication ensures continuity of care, and shortened stays in the emergency department result in more efficient inpatient services. Evaluation of patient and family experience was linked to improving “likelihood to recommend” scores, supporting the enterprise’s vision, and assisting in maintaining patient location within the only children’s hospital in the state. The nursing department strategic plan incorporated the goals of decreasing LOS within the emergency department and improving satisfaction of patients and families across the continuum of care. Real-time, daily metrics continued to provide nursing leadership and clinical teams success stories and the opportunity to address barriers and continue to improve processes.
Results
Aggregate data comprised a population of pediatric patients ranging from 0 to 21 years of age admitted from the emergency department to medical-surgical and critical care units. Figure indicates the percentage of patients deemed ready to admit and physically transferred to the inpatient unit within 60 minutes of this decision. The improvements in the admission model, a registered nurse-initiated “pull process,” reservation time, and a coordinated handoff led to a significant decrease in overall admission time. Admission time is also illustrated in Figure, documenting an improvement from 38.9% to 80.0% of patients who were ready for admission to arrival within unit within 60 minutes from January 2019 to January 2021. This represents an overall improvement of 41.1%.
Before the implementation of the improvements outlined in the article, the mean transfer time from the emergency department to the inpatient unit was 122.49 minutes (January to December 2019); postimplementation the mean time was 83.63 minutes (January to December 2020), a difference of 39 minutes. These data indicate overall improvement, but there is no information that supports what an “ideal” admission time frame is nor what patient outcomes improve as a result. A visual cue provided by our electronic medical record created a signal that offered the largest improvement in visibility.
Discussion
The coronavirus disease 2019 (COVID-19) pandemic has wreaked havoc in the emergency department across both pediatric and adult patient populations. Early in the pandemic months, “lockdowns” resulted in an overall decrease in communicable diseases among children, so emergency departments in children’s hospitals were operating at a much slower pace and inpatient admissions were limited by several variables including suspension of nonurgent surgical procedures.25,26 Overall volume within our department decreased by 33% during this time frame. This project was started before the COVID-19 pandemic, so results obtained between preproject and postproject may not fully represent the “typical” ED patient flow for this institution, which was described early in the article. An annual ED census of 60,000 patients does not normally mean 168 patients per day, given that fluctuations have always included “seasonal” pediatric problems. Although adult hospital emergency departments were overflowing, pediatric emergency departments were slower but quickly escalated to much higher daily census. At times, 1.5 times as many patients per day were seen in our hospital as previously at the same time of year, despite Centers for Disease Control and Prevention data that indicate that pediatric ED volumes did not increase over 2019.27 In latter months of the pandemic, pediatric hospitals also experienced nursing shortages, with excessive turnover in staff, and these hospitals have different issues when hiring new staff than their adult counterparts. Nurses experienced in adult care can move between institutions and require less orientation than adult-trained nurses who are moving to a pediatric hospital, which was sometimes the case at our institution, adding another barrier to ED patient flow during this past year.
As we continue to collect data on the average time to admit from the emergency department, many variables must be considered, some of which were not in place before January 2020. The members of the team who created this new model of care were successful, despite many variables beyond their control.
Limitations
As previously mentioned, the COVID-19 pandemic may have affected the design of this process and should be considered a potential limitation. An additional limitation of this study was the use of data from only 1 children’s health care system, which could result in bias and impede applicability and reproducibility of the methods for other institutions. The QI methodology does not support the ability for the data to be generalized in any setting; it only provides a framework for the process. In addition, this study measured time frame only; it did not document other patient outcomes. Patient acuity data were also not collected, which could assist in determining if rapid, streamlined admission from the emergency department increases the opportunity to efficiently identify and address deterioration in status. Seasonal shifts in acuity and volume of ED patients are also factors that are not easy to control. In times of exceedingly high inpatient census, the emergency department can be used as an inpatient “hold” area, which philosophically eliminates aims to provide care in the best possible environment by the most qualified providers. Unfortunately, there are no benchmark data to compare results or ideal metrics to continue to aim to achieve. There also may be different perspectives between adult and pediatric patients, where decision to admit may be urgent for some and not for others. However, improving throughput in any ED setting can only result in overall improved patient access and patient/family satisfaction. The QI project implementation took place over the course of the pandemic, perhaps affecting the number of patients requiring admission in the pediatric ED setting.
Implications for Emergency Nurses
Emergency departments are tasked with providing care to many patients, often exceeding their capacity. Creating a streamlined process for patients admitted from the emergency department to the inpatient setting improves efficiency of clinical care and patient access to services not available in the emergency department. Improving patient throughput in the department allows ED providers and nurses additional time to offer services to a larger volume of patients with varied acuity presentations.
Implementing a standard work process for patient admission, while also incorporating effective communication, provides a road map to efficiently move patients from the emergency department to the inpatient setting. This is a model that can be replicated for other hospital areas and benchmarks for comparison of results. In this model of care, collaboration between interdisciplinary teams representing the emergency department and various inpatient units is integral to facilitate the movement of patients through the system, ultimately allowing more available physical space/treatment rooms to care for patients arriving to the emergency department. Thus, by improving throughput and expediting admission to inpatient units, the providers, nurses, and support staff initiating care in the emergency department are encouraged to evaluate patient needs and predict disposition for inpatient acute and critical care in a timely manner, which can result in improved patient outcomes and patient/family satisfaction.
Conclusion
Improving the time from decision to admit to actual admission to an inpatient unit was the goal of this ED QI project, with secondary aims to increase patient and family satisfaction. Methods have been continuously evaluated and data collected to document the success or sometimes failure of this method to achieve the intended goal. Decreasing the time for patients to reach the inpatient unit was our ultimate measure of success. Additional factors that demonstrated success included the availability of inpatient beds, that is, clean or ready for admission based on discharge timing of previous patients or environmental services efficiency or both. Although our pilot improvement project was originally implemented on a short-stay unit, where turnover is imperative for unit success, we were able to replicate this process in all inpatient medical-surgical and critical care areas. We believe this methodology can be successfully replicated throughout our organization and plan to evaluate the results in the future.
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