Sunday, November 22, 2009

What can we learn about ED Capacity and Patient Flow from Funnels?

This is part of the support material for the ER Overcrowding Solutions Presentation at the bottom of this Post...

As it has been shown time and time again, an Emergency Department that doubles its bed capacity never ends up seeing double the amount of patients before it requires another expansion. Why is that? The reason is simple. When a Hospital doubles ED physical capacity, it never doubles inpatient capacity nor doubles the number of radiologists, consultants, lab techs, analyzers, transporters, etc. As such, even a modest increase in ED volumes puts significant strain on all the ancillary departments we need to help us service demand and the inpatient units we need to unload admitted ED patients to. This markedly increases variability in system interfaces and increases the time patients actually spend idle in ED beds.

To illustrate this, close your eyes and imagine we are pouring sand into a three-dimensional funnel. As we pour sand on the top of the funnel some sand makes it to the bottom opening and exits the funnel but, if we pour sand more briskly, the funnel will eventually fill up as sand is being poured in faster than it can exit. The sand that spills over the top (because it does no longer fits in the funnel), represents patients accumulating in the ED waiting room and hallways.

Now, let’s imagine we obtain a much larger funnel but this funnel has an even smaller opening to let the sand out. We will now be able to pour more sand initially into the funnel entrance and pack more sand within the inside of the funnel. Nevertheless sand is getting out more slowly. As we pour more sand, each individual grain of sand has a far longer and congested distance to travel from the top to the bottom and is also competing with far more grains of sand to get through the bottom opening. When this funnel eventually spills, the mess will be far greater. That is what happens to Emergency Departments that just expand…

By contrast, eliminating variability is the equivalent of widening the bottom exit of the funnel. The more variability we eliminate, the wider we make that exit. Now, when we pour sand on the top, it travels much faster towards the bottom exit and the funnel is less likely to spill.

If we were able to eliminate all variability, the bottom opening would widen to the same diameter that the top opening making in effect an open cylinder. In such a perfect system, the same amount of sand being poured at the top would swiftly exit the bottom no matter how much is poured into it and could never be saturated even if the overall size of the cylinder was very small indeed.

Unfortunately, such a perfect non-variable system is unattainable when we talk about patient flow. All we can do is to strive to open the bottom of the funnel as much as possible by decreasing and eliminating as much variability in the system as we can. The take home message is that decreasing variability is by far, the most significant, cost-effective, logical and fastest thing we can do to increase ED efficiency, improve asset utilization and free-up functional capacity. Anything else…including ED expansion, is doomed to fail…

Acute ED Decompression Plans

An important management element to consider whenever we attempt to improve ED operations is the implementation of acute ED decompression plans. This involves the design of pro-active strategies that are aimed to facilitate prompt movement of ED admitted patients and/or Holdovers to non-typical or underutilized areas of the Hospital which may be able to take care of these patients at the time. The purpose is to avoid ED overcrowding by promptly redistributing a limited number of patients across several areas of the Hospital without overwhelming any particular unit involved.

Even though operationally efficient Emergency Departments can manage and control the flow of about 80% of their daily patient load, they are still at the mercy of inpatient capacity for the other 20%. As such, even the best managed Emergency Departments can occasionally run into trouble if inpatient capacity is fully maxed out or floor processes are misaligned with the acute needs of the ED. That’s why these Acute ED Decompression Plans are necessary.

Now…just as the ED has underutilized areas than can be tapped to promote ED patient flow, all Hospitals tend to have untapped capacity that could be allocated to support the ED on an occasional basis at particular hours of the day. For example…a limited number of stable ED admitted patients waiting for telemetry beds might be able to be divided between the unused capacity of a PACU and a Cath Lab Recovery Unit during the early operational hours of these areas. A limited number of ED admitted patients waiting for a Med-Surg bed might be able to be divided between the unused capacity of an Endoscopy Recovery Unit, an Ambulatory Care Center, a Maternity unit, and even a Pediatric inpatient unit during particular times of the day...and so forth…

Regardless of which of those areas or services may or may not be available at your Hospital, you are always bound to find some similar staffed areas which can be used to acutely decompress ED admitted patients. The problem is not usually finding them but rather, creating a viable plan that can be executed “on-a-dime” whenever the need arises. I am going to now describe some of the general steps necessary to come up with such a plan…

1st…We need to identify the thresholds for activation. This is obviously going to depend on the size of your ED, the extent of the boarding problem you are experiencing and the capacity of your institution. For the sake of argument, let’s say you have a large ED and your thresholds for activation will be having more than 24 holdovers in the ED at any time and any location. Your team might also consider activating the plan, regardless of the number or holdovers, if all beds in the Main ED are occupied or expected to be soon all occupied based on the number of expected ambulances.

2nd…Your team needs to identify the specific Units or areas that could help decompress the ED including …the types of ED patients each of those individual areas can take care of…the hours during which each of these areas could safely receive those kinds of patients…the number of patients each individual Unit or area could potentially absorb and; the limits beyond which each unit or area should never go over.

3rd…Your team needs to declare who will be allowed to identify the need to activate the ED Decompression Plan and who they need to contact next. These Activators might include the ED Charge Nurse, the ED Nurse Manager, the ED Case Manager…etc. After these “activators” have been identified, your team needs to also identify the people that will facilitate and manage the execution of the plan. These facilitators might include your Inpatient Flow Coordinator or Bed Czar, the inpatient nurse managers, the Director of Inpatient Case Management…etc.

4th…Your team needs to solidify the procedures, protocols and managerial elements of the plan including all the anticipatory steps that must be undertaken every day to prepare the institution in case the plan might need to be activated. For example…your institution might have your Patient Flow Coordinator review the OR schedule, and the expected utilization of all the areas involved in the plan every morning and communicate to all the activators and facilitators which of these areas can be expected to have available capacity in case the ED meets the thresholds for plan activation. In addition, other housekeeping elements and requirements of the plan need to be spelled out. For instance…your team might require that before any ED patients can be moved to a decompression area a verbal “Hand-Off” of care between an ED Provider and the admitting MD still occurs; that a nurse to nurse report take place, that the patient arrives to the decompression area with at least basic admission orders documented, that only patients deemed clinically stable be sent to any of the acute decompression areas…etc…etc.

One of the things that should be evident is than an acute ED Decompression plan must be orderly and unhurried in its execution…not a “knee-jerk” reaction. That’s why it is called a decompression plan instead of a surge capacity plan. In fact, a properly implemented ED Decompression plan (pro-actively activated whenever threshold is met and deactivated after the ED goes back under threshold) can obviate the need for reactionary and resource consuming institutional surge capacity plans from having to be activated as often.

Most of the time…all an Emergency Department needs to regain control of patient flow is to be able to turnover just a few beds within a short period of time before the next bolus of demand presents for service. Institutional Surge Capacity Plans, which are mostly reactionary and move at glacial speed, cannot provide this ability. By the time the bed meeting is accomplished, the Surge Capacity Plan is approved to be activated, the institution receives communication that the Hospital is in surge mode; and some capacity is starting to be freed up…the ED is so far down into the weeds that all these reactionary institutional efforts are basically powerless in arresting ED overcrowding. In contrast, Acute ED Decompression strategies are designed to meet the needs of the ED in almost “real-time” and decrease the need for the institution to implement highly disruptive, resource intensive and even unpopular surge capacity plans and actions…

To illustrate this point, one of the things some of our clients find surprising when they first meet us is the fact that we don’t advocate sending admitted ED patients to the inpatient hallways unlike many consultants and Emergency Medicine Societies currently suggest. These people base their recommendations on the typical model most Emergency Departments operate under, nevertheless…the asset utilization, turnover, efficiency and increased functional capacity that is achieved through operational transformation strategies provides a significant operational cushion against overcrowding and reduces the extent of decompression the ED might require to avoid patient flow issues. As such, whenever a hospital implements these strategies they find that the ED can still operate efficiently with a number of ED admitted patients and holdovers that would have crippled ED flow and cause significant overcrowding in the past.

In other words, the threshold whereby the ED can get into trouble becomes much higher than before and the number of ED admitted patients the inpatient side will need to absorb to prevent ED operational decay becomes much lower. Most find that the simple Acute ED Decompression strategies we just mentioned usually suffice and that the institution doesn’t need to go into surge capacity mode as often. In fact, we have been involved with institutions that prior to our arrival were either thinking or already placing ED admitted patients into their inpatient hallways yet; after changing their patient flow processes, they haven’t found much use for this.

Strategic ED Staffing Plans

Very few Emergency departments and ancillary support interfaces adjust their staffing patterns to have more resources or most efficient members working the days of the week the ED is expected to have more demand. In addition, all departments have what is known as “fatal staff combinations” that should never be allowed to form. For example…having your slowest ED Physicians, your most inexperienced midlevel providers, your less effective charge nurse, your most novice ED techs and the least efficient X-ray Techs all working together a Monday afternoon is hardly a sound strategic choice. Unfortunately, these fatal combinations are allowed to form often and repeatedly in most Emergency Departments.

One reason most Emergency Department Managers cite for not approaching their schedule strategically is because of a shortage of staff members or too much variability in staff skill sets and capabilities. Although these reasons are valid sometimes, in most instances they just represent a “cop-out” for having to actually deal with the backlash that will inevitably ensue when the staffing preferences of some staff members are changed or from having to explain to some staff members why they cannot work on certain days or in certain areas of the ED.

Another barrier is that it takes a lot of time and effort for an ED Manager to create a strategic schedule that takes into account the whole department rather than just a particular group of people. For example, having a true strategic schedule would require that the person in charge of the nursing and Tech schedule and the person involved in the Physician and midlevel provider schedule both coordinate their staffing efforts to prevent fatal staff combinations from happening. The larger the Emergency Department, the more difficult implementing a strategic schedule becomes.

Nevertheless, the fruits of this endeavor can be very beneficial to the ED system and even the ED staff due to smoother system workloads and functional operations. All efficient enterprises adjust their staffing to cover more effectively their busier or seasonal demand days and try to prevent inefficient employees or managers from being scheduled together as much as possible. This is just common-sense.

Another reason strategic scheduling is so rare in Emergency Departments is that, in the typical overcrowded ED, the inefficiencies of some staff members are less visible amidst the chaos and idle time these departments must endure. Nevertheless, as a Department revamps operations and becomes more efficient, the effect that these fatal combinations and ad-hoc staffing approach has on the system become immediately visible. As such, Emergency Departments working on an operationally efficient model can identify these issues more easily and address them conclusively to reach the full performance potential the new operational model is designed to achieve…

Now...this is what must be done step by step...

1. Identify the busiest days and shifts and the lowest demand days and shifts of the ED based on historical data.

2. Adjust the staffing ratios so that you take some resources from the slowest days and transfer them to the busier days in a budget neutral way.

3. Classify all staff members (doctors, midlevel providers, nurses, techs, nursing assistants, X-ray techs, phlebotomists…etc…) as either A, B, C, or D players in the system based on their historical performance and capabilities.

4. Eliminate the D players as soon as possible (they shouldn’t be working in the system any way).

5. Make the schedule by taking your busiest days first and loading them mostly with A and B player across the boards. Afterwards, fill the rest of the schedule by keeping an almost equal proportion of A, B, and C players except in those areas that require a higher level of efficiency. If, due to staffing constraints, you must have a higher proportion of C players scheduled, try to only do this on the historical slowest days and shifts.

As a rule of thumb, never put two C players together if it can be avoided for obvious reasons. Also try to not put A with C players together but rather combine As with Bs and Bs with Cs. The reason for this is as follows:
When you put an A player together with a C player the C player knows he can’t keep up no matter what he does and will not attempt to make any adjustments in their performance. Meanwhile, the A player will tend to adjust his or her performance down partly due in reaction to the C players lack of productivity…Even worse, when you frequently combine A players with C players you will soon demoralize the A players and reduce their performance even more.

Now…when you combine As and Bs the dynamic changes as B players tend to adjust their performance up to more closely mirror that of the A player. When you combine a B player with a C player the dynamic is also different as the C players don’t usually see the performance of the B player as being out of reach and will thus adjust performance to more closely mirror that of the B player.

What I just discussed is based on numerous business productivity studies and is also very evident in sports performance. We all probably have witnessed this dynamic in action with major sport upsets in which a more gifted athlete is beaten by someone considered to be inferior. The usual reason for these upsets is that the gifted athlete adjusted his performance down and this allowed the inferior athlete to be more competitive.