Best Practice Submission

North Central Baptist Hospital Adult Emergency Department Split Flow Operations

Points of Contact:

Heather Anderson, (210) 297-1000,

Tammy Holland, (210) 297-4652,

Group Involved with the Project. The North Central Baptist Hospital Adult Emergency Department

Submitted by Major Jennifer L. Rodriguez

11 May 2012

Executive Summary: The Baptist Health System (BHS) takes pride in providing exceptional care and service to patients and their families. As part of its commitment to high quality care and patient satisfaction, the BHS implemented split-flow operations in all emergency departments in 2009. Split flow operations improves efficiency of care, decreases door-to-doc times, shortens length of stay (LOS), decreases the number of patients leaving without being seen (LWBS) and improves patient satisfaction.North Central Baptist Hospital (NCBH)launched split flow operations in November 2009 and realized a 79% decrease in LWBS within one month.

Objective of the Best Practice:Utilization of split-flow operations improves efficiency of throughput of patients in the emergency department (ED). Improved flow of patients results in fewer patients waiting to be seen, fewer patients leaving without being seen (LWBS), shorter length of stay (LOS) and improved patient satisfaction scores.

Background: Prior to 2009, the emergency departments in all BHS hospitals experienced excessive wait times, high numbers of patients LWBS, greater than onehour door-to-doc times, countless diversion hours and significantly low patient satisfaction scores. In an effort to improve these issues, BHS initiated operational studies of all five hospitalsemergency departments and discovered significant variation in ED flow. In 2009, BHS implemented the “Split-Flow” patient flow model. Developed through a partnership between the Banner Health System in Arizona and Dr. Jeffery K. Cochran of Arizona State University, this model is based on the queuing theory and significantly decreased patient waiting times and LWBS rates in each hospital ED (Banner Health, 2012). In FY 2009, prior to implementation of split-flow,NCBHED experienced an average 3.6% LWBS rate, 75 minute door-to-doctor time and patient satisfaction scores in the 83rd percentile.

Literature Review: Extensive evaluation of ED patient flow in order to decrease waiting time and improve patient satisfaction is well documented. The use of lean processes to evaluate patient flows is extremely beneficial when attempting to improve ED patient experiences and overcrowding (King, Ben-Tolvim, & Bassham, 2006). The authors redesigned patient flows similar to split-flow by focusing on patients likely to be admitted and patients likely to be discharged from the ED. In addition, this process utilized specific triage criteria to assist nurses with determining where to place patients in the queue. Eitel, Rudkin, Malvehy, Killeen, & Pines (2010) discussed methods to improve ED quality and flow. These methods included the use of the Emergency Severity Index (ESI) triage, Lean Six Sigma (LSS) management methods and queuing systems, all of which encompass the split-flow process. Wiler, Griffey, & Olsen (2011) reviewed various modeling approaches related to ED patient flow and identified strengths and weaknesses associated with each model. These various models are valuable when utilized as part of a complete analysis of ED operations. Research by Cochran and Roche (2009) supports the use of a queuing model and split patient flow in order to increase ED access and reduce the number of patientsLWBS. Incorporating these techniques produced significant improvements in door-to-doc times and decreased the number of patients LWBS. This research is the foundation for which the BHS implemented split-flow operations.

Implementation Methods: A BHS Master Black Belt (MBB) conducted an initial baseline analysis of ED flow to identify patient arrival rates, acuity levels, length of stay and staffing models. Utilizing the door-to-doc toolkit (Banner Health, 2012), the MBB determined targets for length of stay, staffing and required rooms. A multi-disciplinary core team consisting of the ED Director, staff, physicians, admissions, ancillary departments and inpatient nursing developed a project charter identifying specific problem areas and goals. Education of all stakeholders included a detailed split-flow process, layout, function of areas and appropriate documentation.

Results: Monthly averages for LOS, door-to-doc time, LWBS and overall patient satisfaction data were compiled for fiscal year (FY) 2009 prior to implementation of split-flow and for FY 2010 following implementation. Significant results included a decrease in average door-to-doc time from 75 minutes to 35 minutes, and a decrease in LWBS rate from 3.6% to 0.6%. See Table 1 for a comparison of before and after results.

Conclusion:Overcrowded emergency departments and long wait times directly impact patient satisfaction. As evidenced by the significant results gained following implementation of split-flow at NCBH, analysis of ED flow and utilization of queuing methods can significantly impact the quality of care provided. Improved patient throughput in the ED can decrease the numbers of patients LWBS and potentially increase patient satisfaction scores. Military health care facilities experience high volumes of patients within the ED regularly. Improvement in processes and patient flow as identified with this best practice can potentially enhance the patient’s experience and improve overall military health care.

Table 1.

North Central Baptist Hospital Split Flow Results
Average LOS for admitted patients (min) / Average LOS for discharged patients (min) / Average Door-to-Doc Time (min) / Average LWBS % / Average Patient Satisfaction Overall %
FY 2009 / 350 / 208 / 75 / 3.6 / 34
FY 2010 / 274 / 153 / 35 / 0.6 / 95

References

Banner Health. (2012). ED door-to-doc toolkit. Retrieved from

Cochran, J.K., & Roche, K.T. (2009). A multi-class queuing network analysis methodology for improving hospital emergency department performance. Computers & Operations Research,36, 1497-1512.

Eitel, D.R., Rudkin, S.E., Malvehy, M.A., Killeen, J.P., & Pines, J.M. (2010). Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the american academy of emergency medicine. The Journal of Emergency Medicine, 38 (1), 70-79.

King, D.L., Ben-Tovim, D.I., & Bassham, J. (2006). Redesigning emergency department patient flows: application of lean thinking to health care. Emergency Medicine Australasia, 18, 391-397.

Wiler, J.L., Griffey, R.T., & Olsen, T. (2011). Review of modeling approaches for emergency department patient flow and crowding research. Academic Emergency Medicine, 18 (12), 1371-1379.

1