Recording and Reporting Wait Times in the Emergency Department

Recording and Reporting Wait Times in the Emergency Department

Sara Dawson

Brian Decker

Samira Madhany

Advisor:

Doris Quinn,PhD

Department of Quality Education and Measurement

BME 273

Vanderbilt University

April 27, 1999Abstract

Becoming familiar with the normal routine of the emergency department allows one conclusion to be drawn: there is no normal routine. With the many administrative changes that are prevalent in medicine, measuring efficiency becomes a very beneficial task. With the cooperation of the Vanderbilt University Department of Emergency Medicine and Department of Quality Education and Measurement, we have designed two applications that independently provide methods to record and report the patient time efficiency statistics in the Emergency Department.

We determined that the times being recorded on the patient charts were not always recorded consistently. We created a flow chart of a visit scenario that includes all times necessary for entry on the patient chart. The current method of collecting the data for use in analysis entails a Microsoft Excel spreadsheet with information and wait times entered from the patient charts. Any charts or graphs have to be designed and created independently every time a graph is desired. We have designed an empty template that calculates all of the wait times in minutes, and automatically generates a multi-bar chart with every wait time plotted against arrival time, and another bar chart that totals the length of stay per patient, versus the arrival time. One template will be used for each day, generating comprehensive reports for each day for which data is entered.

The other application we designed provides an example of how the newest web technology can be used to benefit the Emergency Department. We used Allaire’s Cold Fusion to write a combination of HTML and CFML (Cold Fusion Markup Language) to provide an interface that can be used on any personal computer with a standard web browser. Cold Fusion is a platform that enables the creation of a web-interface to standard databases. We designed a database with Microsoft Access 7.0 that contains tables for users, patient demographics, visit description, and visit wait times. The web interface contains a user login page with built-in security that will allow only those who are specified as “users” login. From the login page, there are three options, the first is to enter the patient demographics, second to enter the visit information for one patient, and the last is to make statistical queries and produce charts providing comprehensive reports on wait times. The times for each process are entered into the database and individual wait times are calculated and entered into the database. The statistics page allows the user to choose which wait time s/he would like charted, spanning what dates, and what times during the day. Upon submission of this page, the database is queried based on the parameters submitted and JavaScript is used to create bar charts of the specified wait time versus arrival time.

Both of these applications will prove to enhance the reporting capabilities and increase the ease with which charts are generated. The MS Excel spreadsheet template is a solution that can be instituted immediately, as it only provides a dynamic template rather than a blank spreadsheet. The Cold Fusion application requires space on a CF Server with security in compliance with Vanderbilt University Medical Center regulations (which has been offered). If a decision is not made to use the Cold Fusion “ED Time Charter” than let it serve as an example of the many possibilities to reduce effort and create user friendly and readily accessible interfaces in the Medical Center.

Introduction

Many accept the events of the emergency department as unpredictable and nearing chaos. Doris Quinn, PhD, from the Vanderbilt University Department of Quality Education and Measurement, initially charged us with the task of utilizing past data to produce results that would display any possible trends in the Emergency Department. She hypothesized that if an adequate amount of conclusive data was collected, trends in the emergency processes would be prevalent. By acknowledging the trends, continual comparisons and reports would assist in the measurement and documentation of the efficiency of the Vanderbilt University Medical Center Department of Emergency Medicine. With the many administrative changes that are prevalent in medicine, measuring efficiency becomes a very important task.

Having a common goal of measuring efficiency and improving operations in every aspect of the health field, benchmarking efforts are very common. The American College of Emergency Physicians defines benchmarking as “a tool in the continuous improvement of key processes. Called process-based benchmarking, this is the focus of the current Quality Imporovement (QI) movement in health care” (ACEP Online, 1). As applied to the health care world, benchmarking can be extremely productive. Such a sharing of information can be accomplished relatively easily, since the essential determiners of efficiency and quality do not change from facility to facility. The time a patient arrives at the VUMC Emergency Department corresponds to the same time recorded at the Emory School of Medicine Emergency Department, etc. Organizations have been formed nation wide to assist in the organization and utilization of shared information. One such organization, the Emergency Department Benchmarking Alliance, states that it’s “mission is to determine the ‘best practices’ in emergency medicine and acute unscheduled care. This is achieved through the determination of standard quantifiable variables of care delivery and the subsequent comparative analysis of these variables.”(EDBA Online).

Understanding the desire to share information to aid in a greater benchmarking effort, we redirected our focus. Rather than utilizing old data, that was collected in a manner that was inefficient and often inconclusive, we attempted to reanalyze the necessary data collected and design applications that would be of more benefit than the current procedure. After literature review and an in depth study of the VUMC Emergency Department flow process, a flow chart was created and the desired wait times were defined. The current process of gathering data was achieved by student workers entering data from the charts to a Microsoft Excel spreadsheet. This spreadsheet contained chart times, but did not define actual wait times or have any reporting/charting capabilities. For a conservative solution, a new Microsoft Excel spreadsheet was completed that had properly formatted cells to represent times accurately, automatically calculated wait times, and generated two descriptive bar graphs (see the Methodology and Results sections for a more detailed description). This spreadsheet offered a solution that could be implemented immediately by simply replacing the blank spreadsheet that was currently used with the new template. The other application we designed provided an example of how the newest web technology can be used to benefit the Emergency Department. We used Allaire’s Cold Fusion 4.0 to write a combination of HTML and CFML (Cold Fusion Markup Language) to provide an interface that can be used on any personal computer with a standard web browser. Cold Fusion is a platform that enables the creation of a web-interface to standard databases. The “ED Time Charter” allows one to record patient information, visit description, and the defined wait times. This also allows for user defined creation of charts reporting wait times, that will aid in measuring Emergency Department Efficiency.

Due to the explosion of information technology and the capability of creating extremely productive applications, much attention has been given to the application within the health field. McDonald et al. state that “[a] well constructed, integrated clinical information system offers clinicians the possibility of a seamless, easy to use information rich, computing environment that provides them with all the right information when and where it is needed.” Many different organizations and companies have formed with a unique focus to explore opportunities and create applications that utilize the newest information technology and web design technology. The University HealthSystem Consortium is an organization that has been formed and is comprised of “clinical enterprises of academic health centers.” They have defined multiple specifications and developed various databases in an attempt to standardize the data collection while providing information to aid in the measurement of quality and efficiency (UHC Online, 1). McDonald et al. assert that “the world-wide web (web), combined with several new clinical coding standards, offer a potential solution to many current problems in clinical computing.” But they warn of the extreme security concerns, stating that “system security and patient privacy are paramount”(1325) and “security requires strong authentication of the user, encryption of all clinical content, individually assigned user identification codes and secret passwords, logging of all accesses and strong administrative policies which include sanctions for violators”(1328). The Vanderbilt University Medical Center has recently formed the Information Security Confidentiality and Privacy Committee (ISCP) to attend to the security issues of utilizing electronic records and computer-based systems at the Medical Center.

When considering the flexibility and magnitude of options while utilizing computer-based records, the advantages seem to greatly outweigh the disadvantages. In “The Lancet”, Powsner et al. describe many advantages of such applications. A few of the benefits that is believed will help drive the insurgence of these applications are the “ability of multiple clinicians [to] access a patient’s record simultaneously from …anywhere in the world,” the ability to monitor and deny access to records, the ease of integrating and linking to other systems, the efficient searching capabilities, and the fact that “all data is immediately available…as soon as the data is entered into the computer.” The “ED Time Charter” application shares many of the benefits outlined above. The greatest benefit of the “ED Time Charter”, as well as all web applications, is the ability to access the stored information from anywhere and anytime. All that is necessary is a personal computer with internet/network access and a standard web browser and one can enter data, edit data, or query data to produce charts that display Emergency Department efficiency measurements.

Methodology

Currently, the Emergency Department calculates wait times using a Microsoft Excel spreadsheet. Patient information which includes patient name, medical record number, chief complaint, and age are downloaded from the main hospital server daily. For each downloaded record, a student enters arrival time, triage time, room time, registration time, resident time, attending time, and disposition time using the information from the patient. Often, the charts do not contain all of the information desired to complete the data in the spreadsheets. There is also some note on the spreadsheet that documents whether or not the patient has labs, x-rays, consulting services, final diagnosis, attending physician, and whether the patient is admitted or discharged. If there is no entry on the chart, the cell in the spreadsheet is left blank. There is no defined algorithm for calculating wait times or producing representative charts. This process is rather tedious and fails to provide any conclusive data.

While brainstorming how we could best represent wait times in the Emergency Department, our attention was focused on Microsoft Excel 97. We did some exploratory work with this program as well as some research on other methods of data representation that would best suit the needs of the Emergency Department. We decided to focus on two different applications that reproduced wait times and displayed the data in the form of charts. Microsoft Excel and Allaire's Cold Fusion in combination with HTML are the two software platforms we chose to complete our task.

The Microsoft Excel template that was being used by the Emergency Department was used to create charts of the total length of stay in minutes as calculated by subtracting disposition time from arrival time. This immediately posed a problem: times that had been entered were simply keyed in as a four digit number on a twenty-four hour clock. The number format was a "general" type, and when the chart was created, the x-axis, arrival time, could not be interpreted as a time on a sixty minute clock. Changing the data type from "general" to "time" caused all of the numbers to be changed to 00:00. In order to enter data in the form of a time, the data type had to be selected as "time" prior to entry onto the spreadsheet. The next step was to try to change the data that had already been entered into a "special" type which we designed. This was done by defining the cells with the syntax that forced a colon as a text symbol between the first two numbers and the last two numbers (00":"00). If the number was not entered in a four digit pattern, the spreadsheet filled in zeros for the numbers previous to the existing numbers. If there are no numbers entered in the cell, the cell remains blank.

The next task was to define wait times according to the patient flow process in the Emergency Department. This required some observation time in the E.D as well as meetings with administrative staff. A flow chart of the patient flow process was created on Microsoft Flow Charter 7.0. This flow chart was approved by the administration and was then used to define all wait times. The wait times that were deemed necessary for analysis are as follows: triage wait, room wait, resident wait, attending wait, interface wait, treatment wait, disposition wait.

After the wait times had been identified, we developed equations to calculate wait times. This was done by nesting a subtraction function in a conditional if statement. The wait time was displayed in a four digit format and then converted into minutes by multiplying the hours by sixty and adding the remaining minutes. The total length of stay in minutes was calculated by subtracting disposition time from arrival time and converting this number into minutes.

The chart function of Microsoft Excel was used to create a bar graph of length of stay as a function of arrival time. Then a multivariable bar chart was used to display a color coded representation of each wait time as a function of arrival time. That is, each wait time was stacked on top of each other, representing individual wait time in minutes and each of the smaller segments summed together equals the total length of stay in minutes.

The results from the manipulation of the pre-collected data were then used to create a template in which equations have already been entered. Once the information from the hospital server has been downloaded and times have been entered onto the spreadsheet, the wait times are immediately calculated and charts are created. The procedure outlined above required time to solidify because as is expected when using a trial and error procedure, there are always obstacles along the way.

The ED expressed an interest in establishing a database for the Wait Times. This would complement the Excel template we created. Thus, we created another application, the “ED Time Charter,” to analyze the wait time data. This application was designed to provide an example of how the newest web technology can be used to benefit the Emergency Department. To do this, we used Allaire’s Cold Fusion as a front end to the database. Cold Fusion uses HTML as its base language, with Cold Fusion Markup Language (CFML) tags incorporated into the normal HTML tags. The CFML combined with the HTML provides an interface that can be used on any personal computer with a standard web browser. Cold Fusion is a platform that enables the creation of a web-interface to standard databases. The database that we chose to use was Microsoft Access 7.0. This program was readily available to us, and we had a working knowledge of its properties. We first tried to upload the data in Excel into the MS Access file. However, as our work progressed, we discovered that the most beneficial database design required the data to be separated into various tables. This would allow the database to be more robust, while still retaining its relational properties. We arrived at two different options for the database design. The first design contained nine different tables for patient demographics, visit description, and one for each wait time, seven total. The other design consisted of only three tables: patient demographics, visit description, and all the visit wait times. The best option was the second design. This design reduced the amount of duplicated information with only one table for wait times, versus seven. It was also more manageable.

Once we arrived at the design for the database, we decided to create the front-end application with the CFML (see Appendix E). The motivation behind this front-end was that it would give the users a quick and easy interface to input the data into the database. With medical records, security is obviously an issue. To deal with this, a user table, which included a username and password, was added to the database. We then created a login page with built-in security that would allow only those who are specified as "users" login (Appendix E: “vedlogin.cfm”). The username and password were verified using cookies (Appendix E: “vedauthentlogin.cfm”). This security is not safe from hackers, however, this application would be kept behind the hospital’s firewall in its intranet, preventing outside hacking. We also proposed removing the patient’s name and medical record number from the database in the future to preserve anonymity.