Three Ways We Are Improving ED Throughput at St. Mary’s

A multidisciplinary team of ED docs/APPs, hospitalists, intensivists, nurse leaders, performance improvement experts, and St. Mary’s hospital leadership has just concluded a “90-day sprint” focused on ED Throughput. The goal is to reduce wait times in our ED by improving patient transitions out of the ED and into the hospital. This project identified three opportunities, outlined below.

Opportunity 1: Patient Placement

We are shifting our approach to managing patients who do not meet the criteria for medical admission. Specifically, we are trialing the use of our CDU (clinical decision unit) for short-stay patients who lack either an inpatient or observation qualifying diagnosis, but are unable to be discharged directly from the ED, typically due to social factors like need for LTC placement:

• While we previously agreed to keep these patients in the ED for ~72 hours while awaiting a placement solution, we are now looking to move patients at ~ 36 hours.

• There is guidance to preferentially request CDU beds for these patients being admitted “outpatient in a bed” so we can save space on our more specialized units.

• Of course, there are times when the CDU will be an inappropriate destination – in particular, if the patient lacks sufficient mobility to utilize a bedside commode (even with lift assistance), as there are no en suite bathrooms in the CDU. 

• A few exceptions:

  • If Case Management determines early that placement will exceed 36 hours (prior authorization, insurance, complex needs), the patient may be admitted as outpatient-in-a-bed status to the CDU prior to 36 hours. These patients should typically remain in the ED for up to 24 hours for CM consultation and PT/OT evaluation, even when delays are anticipated.

  • Fridays/weekends: Patients in the ED late Friday may be admitted to the CDU as outpatient in-a-bed status before 24 hours when placement is unlikely before Monday, inpatient bed availability is higher, and ED weekend volume is expected to increase.

Opportunity 2: Admissions Workflows

Our hospitalists have developed workflows to enable certain admissions to move upstairs without a full set of admission orders, on the understanding that remaining admission orders will be placed within 60 minutes for ICU and A-beds. I-beds are an exception to this, given the relatively high acuity and the lack of an intensivist at bedside to accept the handoff. Historically, our teams at St. Mary’s have grown accustomed to having a full set of admission orders upon arrival to the unit/floor, so this change will be new to us, but it is typical of workflows throughout Intermountain.

Opportunity 3: Bed Request Timing

As part of work completed through the ED throughput committee, we are standardizing the admission process timing once a patient is accepted for admission from the ED. These expectations were developed collaboratively with physician and nursing leadership to support timely patient placement and improve overall flow.

Effective Feb. 2, the following will apply:

• For regular floor and ICU admissions, the admitting provider is expected to place a bed request within 15 minutes of ED callback once the patient has been accepted for admission. Admission orders should be placed within 60 minutes of acceptance; however, admission orders are not required prior to patient movement to the floor or ICU.

• For I-bed admissions, the expectation is that a bed request is placed within 30 minutes of acceptance, with admission orders placed within 60 minutes.

Our colleagues from the ED are committed to supporting this change effort. If you have questions or concerns, please don’t hesitate to reach out to me.

— Michele