FLOW Hacks

FLOW Hacks 1: A Novel ED Surge Protocol

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Starting off the FLOW Hacks series is Dr. Edmund Kwok of The Ottawa Hospital, speaking to us about his innovation: A Novel ED Surge Protocol Based on Input-Throughput-Output Model of ED Flow (link).

[bg_faq_start] FLOW Hacks: The Concept

The FLOW (Featured Leadership & Organizational Workplace) Hacks Series highlights innovative strategies for increasing patient flow in the emergency department (ED).  This series is unique given its focus on the administrative aspect of emergency medicine. We are interested in interventions small or large in nature that increase patient flow from an input, throughput, and output perspective. Our goal is to provide ED leaders a forum to highlight the successes and challenges they have faced. If you have an intervention being implemented in your ED that you would like to share, let us know and we will showcase it on our site.[bg_faq_end]


The Ottawa Hospital in Ottawa, ON which receives over 160,000 ED visits/year

Description of the innovation

Fluctuations in ED visits occur frequently, and traditional global measures of ED crowding do not accurately detect these surges for timely responses. We developed, implemented, and evaluated a novel ED Surge Protocol based on the conceptual Input-Throughput-Output (ITO) model of flow. An inter-professional group developed and validated metrics for various levels of surge in relation to the ITO model (measured every 2 hours), which directly linked to specific actions targeting root causes within those components.

For example, if there was a sudden surge of new arrivals to registration/triage, this would automatically trigger a pre-defined action of moving more resources to registration/triage; if a consultation service is taking longer than a certain number of hours for a disposition decision, there would be an automatic trigger to escalate calls to the senior resident and/or staff to expedite. To our knowledge this is the first study to report on an actual development, implementation, and evaluation of a daily ED Surge Protocol that utilizes the widely-accepted ITO model.

Was a quality improvement methodology used?

Yes, we applied many QI concepts and used the SQUIRE Guidelines as framework for studying and reporting our QI efforts.

What data was used?

We collected ED surge levels for each ITO component every 2 hours, before and after implementation of the protocol.

Who was on the team?

The core team responsible for the initial development of the Surge Protocol included ED physicians, Nursing Managers, and Inpatient Flow Managers. Multiple Key Stakeholders were intimately involved in further refinement and ultimate implementation of the entire Protocol:

Internal to the EDHospital-wideExternal to the Hospital
ED Executive
Physician Chiefs
ED Wait Times Committee
ED Educators
Care Facilitators
ED Physicians
ED Nurses
ED Clerical Staff
ED Patient-care Assistants
Admissions & registration
Evening & Night Coordinators
Patient Flow Department
Biomedical Engineering
Medical Advisory Committee
Housekeeping Services
Patient Advocacy and Risk Management
Intensive Care Units
Logistical Support
Directors of Clinical Services
Non-Clinical Directors
Nursing Professional Practice
Managers of Clinical Services
Ottawa Paramedic Services
Ottawa Emergency Services Network
Champlain Local Health Integration Network
Unions, specifically Ontario Nurses’ Association
What performance measures were used?

We measured:

  • ED Surge Levels every 2 hours
  • ED Surge Level measurement compliance
  • Action Items implementation compliance
How was it implemented?

Given the complexity of the ED- and hospital-wide nature of the Surge Protocol, implementation was done over multiple Phases and continuous Plan-Do-Study-Act (PDSA) improvement cycles over 6 months. Phase I involved the development and validation of the proposed metrics, baseline data collection, and engagement with the various stakeholders. Phase II contained a trial roll-out of a limited Surge Protocol which was continuous refined through feedback with stakeholders. Phase III was the full implementation of Surge Protocol and ongoing PSDA cycles.

How did you get buy in from physicians, nurses, administrators and other allied professionals?

Buy-in was accomplished via alignment of multiple factors

  1. An urgent need identified through an adverse event related to ED crowding
  2. Engagement of senior leadership and administration and agreement on placing this as high priority
  3. Continuous involvement and regular feedback with each individual stakeholder throughout effort.
What impact has it had on your department?

Our ED Surge Protocol led to effective containment of daily high surges despite significant increase in hospital occupancy levels. It has also helped provide a common language for discussion and advocacy with the rest of the hospital and other services with respect to ongoing efforts in tackling ED crowding.

What were some of the barriers to success?

Three significant barriers included:

  1. Finding dedicated time outside of clinical work and other regular duties to fully engage in the development and implementation process
  2. Robust data collection in the absence of dedicated funding for new electronic devices/collection tools
  3. Sustained engagement of both front-line and other stakeholders.
If you could do it all over again, what changes would you make?

I would spend a little more time up front at the beginning of the project to develop more robust data collection methods and determine how to appropriately fund logistical support. This likely would have made things more cost-effective and sustainable in the long run!

This post was copyedited by Stephanie Zhou (@stephanieyzhou).

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.