To continue our FLOW Hacks series, Dr. Lucas Chartier and Dr. Timothy Josephson write about their team’s innovation called the Rapid Medical Evaluation Unit.
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 small or large interventions 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. Send us interventions from your ED and we will showcase it on our site.
- The University Health Network in Toronto, ON, specifically at the Toronto Western Hospital site which receives 64,000 patient visits per year.
Description of the Innovation
- Increasing patient volumes have outpaced the resources in our ED for over a decade, with low-acuity patients representing the largest and fastest growing subgroup of patients. They contribute disproportionately to the congestion of the ED, a bottleneck that has been associated with worse outcomes for both admitted and discharged patients.
- We created and iteratively improved the Rapid Medical Evaluation (RME) unit, a new pathway of care for patients with lower-acuity presentations, by engaging front-line workers to re-imagine usual processes. We designed it as a cost-neutral project by re-purposing a fraction of existing resources and infrastructure and re-assigning one physician and one nurse towards the specific care of these patients. After three months, the 90th percentile of the time to Physician Initial Assessment (PIA) and Length of Stay (LOS) times had decreased for not only the group of interest (CTAS-4/5 patients), but also for the rest of the patients (CTAS-1/2/3) seen in the ED. Overall, by focusing on those patients who did not require urgent care but who caused significant congestion, we were able to accelerate the care of all patients.
Was a quality improvement methodology used?
- Yes: Lean (i.e., a rapid improvement event) for the design process, rapid-cycle testing for the improvement of the RME unit, and control chart for the evaluation and analysis of the project.
What data were used?
- Institutional database linked with the Emergency Room National Ambulatory Initiative (ERNI)
Who was on the team?
- Internal to ED:
- Medical Director
- Quality Improvement Committee
- Nurse Manager
- Patient Care Coordinator
- Clerical staff
- Patient-care assistants
- External to ED:
- Director of Clinical Services for ED-GIM
- Housekeeping services
- Logistical support
What did you use as performance measures?
- We used two performance measures:
- 90th percentile of time to PIA, and
- LOS in the ED.
- We obtained these measures for the 3 patient groups of interest:
- CTAS-4/5 patients seen in the RME unit (i.e., target of this intervention)
- CTAS-4/5 patients seen in the regular Fast Track area (i.e., comparison)
- CTAS-1/2/3 patients (ie. balancing measure)
How did you implement the intervention?
- We designed the RME as part of a multi-disciplinary four-day LEAN event that engaged front-line workers to drastically and quickly alter the status quo of patient care. We improved the RME through testing of multiple sequential Plan-Do-Study-Act cycles over a period of three months, revolving around the themes of scheduling, teaching ability, triage criteria and equipment.
How did you get buy-in from physicians, nurses, administrators and other allied professionals?
- ED wait times and departmental flow are important to both internal and external stakeholders. This, coupled with the fact that the project was inherently centered on the ideas of front-line workers, made buy-in relatively easy. Adaptive leadership strategies and small tests of change that built momentum and personnel commitment to the project also helped.
What impact has it had on your department?
- The patients seen in the RME unit saw their median PIA time decrease from 98min to 70min (29%) and their LOS from 165min to 130min (21%). The RME unit therefore remains a daily physician and nursing assignment in the TWH ED. It has helped alleviate the congestion of our Fast Track area, which remains the busiest area of our ED.
What were some of the barriers to success?
- Given the size of our group (70 MDs over 2 sites, 110 RNs), it took some time for all providers to become familiar with the RME unit, and likely still decreases our gains in efficiency. Some physicians also dislike this specific assignment, which resembles more of a walk-in clinic at times than an emergency department.
If you could do it all over again what changes would you make?
- I would involve more physicians earlier in the design process. This was a multi-disciplinary project and few physicians were consulted. As a result, they became the most vocal opponents of the idea. I would also construct a stronger data collection plan, both for evaluation and for reporting to various stakeholders.
Copyedited by Michael Bravo (@bravbro).