FLOW Hacks

FLOW Hacks 5 – Bed Utilization in the ER

In Education & Quality Improvement, FLOW Hacks by David SavageLeave a Comment

To continue our  FLOW Hacks series, Dr. Lucas Chartier and nurse Barb McGovern write about their team’s innovation called BED-UP: Bed in the Emergency Department Utilization Project.

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.

Does this project have its own website or publication?

Description of the Innovation

  • Patient volumes have outgrown the increases in staffing and resources in our urban ED. The resulting congestion has spilled into the waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. We set a stretcher goal of decreasing the time it took for high-acuity patients to be moved into an ED bed after triage by half.
  • We first addressed the unnecessary patient utilization of ED beds by moving some patients (e.g., those awaiting laboratory or diagnostic imaging test results) into an internal waiting room called the transitional care area (TCA). However, due to infectious disease precautions, paucity of telemetry equipment and cultural issues specific to our ED, the TCA did not achieve the intended results.
  • We then shifted our focus to optimizing the communication between providers, which was contributing significantly to inefficient bed turn around processes. Despite the availability of sophisticated information technology software, we found that low-tech walkie-talkies were the least intrusive yet most effective method of communication. This allowed us to cut in half the length of time a bed stayed ready and idle between patients, from 26 to 13 minutes.
  • Between these two main interventions and the significant work our team did to engage front-line workers, our time from triage to bed placement decreased from 116 to 66 minutes (i.e., a 43% decrease), an impressive improvement despite the trivial financial investment required.

Was a quality improvement methodology used?

  •   Yes: The ‘highly adoptable improvement’ methodology for the development and rapid cycle testing through iterative Plan-Do-Study-Act (PDSA) cycles for the execution of the project, and statistical process control charts for the evaluation and analysis.

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 and Assistant Medical Director
    • Quality Improvement Committee
    • Nurse Manager
    • Patient Care Coordinator
    • Educator
    • Physicians
    • Nurses
    • Clerical staff
    • Patient-care assistants
  • External to ED:
    • Director of Clinical Services for ED-GIM
    • Housekeeping services
    • Logistical support
    • Patients (through informal surveys)

What did you use as performance measures?

  • 90th percentile of triage-to-bed time (i.e., the time that 9 out of 10 patients take to go from being triaged to being placed in an ED stretcher)
  • Bed turnaround time processes, specifically bed idle time (i.e., how long a stretcher stays empty between one patient leaving and the next one being placed in the stretcher).

How did you implement the intervention?

  • This project was designed and executed in conjunction with Health Quality Ontario’s IDEAS program (Improving and Driving Excellence Across Sectors), which provided mentorship and support. The project was designed and implemented iteratively, with continuous feedback from front-line clinicians.

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

  • We were lucky in that our project involved informal and formal leaders in the ED, which allowed us to have buy-in from front-line clinicians early on. The fact that our metrics of interest related to flow, an important organizational and Ministry focus, helped get support from the leadership team as well.

What impact has it had on your department?

  • Prior to this initiative, the 90th percentile time of triage-to-bed time was stable at approximately 116 minutes, with a bed idle time of 26 minutes between patients. At the end of the project, the triage-to-bed time had decreased and was stable at 66 minutes (i.e., a 43% decrease), and the bed idle time was cut in half to 13 minutes.

What were some of the barriers to success?

  • One of the biggest barriers to our project was the competing priorities of the players involved. Our change ideas required some level of involvement of specific stakeholders, who became involved in other endeavors (e.g., Toronto Pan-Am Games, response to Ebola preparedness) that took them away from this project.

If you could do it all over again what changes would you make?

  • We would test change ideas sooner in the project. Despite our knowledge of the importance of iterative PDSA cycles, we spent too much time trying to design the ‘perfect’ system from the outset. We would have been better off learning from experience instead, which would have allowed us to pivot away from the unsuccessful TCA concept earlier on.

Copyedited by Michael Bravo (@bravbro).

David Savage

David Savage is a resident in the FM/EM program at NOSM, Thunder Bay. His interests include EM policy and the application of analytics techniques to physician scheduling, patient forecasting, and capacity planning.
Michael is a PGY1 in Paediatrics at Western University. Michael studied at the Royal College of Surgeons in Ireland and founder of The Presenting Complaint blog. He has an interest in #MedEd and #FOAM.