Clinical efficiency tricks for the emergency department: Arrivals

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After nearly two decades as a practicing emergency physician and medical director, I am all too familiar with traditional ways of operating in the ED. This three-part series describes more efficient alternatives to those standard processes, beginning with the arrivals process. Part 2 and Part 3 of the series will focus on the patient's in-room experience and the discharge portion of the clinical encounter (disposition), respectively.

Obviously, our goal in the emergency department is to meet the needs of patients as quickly as possible, freeing up space and physician attention for the next patient, all while delivering high-quality care. The more efficient an ED operates, the greater volume of patients each emergency physician can appropriately treat and disposition. The key to improving efficiency is recognizing that the opportunity for improving patient flow starts at the very first interaction.

Scrap linear processing

How is the ED clinical team notified of a new patient? Traditionally, new patients endure a tedious hour of "linear processing": each new patient is greeted by non-clinical staff members who collect registration information. Then the patient waits until a triage nurse is available to assign a level of complexity and determine if the patient is low enough acuity to wait. At some point after being seen by the triage nurse, the patient finally gets into a room where his or her wait continues for a primary nurse. After the primary nurse completes the assessment, and only then, is the chart ready for the provider.

When each step takes an average 5 to 10 minutes, linear processing delays the patient, at best, 40 minutes, but likely over an hour. That wait, from the patient perspective, is inexcusable.

Adopt parallel processing instead

The efficient alternative is parallel processing, which eliminates or consolidates steps and shortens arrival-to-provider time. When done right, parallel processing means intermediate steps can be removed entirely from the process. If the steps cannot be eliminated, they can be compressed so that the patient sees all (or most) of the necessary information-takers at the same time.

Parallel processing is a coordinated team approach to the patient arrival. Ideally for all new arrivals, the first point of contact is a clinical person who is able to determine if the patient requires immediate attention by a physician. The "quick registration" — getting the patient's name, date of birth and/or social security number, as well the chief complaint — can be completed while this clinical staff member is "eyeballing" the patient for signs of distress. In some cases, the clinical person can be cross-trained to enter the information into the registration system. In other cases, the registration clerk and clinical team member are stationed together at the front of the ED. With the chief complaint entered, the patient can be loaded onto the tracking board as "ready to be seen." He or she should be going to a space where they can be assessed rapidly. This space can be housed in the triage area or another location close to the ED entrance (someplace with 2 or 3 rooms for assessments), and should be staffed by at least one nurse and a provider. That team can order whatever work-up is necessary, or else they can discharge the patient straight from there.

Leverage the whole ED team: The care-team model

EDs have made use of the provider-in-triage model, described above, for a while, stationing an advanced practice provider (APP), or sometimes a physician, in the triage area. The greater range of decisions available to triage clinicians—they can place orders or even discharge where appropriate—increases patient flow substantially.

Some hospitals have adopted a new process called care-team, which bypasses the triage step altogether, putting the patient and all members of the care-team, including a dedicated care team nurse and a physician or APP who is available at that time, in the same room as the first step of patient processing. Typically, the physician will take on the higher acuity chief complaints, and the APPs will take the lower acuity, but there are no hard and fast rules; the goal is to get somebody in front of the patient as soon as possible. (In the event an APP takes on a higher acuity patient, the APP would involve a physician in that patient's care.)


The No. 1 benefit of the care-team approach is to minimize patient hand-offs, which are shown to lead to more errors and miscommunications.i The second benefit is that the approach increases patient flow and decreases waste by reducing repetition and redundancy.

Hospitals that have committed resources to the care team model have achieved major efficiency gains while improving patient satisfaction. At one hospital with a busy, high acuity trauma center ED, arrival-to-provider time (or "door-to-doctor") was initially over an hour. Combining parallel processing and the care team approach, we brought that time down to 13 minutes, and the left without being seen (LWBS) metric went from about 7% to a little over 1%. And patient satisfaction scores shot up alongside those efficiency gains.

We have shown two examples of streamlining the ED arrival through parallel processing. There are certainly many methods and variations, but these are two I have found to be particularly effective.

Ultimately, while a smooth arrivals process is the first opportunity for a bottleneck, it's not the last. It is crucial that, in focusing on getting patients admitted into the ED, hospitals do not neglect the other aspects of patient flow: the in-room process and disposition. An ED should not fine-tune its arrival process only to strand patients in an endless in-room stay or a discharge process. The next two posts in this series address how to capitalize on the gains made through parallel processing and a team approach to the arrival process.

i See for example the AHRQ's "Handoffs and Signouts" (November 2015) See also AHRQ's 2014 "Handoffs and Transitions"

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