Patient Flow E-Newsletter
Volume 3, Issue 3
Wednesday, October 25, 2006

Perspectives
Changing the Paradigm: Measuring Patient Flow Instead of Emergency Department Crowding

All of us hear that emergency department (ED) crowding is a growing public health threat, and there is certainly truth in that. But it seems like the term "ED crowding" implicitly lets the rest of the hospital off the hook, even though experts recognize that crowding is a hospital-wide problem that most obviously manifests itself in the ED.

The core of the problem is that without common definitions and standard measurements for crowding, key questions are left unanswered. We can't define a level at which an ED is officially crowded. We can't determine how crowding affects efficiency of patient care. We can't measure the impact of crowding on quality of care.

Although some researchers (including our own group) have developed workload scales that are fairly good at measuring crowding, I don't think we will ever come to agreement about how to measure crowding across multiple sites. That's why it is time for healthcare researchers to stop trying to measure crowding and start measuring patient flow.

Why Patient Flow?
I strongly believe measuring patient flow is more useful to solving crowding problems in America's hospitals. The problem of establishing a benchmark immediately disappears. The fundamental measure of patient flow is throughput, and the criterion standard for measuring throughput is length of stay (time from patient arrival in the ED to patient departure). Measuring throughput is not complicated; everyone understands it, and patient tracking systems or charts already record this time. In addition, it makes it easier to conduct multi-site studies on the relationship between patient flow and quality of care.

Measuring throughput also supports system-wide improvement efforts. Hundreds of hospitals have successfully made improvements in patient flow parameters using tools like ED operational dashboards. I have yet to find a hospital-wide improvement project that uses an ED crowding measurement system.

Further study is required on how throughput should be adjusted for patient mix across EDs - patient length of stay at a Level 1 Trauma Center probably should be different than a small community hospital ED. We also must not hastily make improvements in patient flow at the expense of quality patient care. Quality of care measures must be a part of patient flow measurement if used as the criterion standard.

Next Steps
In order to follow the quality improvement and consulting worlds, which have already begun shifting to measuring patient flow, there are several things hospital administrators and physicians can do to focus on patient flow at their own institutions.

Senior leadership is key. It is imperative that examining patient flow at an institution be a facility-wide initiative. An institution must have full support from its chief executive and other high-level administrators. If the support doesn't start at the top, it is impossible to make meaningful process changes.

Start collecting data. If your institution doesn't already measure patient throughput, begin measuring throughput times. This doesn't have to be complicated - measure total length of stay first, then begin tracking subcomponents of the patient visit (e.g. arrival to bed, bed to doc, doc to disposition).

Develop an operations dashboard. Assessing patient flow operations as part of staff and productivity review is a good way to observe patient flow patterns. By more effectively measuring patient flow, you will be able to better identify problem areas. You can then focus on places where gaps in flow may exist and determine ways to create change and to re-align staff incentives.

Impact on the Future
Facilities that have made the most progress reducing crowding problems have already made the paradigm shift to measuring patient flow. These hospitals look at crowding from an operational and management standpoint, which is the most important thing a hospital can do. As more hospitals successfully shift from measuring crowding to measuring throughput, it will encourage other hospitals to do the same.

This approach has the potential to move the research agenda forward and will likely answer key questions about crowding, such as how delays in care affect quality and what we can do to alleviate those delays. But the paradigm shift must start with interested investigators and the emergency medicine community. If we wait for a policy solution, we will be waiting too long.

Brent R. Asplin, M.D., M.P.H.
Department of Emergency Medicine
Regions Hospital and HealthPartners Research Foundation
St. Paul, MN
And Department of Emergency Medicine
University of Minnesota Medical School
Minneapolis, MN

For more in-depth information on this subject, Dr. Asplin wrote a commentary piece, "Measuring Crowding: Time for a Paradigm Shift," which appeared in the April 2006 issue of Academic Emergency Medicine.