Serving more than 300 patients each day, the ED at Grady Memorial Hospital in downtown Atlanta is one of the busiest in the country. It houses the only Level 1 trauma center within a 100-mile radius of Atlanta and one of only two burn centers in the state.
In 2003, Grady was selected to participate in the first Urgent Matters Learning Network. As part of this year-long project, Grady’s Urgent Matters team set out to address crowding in the ED by reducing overall patient throughput times. They tested a wide range of strategies, from creating a new centralized system for entering physicians’ orders for laboratory and radiology tests to changing the location of the in-basket for the charts of patients in the Fast Track unit. In addition, the team established a new seven-bed Care Management Unit in the ED for patients with diagnoses of asthma, chest pain, congestive heart failure, or hyperglycemia who might otherwise be admitted to the hospital. During the year that these changes were implemented, there was a 22% decrease in the total throughput time in the ED
“The Urgent Matters project set a good framework for us to work on improving patient flow and it helped us put systems in place that we have continued to this day,” says Leon L. Haley, Jr., MD, deputy senior vice president of medical affairs and chief of emergency medicine for the Grady Health System, and project director for Grady’s Urgent Matters team. He notes that while some of the strategies the ED staff adopted during the project are no longer being used –the following three have stuck:
Routine Meetings with the Hospital’s Senior Leadership: Haley and his team meet twice a month with the CEO of the Grady Health System and other senior hospital leaders to discuss issues and problems related to ED throughput and patient care. “Although the senior leadership has changed – for instance, we’ve had six different CEOs over the past few years – we’ve been able to maintain this structure,” says Haley. “Because of these meetings, everybody is still focused on ED throughput. The level of accountability has increased because the CEO and senior leadership are looking at the data we collect on a regular basis.”
Tracking Data with a Dashboard System: The ED staff uses dashboard software to monitor throughput time, patient turnover, lab turnaround times, hours spent on ambulance diversion, core compliance measures, and other key data elements. Haley says the team has modified the dashboard since the Urgent Matters project and continues to collect data that can be used for quality improvement.
Recently, the entire hospital began using a new electronic patient medical record database. This system enables ED staff to track additional measures, such as how long it takes for a patient to be seen by a provider. “During the Urgent Matters project, we recognized that we needed a hospital-wide electronic health record system,” says Haley. “We’ve spent a lot of time in the past year trying to make sure it’s being implemented in the right way and that it’s meeting all of our needs and objectives.”
Rapid Cycle Testing of New Initiatives: During the Urgent Matters project the Grady ED team tested a new tool or strategy almost every week. Now they try out a couple of changes each month. “We’ve learned we can test a change for a few days or weeks and then if it seems to work we’ll continue to try to optimize it,” says Haley. Last fall, for example, they decided to divide a medical treatment area in the ED known as the Blue Zone in half. They assigned a faculty member and resident to each half, patients were then distributed to one of these two sections. This process improved efficiency and the increased the accountability of the staff assigned to a particular section. After testing two versions of this new system, they tweaked and then adopted the one that worked better.
Haley says one of the challenges his team faces, however, is that sometimes they’re implementing changes in the ED so quickly that it’s difficult for the staff to keep pace. “To mitigate that, we try to communicate better with the staff through emails and briefings, and to schedule staff meetings on a regular basis.”
Addressing New Challenges
As the Grady team keeps working to improve patient satisfaction and reduce ED length of stay using these strategies from the Urgent Matters project and others they’ve developed more recently, new challenges keep emerging every year. “Our volume has increased and we have seen in rise in number of uninsured patients coming to the ED,” notes Haley.
In the future, he hopes to make changes that enhance the care of specific groups of patients. “The volume of mental health patients has increased dramatically, we are looking at ways redesigning parts of the ED to provide better support for this population,” he says. “We’re also planning to expand the space for our trauma beds so we can take improve care of our trauma patients.”
Leon L. Haley, Jr., MD, MHSA, CPE, FACEP, Deputy Senior Vice President of Medical Affairs and Chief of Emergency Medicine, Grady Health System, Vice-Chairman of Clinical Affairs and Associate Professor, Department of Emergency Medicine, Emory University.