The impact of a multimodal intervention on emergency department crowding and patient flow

Crowding in the emergency department (ED) is associated with lesser patient flow and adverse patient outcomes [1‐3]. ED crowding is usually a consequence of insufficient inpatient hospital capacity or inadequate coordination of capacity within a hospital, and subsequently, the boarding of patients in the ED for extended periods of time [4, 5]. Experts widely agree that ED crowding is a system-wide problem, not one that solely results from problems in the ED or one that can be addressed using only ED-based interventions [6, 7]. Improving patient flow is essential to reduce ED crowding, but requires involvement of professionals outside the ED [8, 9] and support from hospital management. Therefore, a Taskforce Acute Care Team (TACT) was introduced in the study setting: a group of hospital managers and medical specialists dedicated to improve the quality of patient care and patient flow, addressing acute care as a strategic priority. The TACT introduced four process changes with the intention to improve patient flow at the ED: (1) adding an emergency nurse practitioner (ENP) and (2) adding five medical specialists during ED peak times (noon to 8 pm) to the 24/7 available emergency physicians (EPs), (3) a Lean programme to improve radiology report turnaround times and (4) extending the admission offices’ openings hours to help ED staff with finding an inpatient bed. This multimodal intervention was formally implemented in November 2017. The present study focuses on the impact of the multimodal intervention on ED crowding and patient flow.

In previous research, similar clinical redesign projects have been studied, including streaming patients directly from triage to dedicated minor injury units or super tracks [10] and ENP-led units [11‐13], senior early assessment models of care [14‐17], Lean methods [18‐21], and improving access to inpatient admission [22]. Improving ED processes has been shown to reduce the length of stay (LOS), although studies show varying results, and the effect on crowding is uncertain [23].

The purpose of this study is to test the impact of a multimodal intervention on ED crowding and patient flow in a Dutch level 1 trauma center. In this study, we assess crowding levels, radiology report turnaround times and patients’ ED LOS during peak hours and overall. To ensure that enhanced patient flow is not achieved at the expense of high quality of care, we assess the percentage of patients leaving without being seen (LWBS) by a medical provider, reflecting potential harmful outcomes [24]. Furthermore, we describe the number of unscheduled representations to the ED within 1 week of the initial visit, a measure of patient safety [25].

During the 18-month study period, 81,213 patient presentations were registered, 39,535 (48.7%) during the pre-intervention period, of which 7644 (19.3%) were diverted to the GPC, and 41,678 (51.3%) during the intervention period of which 9557 (22.9%) were diverted to the GPC. The remaining 64,012 patient presentations were included: 31,891 in the pre-intervention period and 32,121 in the intervention period (Fig. 1).

In the intervention period, there were more elderly patients and lesser children, lesser self-referred patients, lesser high-acuity but more urgent patients, lesser patients with limb problems and ear/nose/throat/eye problems, and more patients with shortness of breath and feeling unwell, compared to the pre-intervention period. There was no difference between the pre-intervention and intervention period in the number of patients arriving during peak hours (Table 2), and no differences in the number of patients needing hospital admission, patients who died at the ED and patients with one or more requests for imaging procedures during their ED visit (Table 3).

During the intervention period, significantly less plain radiographs but more CT-scans, ultrasounds, and other radiology orders were executed (Table 4). These findings were similar when focusing on the peak hours of the study periods (data not shown).

This study demonstrates improvement in ED flow after the introduction of the multimodal intervention. Hours of crowding decreased significantly, as did the patients’ ED LOS. During the peak hours in the intervention period, we found a 13-min reduction in ED LOS per patient, totaling 3369 h between noon and 8 pm during the 274 day-intervention period. This additional time is now available for direct patient care.

The process changes were based on previous research: implementing care by ENPs can reduce waiting times in the ED [11‐13]. Involvement of medical specialists is associated with increased decisiveness resulting in decreased LOS [17]. In a pilot study performed in the study setting, a decrease in LOS for admitted patients was found when medical specialists are involved at the ED. In that study, delays in radiology turnaround times were considered a main constraint for ED throughput [28]. This finding led to the organisation of a 5-day Lean project within the radiology department, focusing on improved turnaround time for radiography. Alike shown in other studies [18, 20], the Lean methodology was effective in reducing turnaround times for radiology results. Unfortunately, this reduction in waiting time for radiology results is only partially translated into reduced overall LOS. This is not surprising, since LOS is affected by factors beyond the ED process [20].

Our findings are in line with other studies showing that hospital-wide interventions reduce ED crowding [7, 9, 12]. The support of our hospital leadership and the TACT towards improving patient care was a mitigating factor in the success of the process changes. Bringing together diverse disciplines including medical specialists and ED staff fostered a new focus on ED flow as being not only an ED issue but a system-wide issue. Our multimodal intervention alleviated ED crowding and reduced ED patients’ LOS. Crowded circumstances (mNEDOCS > 100) decreased significantly. It seems plausible that the additional medical specialists available at the ED during peak times were (at least in part) responsible for this. When attending specialists make immediate assessments in the ED, there is less replication of work and decisions about next steps are made more quickly [32]. Additionally, the intervention enhanced focus on acute care throughout the hospital. This was an important driving factor in freeing hospital beds on behalf of acute admissions.

From the current research, it cannot be concluded whether additional attending specialists and ENPs were needed to obtain these results, or whether additional EPs or other human resources would have generated the same or even better effects. Adding attending specialists to the ED staff during peak hours is a costly intervention, while for some patient groups (e.g. internal medicine), there was no change in ED LOS. The total costs and cost-effectiveness of the current intervention and alternatives need to be compared. To study the cost-effectiveness of alternative staffing decisions, ED simulation modelling may be valuable.

A reason why ED LOS did not reduce for internal medicine patients might be that an internist had been available for the acute admission unit and the ED for many years already, focusing on ED outflow far before the current project started. Also, confounding factors may have played an important role. For example, the flu season lasted until the end of February during the intervention period, while it ended a month earlier during the pre-intervention period.

Our positive findings of decreased crowding and reduced patients’ LOS cannot be attributed to differences between the pre-intervention and intervention population. There was a small (0.7%) increase in the number of presentations and no difference in the number of hospital admissions. The differences between the populations suggest a sicker population in the intervention period: there were more elderly patients and patients with shortness of breath and feeling unwell, and lesser patients with limb problems and ear-nose-throat-eye problems. The first two groups are usually more labour-intensive for ED staff and patients have lengthier stays compared to patients with limb or ear/nose/throat or eye problems. Since the patient population in the intervention period was at least as high complex as the patient population in the pre-intervention period, the main reason for the significant decrease in crowding levels during the intervention period is probably the shortening of LOS. Shorter LOS is associated with improvements in patient experience [33] and a reduction of adverse events [34].

In this hospital, a multimodal intervention successfully reduced crowding, radiology turnaround times, patients’ LOS, number of patients LWBS, and the number of unscheduled return visits, suggesting improved ED processes. Further research is required on total costs of care and long-term effects.