112 Patient Flow Solutions for Emergency Departments

This list should get us started…  Please add your ideas in the comment section at the end!

1. Close your waiting room – bring patients straight inside to chairs if no beds open
2. Use triage to enhance flow: triage = sorting and nothing else
3. Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
4. Have patients self triage
5. Use on-line triage
6. Use Bedside registration
7. “Quick Reg” – limited registration; just enough to create a chart
8. Have patients use self registration
9. Offer pre-registration on line
10. Post live wait times on-line to smooth patient volumes
11. Use patient passports – patient education hand-outs at front door
12. Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
13. Educate community to avoid the surges on Sunday evening/all day Monday
14. Limit 1 visitor per patient
15. Encourage patients to bring med lists with them
16. Encourage community MDs to send in referral notes
17. Have on-call MDs
18. Have flexible start and stop times for MDs
19. Get MDs to take responsibility for flow in real time
20. Have on call RNs
21. Shorten nursing documentation (1-2 pages max)
22. Use combined triage & nursing secondary assessment form
23. Use physician scribes/navigators
24. De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
25. Use advanced directives
26. Use pre printed orders
27. Measure and reward MD performance
28. Measure consultant response times
29. Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
30. De-unionize – flow will improve
31. Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
32. Track RN break times – insist on accountability
33. Reward RN extra effort (staying late, skipping breaks, going the extra mile)
34. Match RN staffing to patient volumes by hour
35. Match MD staffing to patient volumes by hour
36. Never allow MDs to go home if waits are long
37. Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
38. Encourage MDs/RNs to work in teams and hand over readily
39. Stagger RN shift changes
40. Have dedicated ED X-Ray
41. Have U/S (and tech) in the ED
42. Use techs for lab draws and ECGs
43. Stat labs
44. Prioritize ED lab and DI
45. Don’t batch
46. Dedicated porters (RN/tech should porter if porters overwhelmed)
47. Track DI and lab turn-around times
48. Get a great EDIS (ED information system)
49. Create meaningful alerts on EDIS to identify LOS, reassessments, etc
50. Have a modern EMR linked to the EDIS
51. Retire outdated EMRs – an old, slow EMR might be worse than none at all
52. Consider a real time locating system (e.g., RFID)
53. Consider EMR on tablets for each MD
54. Computer terminal in each room
55. Link ED EMRs with community EHRs
56. Have forms available on-line
57. Bypass ED for STEMI identified by EMS (straight to PCI)
58. Eliminate phone calls for CT, etc
59. Extend CT hours of operation
60. Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
61. Do not schedule big surgical cases on Monday
62. Track admits and discharges by time of day and day of week
63. Eliminate day-day variations of admits/discharges
64. Perform nurse handover on the ward; not by phone from the ED
65. Get admitted patients straight up to the ward before a bed becomes available
66. Use a visual bed management system for inpatient flow admitted patients leave promptly
67. Use patient flow navigators
68. Create robust medicine clinic follow-up clinics (next day)
69. Do not allow consultants to ‘send patients to the ED’ and see them there
70. Teach residents about quality and efficiency as paramount in their education
71. Use PO instead of IM, and IM instead of IV treatments if possible
72. Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
73. Form psychiatric patients promptly as needed
74. Do not perform an internal medicine ‘ward’ work-up in the ED
75. Order all tests and treatments on the first touch
76. Plan on disposition from the first encounter
77. Have Multi-use rooms (eliminate bottle-necks)
78. Establish procedures to sedate patients in any room
79. Partner with volunteers – they can help a ton!
80. Establish CDUs on in-patient wards – do consultations there
81. Give every MD, RT and Consultants a phone to carry
82. Do not scale down services over holidays when demand always goes up!
83. Encourage same day, out-patient cardiac diagnostics and consultation
84. Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
85. Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
86. Use pre-printed prescriptions
87. Have the chief call in 2-3 times per day to monitor flow
88. Create an internal, real-time ED surge plan
89. Create a hospital wide surge plan and link it to the ED surge plan
90. Give admin on call authority to move admitted patients out the ED
91. Have back on-call to support internal medicine consults
92. Do not allow surgeons to be on-call to the ED on their OR day
93. Teach all nurses to apply splints and/or casts
94. Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
95. Avoid batching
96. Assign patients to areas; not rooms
97. Use overhead paging liberally – don’t walk around looking for patients
98. Improve patient signage
99. Use patient instruction sheets
100. Use a re-assessment check-list so MDs aren’t called to reassess prematurely
101. Build a minor treatment area (aka fast track)
102. Get rid of as many stretchers as possible (limits holding admitted patients)
103. Use exam tables where-ever possible
104. Use some chairs instead of stretchers in the acute area for telemetry patients
105. Get rid of walls – use curtains to divide most rooms
106. Eliminate sequential processing
107. Insist on parallel processing
108. Look for bottlenecks – theory of constraints
109. Learn queuing theory and how it applies to your department
110. Learn and love LEAN
111. Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
112. Adopt a ‘get it done NOW‘ attitude across the organization!

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