Long wait times to see a physician at hospital emergency rooms has become an unfortunate reality in the U.S. healthcare system. The physicians and staff at Kaiser Permanente South Sacramento sought to change this through the use of Lean methodology for performance improvement with an overall goal of reducing patient time in the emergency department (ED) to one hour.
Karen Murrell, M.D., the chair of emergency medicine at Kaiser Permanente Northern California, shared how Kaiser Permanente South Sacramento was able to reduce ED wait times to well below the national average and improve patient flow during a webinar presented by the Maine Health Management Coalition. Dr. Morrell also serves as assistant physician in chief overseeing hospital operations, emergency medicine, psychiatry and trauma as well as process management and optimization at Kaiser Permanente South Sacramento, which is part of the integrated health system Kaiser Permanente Northern California.
According to Dr. Murrell, Kaiser Permanente South Sacramento is the busiest emergency department in Sacramento and serves as a Level 2 Trauma Center. As a trauma center for the county, the hospital ER has seen its patient volume almost double since 2008, when annual patient volume was 67,000. The hospital is on pace for 120,000 patient visits this year and this past January patient visits were up 27 percent year-over-year.
“We are very space constrained and the ER only has 49 ED bays and we lose three of those for trauma and four are dedicated to pyschiatry. So that’s 2,500 patients per ED bay and what’s recommended is 1,500 to 1,800. And on the hospital side, we have 144 beds for 120,000 ED visits,” Dr. Morrell said.
The increased patient volume and space constraints resulted in long ED wait times.
Seven years ago, the average ER wait times, or time from arrival to seeing a doctor, at Kaiser South Sacramento was 55 minutes. For patients, total time in the ED averaged at 4.5 hours for discharged patients and 8 hours for admitted patients.
“Patients were waiting five to six hours to see a doctor and every night there were 30 to 40 patients in the waiting room,” Dr Morrell said. “But trying to eliminate waits and get a good flow, it’s like chasing a moving train.”
The ER’s Leave Without Being Seen (LWBS) rates were 6.6 percent, but some months the LWBS rates were as high as 12 percent. And, at that time, the hospital reported 450 hours of ambulance diversion annually.
“What killed us was this wide variability day to day and longer times some days,” Dr Morrell said. “For me as a doctor, I work a 12-hour shift, and I would only see eight patients with 30 or more patients in the waiting room. The poor flow made it impossible to see patients. Doctors were frustrated and complaining to administration about ED function; patients were angry and the staff was angry.”
Through a performance improvement program, Kaiser South Sacramento’s ED has reduced the patient ER wait times down to a consistent 19 minutes; the national average, by contrast, is 58 minutes with wide variability. The department’s LWBS rates are now down to 0.4 percent. The hospital reported zero ambulance diversion hours last year.
Kaiser South Sacramento also significantly decreased patient length of stay (LOS) in the ED. The average LOS for low acuity patients is now 43 minutes, compared to the national average of 118 minutes. And, the LOS for discharged patients decreased from 4.5 hours to about 2 hours and the LOS for admitted patients dropped from 8 to 6 hours. There are now rarely inpatient holds in the hospital’s ED and hospital length of stay is just over three days, Dr. Morrell said.
In 2014, 80 percent of patients were out of the ED in under 4 hours and 55 percent were out in under 2 hours.
“What we’ve learned over time is that decreasing length of stay creates capacity,” she said.
In order to decrease patient length of stay in the ER, the department focused on improving patient flow with a program that centered around leadership, vision setting and the use of Lean methodology and open data for performance improvement. Dr. Morrell says the department applied Lean principles to develop a Rapid Triage and Treatment (RTT) system in the ER, which ultimately improved the hospital’s ED metrics.
“How do you start a program like this? You look at every process and then create a culture. You look at everything with a critical eye to make it better for patients and easier for providers,” she said. “The steps to setting this up were establishing strong leadership that sets a vision, looking at every process critically, involving frontline staff and then continuous improvement.”
Another key step to improving patient flow is having open data with clear metrics, and the department identified decreasing length of stay in the ED as the key metric, Dr. Morrell said.
To improve patient flow from waiting room to doctor specifically, the ED team at Kaiser South Sacramento streamlined rapid care by first eliminating a long triage process. When patients arrive, there had been a 19-minute screening exam used to triage patients and that was changed into a two-minute process.
“That triage was non-value added. There should never be a time when a doctor is sitting idle and a patient is being triaged,” Dr. Morrell said.
The ED also created a team assignment system in which teams consisting of a physician and one or two nurses “own” the patients in the waiting room. The goal is to have only one contact with the patient and the patient flow is controlled by the team rather than a charge nurse.
“We set a vision with the staff – our patients do not wait. We want to be the best ER in America,” she said.
The hospital’s ED then looked to improve patient flow and efficiency once the patient was in the ER, or time from doctor-to-disposition, and open data played a key role in improving productivity.
“With regards to open data, first we met together as a group and decided goals, and then we worked on systems so physicians could reach goals,” Dr. Morrell said. “We start with low acuity, so one hour is for rapid care patients, two hours is level 3 patients, three hours is the higher acuity and four hours is the admissions.”
“We don’t try to push the people out; our goal is to eliminate the non-value added parts of it and keep the value-added parts,” she said.
The ED then held staff meetings to discuss efficiency tips and share best practices and physicians and staff often shadowed their fastest colleagues.
Dr. Morrell said the use of open data and metrics helped to decrease patients’ length of stay in the ED by 10 percent as “the staff most impacted were the ones who were slower; the faster ones stayed fast and the slower ones got faster.”
“The metrics are not random, but are chosen to create the capacity. Again, decreasing the length of stay creates capacity, so if we have a patient in a bed for two hours rather than four hours, we can see twice as many patients,” she said.
“When we started, our goal was one hour [arrival to discharge time] and almost nobody was meeting that metric. And in 2014, almost everyone is meeting that goal and many people are down to 30 minutes,” Dr. Morrell said.
“And, we make sure efficiency is balanced with quality and patient satisfaction,” she said. “We have developed this culture of patient-centered innovation and flow.”
