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Essay Example: Improving Patient Flow in the ER and ICU

7 pages
1843 words
Carnegie Mellon University
Type of paper: 
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Emergency Rooms (ER) are among the busiest departments in the healthcare system. Research studies indicate that about 50 percent of all admissions of patients are first referred to the emergency room before they are admitted to the intensive care and medical-surgical units (College of Emergency Medicine, 2014). Unlike other departments, ER receives all patients at all times, and a significant number of them comes outside the normal working hours during the evening and weekends. This makes ERs the most crowded places, and patients flow usually limited to a greater degree. The situation is often made worse by the busy hospital environment where nurses and physicians are expected to address different kinds of patients injuries or illnesses.

The increased overcrowding of patients expected at ER is the major impediment to the delivery of high quality and timely patient care. The limited staff and resources deployed at this department in relation to the ever-increasing numbers of patients seeking admissions have led to the poor patient flow (Hall, 2013). This has negatively affected the quality of care and patients outcomes. This paper provides a deeper review of how ER staff tends to push the admissions of patients to the intensive care and medical-surgical units. It offers the reasons why patient flow in these departments is slow in most healthcare facilities. Besides, the relevant tools and techniques required to improve patient flow including the Six Sigma and Lean improvement processes are discussed in this paper.

ER Admission Process

The process of admitting patients to the ERs is based on their medical emergency needs. Patients details are entered by the administrative registration clerks, who take patients personal details including name, date of birth and insurance provider information (Hall, 2013). After patients have checked in, they begin the first stage known as triage. First used during wartime, triage represents a system of organizing the patients based on how much and how soon they need care. At this stage, patients are prioritized according to the level of severity exhibited by their illness or injury. They are then classified into three categories: emergent, urgent and non-urgent. The emergent category represents an injury or illness that needs immediate attention to avoid the risk of a possible fatality. The urgent category represents an injury or illness that needs treatment within four hours (Vile, Allkins, Frankish, Garland, Mizen & Williams, 2017). The non-urgent category represents an illness or injury that has an undetermined time frame for treatment. Patients in the emergent or urgent category are prioritized, and they do not usually wait for long.

Triage nurses have the responsibility to examine the conditions of the patient. They test the severity of their complaints and set the priorities of who should be seen first. Provision of care in the emergency department is not first-come, the first-served basis but it is based on the nature of severity of patient's illness. If a patient arrives at the emergency room in an ambulance, unresponsive or unconscious, or if they have symptoms that might show a stroke or heart attack are first attended. They are immediately classified in the triage process to be at the top of the list, making sure the patients with these conditions get treated before another with a sprained ankle (Hall, 2013). The nurses at this stage, typically takes patients data such as oxygen levels, temperature, blood pressure and examine patients pain levels. Registered nurses assigned to the department are required to take this data. The assigned nurses use this information to classify the patients whether they need quick care or no care at all.

After nurses have completed examining the urgency of the illness or injury, they will then take the patient either directly to the treatment area or directly to the waiting area. In the event, the patient develops new complication while they are waiting they are required to inform the triage nurse urgently without delay. The ER is the most congested departments for most patients seeking admission are first checked in to the department (Rowe, Guo & Villa-Roel, 2011). Patients often do not know how long they have to wait, but in some hospitals, patients are informed from time to time to how much longer they will have to wait to receive care. The wait time varies depending on some factors, mostly due to a high number of patients to be attended and the number of staff available to handle patients complaints. In certain instances, the ER is busier than others, for instance during weekends. As shown by the National Center for Health Statistics about 70 percent of patients who visit ER arrive during non-business hours, normally before 8 in the morning and after 5 in the evening(Vile et al., 2017).

Admissions to the Intensive Care and Medical, Surgical Units

The increased number of patients has brought about a poorly managed flow that has resulted in overcrowding both in the emergency departments as well as intensive care and medical, surgical units. This has led to severe outcomes because support staff expected to offer services such as radiology and laboratory tests are stretched beyond their normal capacity (Hall, 2013). Besides, the attending nurses and physicians do not have adequate time to focus on individual patients.

Due to increased admission beyond their capacity, nursing staff in intensive care and medical-surgical units have been reluctant to receive more admission of patients. Mostly they decline further admission because managing and providing care to an additional number of patients is quite difficult and chances of fatalities are increased significantly. For instance, studies have indicated that for each additional patient assigned to a nurse with myocardial infarction, heart failure or pneumonia, the rate of readmission rises between 6 percent and 9 percent (Farrohknia, Castren, & Ehrenberg, 2011). Also, it has been found out that in the event a patient gets discharged from intensive care unit due to overcrowding, their odds of readmission increases significantly (Vile et al., 2017). Moreover, mortality rates have been proved to rise when the ratio of surgical nurses per patient goes down. At the same rate, when patients are held for too long in the emergency room until inpatient beds are freed up normally have higher rates of morbidity and mortality.

How to Improve Patient Flow

The greatest need every emergency room and intensive care units to improve patient flow are evidence-based strategies that decrease the amount of time patient have to wait before they receive care. It requires lean improvement processes or Six Sigma that ensures the quality of output is improved by identifying and minimizing defects that hamper the effective provision of timely care and treatment of patients (Rowe et al., 2011). As explained by Bill Smith, who first introduced the Six Sigma concept while working at Motorola in 1986, appropriate tools and techniques must always be researched and adopted to improve delivery of service at any given work environment (Vile et al., 2017). In his argument, Bill pointed that quality management method especially the statistical and empirical methods should be put in place to establish a special infrastructure of people within the organization who are experts in these methods. For improved and effective processes to be realized within an organization specific value targets such as the reduced process cycle time, reduced costs and increased customer satisfaction must be upheld at all times.

Hospital management should always be proactive to adopt new methods and techniques that guarantee effective patients flow. Techniques such as streaming, rapid assessment, doctor triage and co-location of a primary care clinician in the emergency room have been proven to improve patient flow. Also, the point of care testing when adopted well reduces significantly time spent by patients in the emergency rooms.

Doctor Triage

Doctor triage is a method that researchers have proven to bring order and facilitate faster patient flow in ER (Farrohknia et al., 2011). This method involves a brief intervention that takes place within fifteen minutes after the arrival of the patient in the ER. This process is aimed at classifying patients' risk and assigning them appropriate priority as a way of utilizing the limited available resources, for instance, the clinical space and staff based on their clinical needs. The internationally accepted standard is the nurse-led triage model which is known to work similarly as the doctor triage (Hall, 2013). Doctor triage helps to facilitate the improved collection of patients data such as blood tests and X-rays, and its adoption shortens significantly waiting times for patients. Hence this system gives faster delivery of care in the ER.

For proper adoption of this system a standardized approach, protocol, and training program must be carried out constantly by the hospital management to ensure improvement is always guaranteed. According to Rowe et al. (2011) presence of a physician in triage helps to reduce the incidence of overcrowding, this is achieved because they accelerate patient flow by providing timely information to aid their treatment process. By incorporating doctor triage at ER, the hospital will be able to address the second and third order effects, for instance, not only will this process result in improved patient flow, but also it will result in the quality of treatment administered to the patients.

Rapid Assessment Models

Use of rapid assessment models aids the process of patient flow. This model ensures patients are assessed and given initial treatment as soon as they arrive in the emergency room. The operation of this model embodies the principle of single piece flow that in most cases applied in the automotive manufacturing industry (Oredsson, Jonsson & Rognes, 2011). The hospitals that embrace this model reduce the amount of wait time by carrying out early assessment and investigation that are immediately followed by a prompt initial treatment normally absent in the traditional model. Patients who are given prompt treatment are those who do not require heavy or high dependency unit treatment. Once it is implemented, this model gives staff a smooth and seamless attendance of patients without many complexities that characterize traditional systems that are rigid and unable to adjust to the needs of patients (Oredsson et al., 2011). This model does not focus only on the immediate outcomes of patients, but it reflects an all rounded approach that gives patients an opportunity to receive prompt treatment that meets the required standards at the same time. Thus essentially this model put into consideration the second and third order effects, unlike the traditional techniques.


Streaming is another technique that has been developed to address the challenge of patients overcrowding in the ER and ICU. It involves the process of allocating patients with similar conditions (nature of their complaint or severity of the disease) to a given work stream. Once the patients have been streamed, staff specialized in the identified areas are then assigned to attend to their needs. This approach has proved to be effective as time is not wasted for physicians or nurses to consult their colleagues on how to treat or provide care to specific ailments, not within their area of specialization (Oredsson et al., 2011). Patients with less severe illnesses are attended faster as the streaming process allows "see and treat" approach by a team of dedicated staff. Usually, emergency departments are designed in such a way that critically ill patients are given priority while patients...

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