362 - Reducing Waiting Room Times for Mid-Acuity Patients Presenting to the Emergency Department by Use of an Alternate Care Space

Poster Number: 362
Publication Number: 362.313

Megan Gerling, Boston Children's Hospital, Boston, MA, United States; Andrew F. Miller, Boston Children's Hospital, Brookline, MA, United States; Ashley L. Marchese, Boston Children's Hospital, Boston, MA, United States; Rebekah Mannix, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; joel Hudgins, Boston Children's Hospital, Boston, MA, United States; Jason Levy, Boston Children's Hospital, Boston, MA, United States

Background: Emergency department (ED) waiting room (WR) census and times have steadily increased due to limited hospital capacity for admitted patients and prolonged stays for patients with mental illness, leading to reduced ED room availability. Increased waiting room time leads to poor patient experience, patient complaints and delays in care. Though many EDs have developed spaces and processes to treat low-acuity patients, few studies have determined whether such processes can be effectively altered to treat mid-acuity patients. The modification of a pre-existing “Fast-Track” alternate care space to accommodate mid-acuity Emergency Severity Index (ESI) 3 patients could allow for increased room turnover, leading to decreased waiting and improved patient experience.

Objective: To determine if development of a mid-acuity alternate care space leads to decreased ED waiting room time for ESI 3 patients.

Design/Methods: We performed a Lean Six Sigma project following the DMAIC (Design, Measure, Analyze, Improve, Control) methodology (Figure 1). Process mapping techniques were used to understand the current state and identify system inefficiencies. In addition to staff education, modifications of the existing “Fast-Track” space included adjusting staffing mix, using electronic medical record (EMR) prompts for patient identification, updating equipment and supplies, and developing a triage algorithm to identify appropriate patients. We analyzed total WR time for ESI 3 patients during the hours of operation of the modified clinical space. Baseline data was collected from 11/2018 – 02/2019 and compared to data from the same time frame the following year to account for seasonal ED volume, a major determinant of WR time. Balancing measures included total WR time for ESI 4 and 5 patients.

Results: 4,876 ESI 3 patients were analyzed in the pre-implementation phase and 4,854 post-implementation. There was a 31% decrease in median waiting room time from 55 to 38 minutes (p < .001), and a 26% decrease in standard deviation from 68 to 50 minutes (p < .001), with a significant reduction in extreme outliers (Figure 1). Median WR time by month is shown in Figure 3. There was no change in WR time for ESI 4 or 5 patients during the same study period.Conclusion(s): By utilizing a Lean Six-Sigma DMAIC approach, we significantly decreased waiting room time for mid-acuity patients using an alternate care space. We believe that thoughtful evaluation of the process, EMR based solutions and algorithm driven triage allowed for the improvement of ED throughput.
Figure 1Lean Six Sigma Design, Measure, Analyze, Improve, Control (DMAIC) Process
Figure 2Waiting room time for ESI 3 patients arriving between 1p and 12a, November – February, pre- and post-implementation