Lean techniques for the improvement of patients' flow in emergency department

doi:10.5847/wjem.j.issn.1920-8642.2014.01.004

Abstract

Abstract:

BACKGROUND: Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process.
METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.
RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05).
CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiesce-nce to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.

Key words: Lean, Triage, Waiting time, Patient flow, Emergency department

HY Chan, SM Lo, LLY Lee, WYL Lo, WC Yu, YF Wu, ST Ho, RSD Yeung, JTS Chan. Lean techniques for the improvement of patients' flow in emergency department[J]. World Journal of Emergency Medicine, 2014, 5(1): 24-28.

Figures/Tables 5

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References 13

1	Holden RJ. Lean thinking in emergency departments: a critical review. Ann Emerg Med 2011; 57:265-278. doi: 10.1016/j.annemergmed.2010.08.001
2	Khan NS, Jain S. Quality initiatives in the emergency department. Curr Opin Pediatr 2010; 22:262-267. pmid: 20463485
3	Kimsey DB. Lean methodology in health care. AORN J 2010; 92:53-60. doi: 10.1016/j.aorn.2010.01.015 pmid: 20619772
4	Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J. Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care 2010; 19:376-382. pmid: 20724397
5	Black J, Miller D. The Toyota way to healthcare excellence: increase efficiency and improve quality with Lean. Foundation of the American College of Healthcare Executives: Health Administration Press. 2008.
6	Dart RC. Can lean thinking transform American health care? Ann Emerg Med 2011; 57:279-281. doi: 10.1016/j.annemergmed.2010.11.027 pmid: 21227539
7	Graban M. Lean hospitals: improving quality, patient safety and employee satisfaction. London: CRC Press. 2009.
8	Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS. Application of lean manufacturing techniques in the emergency department. J Emerg Med 2009; 37:177-182.
9	Ng D, Vail G, Thomas S, Schmidt N. Applying the lean principles of the Toyota Production System to reduce wait times in the emergency department. CJEM 2010; 12:50-57. doi: 10.1017/s1481803500012021 pmid: 20078919
10	Pester J, Robinson J, Prestosh J, Roozendaal S, Jeanmonod R. Impact of the United States propofol ban on emergency providers' procedural sedation agent choice and patient length of stay. World J Emerg Med 2012; 3:177-181. pmid: 25215059
11	King DL, Ben-Tovim DI, Bassham J. Redesigning emergency department patient flows: application of lean thinking to health care. Emerg Med Australas 2006; 18:391-397. doi: 10.1111/j.1742-6723.2006.00872.x pmid: 16842310
12	Miró O, Sánchez M, Espinosa G, Coll-Vinent B, Bragulat E, Millá J. Analysis of patient flow in the emergency department and the effect of an extensive reorganization. Emerg Med J 2003; 20:143-148. doi: 10.1136/emj.20.2.143 pmid: 12642527
13	Simon RW, Canacari EG. Applying lean to the perioperative environment. AORN J 2012; 95:85-100. doi: 10.1016/j.aorn.2011.05.021 pmid: 22201573

Process change	Specific example	Expected outcome
Structured re-design process	Re-engineering the layout of each consultation room	Reduce end waiting consultation time
	Inventory control and easy access in each consultation room	Reduce total processing time
	Relocate the drug cupboard	Reduce triage waiting time
	Relocate the treatment area	Reduce intervention time
	Increase the number of consultation rooms
	Re-design the signage
	Re-construct nursing station
Priority Admission Triage Program	Admission screening and prioritization by emergency specialist	Reduce EMW admission waiting time
Priority Admission Triage Program	Diverse the sub-acute medical patient to EMW	Reduce avoidable medical admission
Communication with medical department	Centralized bed co-ordination system	Reduce admission waiting time
	Report medical bed vacancy every three hours
	Update medical bed vacancy in a timely manner	Reduce ED overcrowding
	Consult medical bed coordinator in urgent situation
	Activate overflow system when necessary
Cardiac Troponin-T blood test	Perform for patient complained of chest pain	Reduce blood result time
	Distinguish unstable angina patient from one with myocardial infarction without ST-segment elevation
	High sensitivity and specificity	Reduce total processing time

Variables	Pre-lean mean (min)	Post-lean mean (min)	P<
Triage waiting time	3.18 (4.235)	2.63 (3.591)	0.05
Consultation waiting time	13.68 (9.731)	11.65 (7.213)	0.05
Final waiting time	16.86 (10.92)	14.28 (7.876)	0.05
Blood result time	60.01 (30.31)	76.42 (33.69)	NS
Admission waiting time	28.99 (55.60)	38.24 (66.34)	0.05
EMW admission waiting time	54.76 (80.89)	24.45 (41.63)	0.05
Processing time	100.86 (81.40)	143.41 (114.26)	0.05
Length of stay in ED	117.71 (82.28)	157.70 (113.51)	0.05

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