Elsevier

Annals of Emergency Medicine

Volume 55, Issue 2, February 2010, Pages 142-160.e1
Annals of Emergency Medicine

The practice of emergency medicine/concept
Optimizing Emergency Department Front-End Operations

https://doi.org/10.1016/j.annemergmed.2009.05.021Get rights and content

As administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), “front-end” operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated “fast track” service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology (“smart cards”) have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.

Introduction

For nearly 2 decades, emergency department (ED) crowding has been recognized as a growing problem. From 1995 through 2005, the annual number of ED visits in the United States increased nearly 20%, from 96.5 million to 115.3 million, yet the number of hospital EDs decreased nearly 10% during this same period.1 The American Hospital Association reports that 69% of urban hospital EDs and 33% of rural hospital EDs are operating at or over capacity. Crowded conditions have resulted in prolonged ED ambulance diversions in 70% of urban hospitals and 74% of teaching hospitals.2 Timeliness of care has a strong correlation to patient satisfaction,3, 4 with wait time to be treated by a physician having the most powerful association with satisfaction.5

Much has been published in the academic and lay literature about the negative consequences of ED crowding. Prolonged patient wait times,6, 7 increased patient complaints,6, 8, 9 decreased staff satisfaction,7 and decreased physician productivity6, 10, 11 are examples of the negative ramifications of ED crowding. More worrisome is a burgeoning volume of literature linking ED crowding to suboptimal patient outcomes.6, 12, 13, 14, 15, 16, 17, 18

Optimizing ED throughput is one means by which to handle the increased demands for ED services. The Joint Commission has emphasized the need for smoothing ED patient flow and, in January 2005, implemented a new leadership standard, managing patient flow, which mandates that hospitals “…develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital.”19 Other organizations, including the Institute for Medicine, Agency for Healthcare Research and Quality Improvement, and Institute for Healthcare Improvement, have also emphasized the valuable effect streamlining ED operations has on hospital operations and patient outcomes.

ED activities occurring during the front-end processing of patients can vary from one ED to another; however, they typically include initial patient presentation, registration, triage, bed placement, and medical evaluation. When these processes do not occur simultaneously or in immediate succession, a patient is typically required to wait in a queue. The time needed to complete these front-end processes contributes to the ED total length of stay. The design, implementation, and assessment of innovative throughput solutions are the building blocks of departmental quality and operational performance improvement efforts. No one front-end process solution is likely to be optimal for all EDs, but the contribution of select tactics may help bring the patient and ED provider together more expeditiously. As a result, in October 2006 the American College of Emergency Physicians (ACEP) Council passed a resolution directing the “development of a position paper which defines optimal emergency care related to the front-end processing of patients presenting to the ED.”20 Subsequently, an Emergency Medicine Practice Subcommittee was appointed to develop a comprehensive information article summarizing the basic lay and academic literature with regard to ED front-end operations. The identified potential strategies are listed in the Figure and published on the American College of Emergency Physicians Web site.21 Thereafter, a focused critical analysis of potential high-impact strategies studied in the academic literature was undertaken by the authors as an extension of the subcommittee's original work and is presented in this report.

Section snippets

Select ED Front-End Processes

Attempts have been made to standardize the language of ED operations22; however, we could find no consensus definition of the ED “front-end.” For this discussion, we define it as the patient care processes that occur from the time of a patient's initial arrival to the ED to the time an ED health care provider formally assumes responsibility for the comprehensive evaluation and treatment of the patient, which typically includes the accepted metrics of “patient arrival to triage,” “triage time,”

Materials and Methods

A search of MEDLINE from 1966 to January 21, 2008, was performed, using the key word “ED” as well as “triage,” “registration,” “efficiency,” ”length of stay,” “urgent care,” “fast track,” “immediate bedding,” “accelerated triage,” “bedside registration,” “triage protocols,” “advanced triage protocols,” “tracking system,” “mobile phones,” “wireless telecommunication,” “kiosk,” and “smart card” (n=6,902). All abstracts related to front-end processes were reviewed and full-text articles in English

Immediate Bedding and “Quick” or Bedside Registration

Although implementing immediate bedding and bedside registration has been touted to increase patient satisfaction in the lay literature,89 very little has been published to prove this in the academic literature. Six studies were identified that address immediate bedding or bedside registration in the ED.26, 27, 28, 29, 30, 31 A synthesis of the published experiences at this point is limited but does suggest that immediate bedding may decrease waiting times,26, 27, 28 shorten total ED length of

Conclusion

As ED crowding worsens, it is important for departments to improve operations to promote patient throughput. No doubt operational bottlenecks at the “back-end” of the ED will ultimately lead to front-end delays. However, proficient patient processing at the ED front-end may minimize wait times, decrease the total ED length of stay, and improve patient satisfaction. This critical review of the academic medical literature reveals that few and often methodologically limited studies have been

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  • Cited by (0)

    Supervising editor: Theodore R. Delbridge, MD, MPH

    Author contributions: JW conceived the project, designed the outline, supervised data collection, and was subcommittee chair. DF was EM Practice committee chair. AH, MM, JH, CG, AM and JW drafted the manuscript, and all authors contributed to its revision. JW takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Publication date: Available online June 25, 2009.

    Reprints not available from the authors.

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