Editor's note: This story was updated on January 25, 2019, as the first post in a three-part ED series, where we'll be featuring stories and resources on ED efficiency. Check back over the coming weeks to read more.

When officials at Ann & Robert H. Lurie Children's Hospital of Chicago noticed ED length of stay was up, the team made comprehensive—rather than fragmented—changes to streamline its triage process and ultimately reduced length of stay below target levels, hospital leaders write in NEJM Catalyst.

ED operations slow, while length of stay increases

In December 2016, Daniel Skarzynski, manager of Operations, ED, and Interfacility Transport, at Lurie and his colleagues write, the pace of the hospital's ED operations had declined and the length of stay had risen by 20%. In January 2017, the hospital found its average ED length of stay was 3:11 hours—11 minutes above the ED's target of 3:00 hours.

Skarzynski and his colleagues write, "While 11 minutes may not sound like a lot, the average masked a wide variability." Patients who visited the ED in the daytime might move through the hospital faster than average, while patients who visited the ED between 4 p.m. and midnight experienced wait times that could exceed 3 hours, as the ED saw 60 to 70% of its patients during that timeframe, Skarzynski and his colleagues explain.

Transform the ED’s role in delivering coordinated care

They write, "The [overall] increase in length of stay hindered our ability to serve our patients effectively, and stressed both patients and staff (who either left the department or became disengaged, damaging the collegial culture that had been one of our ED's most valuable assets)."

Changing operations and culture

To reduce length of stay, Lurie launched "a comprehensive and targeted intervention plan," and, according to Skarzynski and his colleagues, it worked. They write, "[O]perational and cultural changes … have reduced length of stay … and have helped restore our esprit de corps."

The hospital's ED team created an infrastructure and management system that used Lean techniques to emphasize continuous improvement and patient care. Under the infrastructure and management system, the ED developed:

• An implementation plan with deadlines for new interventions to be adopted, processed, and tracked;
• A multidisciplinary ED operations committee (EDOC) of 12 members who meet weekly to guide efforts to improve ED operations and track progress;
• A multi-modal communication plan at the beginning of the fiscal year involving a quarterly 1-hour update meeting for ED staff, a quarterly print newsletter, and a biweekly department update;
• A schedule at the beginning of the fiscal year to test new strategies on Tuesday, a high-volume day, and Thursday, a low-volume day—which allowed the ED to plan and alert staff of the changes ahead of time in addition to setting deadlines for ED members to complete their plans for interventions; and
• Project teams and a shared responsibility structure involving teams with four to six members, who are in charge of leading project sub-groups and reporting on the progress of initiatives to improve ED operations, and pre-planned frontline assignments, including off-unit time to work on initiative to improve ED operations.

In addition, the hospital's ED hosted a two-day event to analyze the ED's workflows and identify areas of improvement. The event involved team members from acute care, critical care, environment services, the ED, and the patient access center.

At the event, participants found the hospital could streamline the triage process beginning at the front door. Skarzynski and his colleagues write, "We discovered that we were doing the full triage assessment (head to toe) in triage even when it could be done in an exam room, resulting in a bottleneck at triage and empty exam rooms."

They continue, "If we moved some steps to the exam room, the triage nurse could continue to triage at the same time the [ED] physicians saw patients. When rooms are available, the triage nurse could record name and demographics, chief complaint, acuity, and weight, and then move patients to an exam room. At the same time, when the exam rooms are full, some steps usually done in the exam room could be moved to triage."

The team also found ways to improve during high-volume seasons, such as the flu season, by designating a specific provider to triageless acute patients and identifying "a more efficient way to care for them."

According to Skarzynski and his colleagues, the provider "sees potentially 30 patients per day who would otherwise take bed space in the ED."

In addition, Lurie changed its staffing model to adjust for patient volume fluctuations, Skarzynski and his colleagues write. "Previously, we had had a high-season and a low-season staffing plan; now we tier both seasons according to the days of the week, with the highest level for Sunday-Monday-Tuesday, a lower level for Wednesday, and the lowest level for Thursday-Friday-Saturday."

The interventions led ED length of stay to fall by 11% to 2:50 hours, below the three-hour target.

According to Skarzynski and his colleagues, the interventions led to other improvements. For instance, Skarzynski and his colleagues write the provider in the triage "has seen up to 50 patients in a 12-hour shift" and "[o]ur patient surveys show that we have improved at seeing the lowest-acuity patients in a timely manner and are spending enough time with patients, and our scores now exceed the national average for children's hospitals."

"Moreover, our team feels a difference. Seeing 250 patients per day no longer feels unmanageable but rather a routine winter day. We are now thinking as one ED," they write (Skarzynski et al., NEJM Catalyst, 9/27).

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