Computers in Emergency Medicine
Prospective Evaluation of Daily Performance Metrics to Reduce Emergency Department Length of Stay for Surgical Consults

https://doi.org/10.1016/j.jemermed.2012.02.058Get rights and content

Abstract

Background

As part of a quality improvement initiative to reduce Emergency Department (ED) length of stay (LOS) for surgical consult patients, we e-mailed performance metrics to key stakeholders on a daily basis. ED and Surgery leadership used these daily metrics to identify and remedy contributing factors for increased ED LOS in patients who received surgical consults.

Objective

To evaluate whether a quality improvement process driven by a daily performance metric e-mail would be associated with a change in ED LOS for surgical consult patients.

Methods

Prospective before-after study looking at ED LOS for surgical consult patients after an e-mail intervention at a tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult were enrolled. The primary outcome measure was ED LOS, and secondary outcome measure was time to consultation.

Results

There were 916 patients who had surgical consults placed during the study period; 459 patients presented before the intervention and 457 patients presented after the intervention. The median LOS decreased 54 min, from 463 min (interquartile range [IQR] 326–617) before the intervention to 409 min (IQR 294.5–528.5) after the intervention (p < 0.001). Time to consultation decreased 25 min, from a median of 160 min (IQR 87–265) to 135 min (IQR 70–239.5) (p = 0.002). There was no difference in age, severity, number of consults, or disposition. There was also no difference in median LOS for other consultation services or in previous years during the same time period.

Conclusions

ED LOS and time to consultation were decreased for surgical consult patients after initiation of daily performance metric e-mails.

Introduction

In 2008, the National Quality Forum endorsed a set of 10 voluntary consensus standards for hospital-based Emergency Department (ED) care to reduce overcrowding, decrease patient wait time, and improve overall quality of care (1). Additionally, The Joint Commission approved a standard in 2005 requiring hospital leadership to develop and implement plans to identify and alleviate barriers to patient flow throughout the hospital (2). Despite these interventions, length of stay (LOS) in the ED continues to rise (3).

Recent efforts to alleviate the upward trending LOS in EDs have largely focused on improving flow in core operational processes. Several studies have successfully improved ED throughput by improving laboratory turnaround time 4, 5, 6, 7. Other studies have reduced LOS by beginning patient evaluation and treatment in triage (7). Further studies have described large process redesign projects with significant improvements, but also engendering significant cost (7).

Improving service-line efficiency, such as consultation time, can reduce LOS in the ED. Specialty consultations in the ED are frequent events, with some studies showing they involve 20–40% of patients (8). There is evidence that lack of timely consultation is a leading cause of ED overcrowding (9). Acuity level, laboratory and imaging utilization, and use of consultant services have all been shown to correlate with prolonged LOS (10). Effect of consultants on LOS was highly variable depending on the particular service involved. Although controversial, physician profiling has been shown to have a positive effect on average LOS for inpatient services 11, 12, 13, 14. Furthermore, automating the consultation process in the ED can eliminate inefficiencies of a manual consultation process and reduce ED LOS (15).

A recent systemic review highlights the importance of process improvement strategies to improve ED operations (16). However, these process improvement strategies are dependent on comprehensive data on process metrics, often automated, to drive cycles of quality improvement. The use of regularly collected and reported process metrics have previously been successful in reducing ED LOS 16, 17. However, little literature exists on how to implement information technology interventions to provide ED leadership with operational data to best support process improvement initiatives.

Our goal in this study was to evaluate the effect of a daily performance metric e-mail to drive process improvement efforts to reduce ED LOS for patients who received general surgery consults. We have previously used this strategy to reduce door-to-balloon times for ST-elevation myocardial infarction patients as well as door-to-computed-tomography (CT) time for suspected stroke patients. We hypothesized that daily performance metrics could also be used to identify contributing factors for increased ED LOS in patients who received surgical consults and consequently, reduce ED LOS for subsequent surgical patients.

Section snippets

Study Design

We conducted a prospective, before-after quasi-experimental study looking at ED LOS for surgical consult patients after an e-mail intervention. The study was submitted to our institutional review board and a determination was made that no further review was required.

Setting and Selection of Participants

The study was performed in a 55,000 visits/year Level I trauma center and tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult via

Results

A total of 916 patients had surgical consults placed during the study period. Of these, 459 were before the intervention, and 457 were after the intervention. The mean age of study patients was 55.1 years (95% CI 53.3–56.9), and 49% were male. There was no significant difference in age, severity, number of consults, or disposition between the two groups (Table 1). There were slightly more males in the before vs. the after group, however, this is likely not clinically significant. The median LOS

Discussion

Although quality improvement processes are well described in the business as well as medical literature, they both rely on continuous, high-fidelity data that can be automatically collected and analyzed. The optimal method to deliver this type of data to decision-makers in health care has not previously been described. Our goal was to describe a process of delivering actionable data to decision-makers that would be easy to implement at any institution.

Daily performance metrics were able to help

Conclusion

The results of this study suggest that a daily performance metric e-mail is effective in reducing consultation times and LOS for surgical consult patients. Our results suggest considerable potential for this simple and inexpensive method of driving process improvement for ED consultations. Future study is warranted to evaluate the generalizability across other consultation services and in different care settings.

Article Summary

1. Why is this topic important?

  1. Automated, systematic collection of process metrics is necessary to drive quality

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    In managing EDs, managers may have to deal with different performance criteria (i.e., indicators) that drive the establishment of improvement action with a view to ensuring quality in managing the patient service and treatment delivery processes. The criteria usually applied are: patient Length of Stay (LOS), patient Waiting Time (WT) and Resources Utilization, such as, use of physicians and nurses (Ahmed & Alkhamis, 2009; Bahadori, Jamil, Pejman, Seyyed, & Mostafa, 2011; Eskandari et al., 2011; Horng et al., 2013; Sinreich & Jabali, 2007; Vanbrabant et al., 2019; Visintin, Caprara, & Puggelli, 2019). However, many studies involving the area of ED management consider just a small number of criteria, while others, such as, productivity, efficiency of layout, working environment at the ED, Technology, Materials and Patient Safety are less used, being Patient Safety as one of the main objectives of an ED (Vanbrabant et al., 2019).

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Disclaimer: L.A.N. and R.E.W. both own stock in an ED information system company that is a derivative of the system at Beth Israel Deaconess Medical Center, which was used in this study. However, this study does not evaluate the ED information system, but instead a general approach that can be used by any ED information system to deliver actionable information to decision-makers to drive quality improvement processes.

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