Description:
Medical College of Georgia (MCG) Health System offers comprehensive primary and specialty care facilities to provide residents in the 13-county region around Augusta with the most advanced medical care available. The MCG Medical Center complex forms the core of MCG Health System's facilities and includes a 520-bed hospital, an Ambulatory Care Center with over 80 outpatient clinics in one convenient setting, a Specialized Care Center housing a 13-county regional trauma center, and a 149-bed children's medical center.

MCG Emergency and Express Care Services consists of a 40-bed full-care trauma and emergency medical service. The Emergency Department is staffed 24 hours a day, 7 days a week by the emergency medicine faculty, all of whom are board certified or residency trained in emergency medicine, and by emergency medicine residents. In the past year, the MCG Emergency Department has cared for more than 76,000 patients.

Challenge:
To optimize patient flow in the emergency department in an era of unprecedented patient volume growth (10% per year), thereby improving the efficiency of service, customer satisfaction, and the quality of care.

Solution:
In 2003, a project was initiated to evaluate the efficiencies within the department and to provide recommendations on how to improve patient flow. A task force from various departments within the hospital, including administration, emergency medicine, pathology/laboratory, information services, and quality management, was assembled to perform the evaluation.

Among the key components in the study were:

• Track and analyze ED metrics
• Analyze correlation between ED patient volume and patient satisfaction
• Identify bottlenecks in the system
• Institute process consolidation and standardization protocols
• Improve staff training and proper delegation of tasks
• Optimize utilization of space within the work environment
• Enhance efficiency of verbal and electronic communication
• Streamline process automation

Benefits Realized:
In the evaluation process, the ED "experience" was divided into three segments and time frame goals were established:

SEGMENT #1: DOOR TO DOCTOR – 30 MINUTES
A key to the reduction in the time for the patient to see the doctor was to elevate the triage skill level. Toward that end, physician triage was instituted between the peak volume hours of 11:00 AM and 7:00 PM with advanced nurse triage outside of this time frame. The number of registration clerks was augmented during the peak volume hours and wireless laptops were installed for faster data input. In addition, nurses were instructed to remind physicians of patients waiting in rooms for more than 10 minutes.

SEGMENT #2: DOCTOR TO DISPOSITION DECISION – 50 MINUTES
According to Dr. Michael Shafe, Chief of ED/Trauma at MCG Health System, the goal for Segment #2 was to "reduce times for testing, treatment, and consultant evaluation." Drawing on experience at institutions such as the Massachusetts General Hospital¹, MCG installed a Nova Stat Profile® Critical Care Xpress point of care testing system in the ED to measure blood gases, electrolytes, glucose, lactate, and other chemistries. With the Nova CCX analyzer, all tests were performed directly in the ED with a turnaround time of just 15 minutes from blood draw to reporting of results.

In addition to the Nova analyzer, a Biosite Triage® Cardiac Marker System was installed to measure troponin, Creatinine Kinase-MB, Myoglobin, and BNP with results reported in about the same time frame.

SEGMENT #3: DISPOSITION TO ADMIT/DISCHARGE – 50 MINUTES FOR ADMISSION/10 MINUTES FOR DISCHARGE
Dr. Shafe indicated that the goal of Segment #3 was to "reduce all the steps to get the patient where they are going! The longer the patient occupies the bed in the emergency department, the longer it takes to provide care to another." The success of the admission portion of this segment was the availability of hospital beds throughout the institution. With the help of a newly created position of "bed flow coordinator" whose responsibility it was to manage bed flow throughout the institution, a 15-minute time frame was established for ED patient bed assignment from the time requested. Time to discharge was also tracked from the creation of the discharge order to the actual discharge.

Cost Implications:
While cost implications were not reported, Dr. Shafe points out that "the true cost of the lab test is the time it keeps another patient from being seen in the room." In the case of MCG, the rapid turnaround time most assuredly had an effect on cost reduction in their emergency services project.

¹How the Clinical Laboratory and Emergency Department Can Work Together to Move Patents Through Quickly. Lewandrowski, K., POCT in the ED, CLMA, Clinical Leadership & Management Review, May/June 2004.

This article is based on information provided in a presentation by the Medical College of Georgia at the American College of Emergency Physicians Scientific Assembly, Washington, DC, September 2005.