Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion

ABSTRACT

Objective: To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children’s hospital.

Methods: The study was conducted at a tertiary care children’s hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics’ service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient’s bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day’s discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times.

Results: For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM.

Conclusion: Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

KEYWORDS:

• Lean
• six sigma
• process improvement
• discharge time
• capacity management
• ED boarding

Acknowledgments

The authors would like to recognize the contributions made by the division of Pediatric Hospital Medicine at PSHCH without which, this project would not have been possible. They are: Drs. Justen Aprile, Marta Biderman, Patrick Lin, Margaret Mikula, Chris O’Hara, Brandon Smith, Nikki Waldstein, Ron Williams, and Heidi Wolf, and Lyndsay Gardener, CRNP. This project would not have been possible without the help from Brenda Ruhl, Manjula Narasimhan and Heather Boyle from the Department of Logistics. Finally, the author would like to thank the following for their thoughtful reviews of this manuscript: Drs. Barbara Ostrov, Harriet Nembhard and The Office for Scholarship in Learning and Education Research (OSLER).

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This article was not funded.