A 5-year time study analysis of emergency department patient care efficiency

Study objectives: We conducted a 5-year time study analysis of emergency de partment patient care efficiency. Our specific aims were (1) to calculate t he main ED patient care time intervals to identify areas of inefficiency, ( 2) to measure the effect of ED and inpatient bed availability on patient fl ow, (3) to quantitatively assess the effects of administrative intervention s aimed at improving efficiency, and (4) to evaluate the relationship betwe en waiting times to see a physician and the number of patients who leave wi thout being seen (LWBS) by a physician. Methods: Seven 1-week ED patient flow time studies were conducted from Sept ember 1993 to July 1998 using identical study design and methodology. Patie nts presenting with complaints of chest pain, abdominal pain, vaginal bleed ing, and extremity injury were included to represent the level of severity of patient conditions seen in our los Angeles County hospital ED. The calcu lated time intervals representing the main phases of evaluation and treatme nt were (1)triage presentation to completion of registration, (2) completio n of registration to ED treatment area entry, (3) ED treatment area entry t o initial medical assessment, (4) triage presentation to initial medical as sessment, (5) initial medical assessment to disposition order, and (6) disp osition order to patient discharge from the ED. Total ED lengths of stay (L OS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient be ds. The effects of administrative interventions on the specific time interv als were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative i nterventions were implemented by a special interdepartmental continuous qua lity improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies. Results: Eight hundred twenty-six patients were included in the 7 time stud ies. The unavailability of ED and inpatient beds was associated with signif icant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increa sed from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a re sult of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal cri sis. The number of LWBS patients was closely correlated to waiting time to see a physician (r=0.79, beta=5.20, P=.033). Conclusion: Time studies are an effective method of identifying areas of pa tient care delay. In our ED, targeted administrative interventions apparent ly reduced the total ED LOS and improved overall efficiency. Despite initia l decreases in ED LOS, efficiency appeared to be adversely affected by redu ctions in nursing and physician staffing and increases in our patient censu s. The strength of the relationship between waiting times to see a physicia n and the number of LWBS patients suggests that decreasing waiting times ma y reduce the number of LWBS patients.