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

Key performance indicators of hospital supply chain: a systematic review

BACKGROUND

Performance measurement is vital for hospitals to become service-oriented, operate efficiently, attract customers, increase revenue, and improve both clinical and non-clinical outcomes, enabling them to succeed in the competitive healthcare sector. Key Performance Indicators (KPIs) play a crucial role in monitoring, assessing, and enhancing care quality and service delivery. However, identifying suitable KPIs for performance measurement can be challenging for hospitals due to a lack of comprehensive sources. Although many studies have explored KPIs, few have specifically addressed performance indicators within the hospital supply chain.

OBJECTIVES

This systematic review seeks to identify and categorize the current knowledge and evidence concerning KPIs for the hospital supply chain.

METHODS

Seven bibliographic databases (PubMed, Scopus, Science Direct, Web of Science, Embase, ProQuest, and IEEE Xplore) were utilized in this research. The initial search identified 3661 articles; following a review of the titles, abstracts, and full texts, 32 articles were selected. Additionally, backward reference list checks were performed on the selected studies. Relevant studies were included based on the objectives, and data extraction was conducted using a form created in Word 2016.

RESULTS

A total of 64 KPIs for the hospital supply chain were identified. The performance indicators were categorized into financial (n = 37), managerial (n = 15), and clinical (n = 12) categories.

CONCLUSIONS

This comprehensive review successfully identified 64 KPIs, highlighting their potential to advance clinical practice and enhance patient care in hospitals. Further research is essential to establish a standardized methodology for KPI development within the hospital supply chain.

Operational outcomes of community-to-academic emergency department patient transfers

BACKGROUND

Many patients require inter-hospital transfer (IHT) to tertiary Emergency Departments (EDs) to access specialty services. The purpose of this study is to determine operational outcomes for patients undergoing IHT to a tertiary academic ED, with an emphasis on timing and specialty consult utilization.

METHODS

This study was a retrospective observational cohort study at a tertiary academic hospital from 10/1/21-9/30/22. Key operational metrics, including specialty consultations, were queried from the ED Information System (EDIS). Data were analyzed for temporal variation in operational metrics and consulting patterns between transferred and non-transferred patients, stratified by time of day and week.

RESULTS

During the study period there were 50,589 ED patient encounters, of which 3196 (6.3 %) were identified as IHTs. Transferred patients made up a larger proportion of patient arrivals in off-hours compared to daytime hours (p < 0.001). Transferred patients were more likely to be admitted to the hospital (76 % vs 35 %, p < 0.001), go directly to a procedure (6 % vs 2 %, p < 0.001), or receive a specialty consult (90 % vs 42 %, p < 0.001), regardless of the day of week or time of day. Relative risk of consults amongst transferred patients varied by service, though was particularly increased amongst surgical sub-specialties.

CONCLUSIONS

Transferred patients represented a larger proportion of ED volume during evening and overnight hours, received more consults, and had higher likelihood of admission. Consults for transfers were disproportionately surgical subspecialties, though few patients went directly to a procedure. These findings may have operational implications in optimizing availability of specialty services across regionalized health systems.

Interventions to improve consultations in the emergency department: A systematic review

OBJECTIVES

Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process.

METHODS

Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted.

RESULTS

Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I²  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied.

CONCLUSIONS

The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

INTRODUCTION

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED.

OBJECTIVE

To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT.

METHODS

The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume.

MEASUREMENTS

The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours.

RESULTS

Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001).

CONCLUSIONS

The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Improvement through Small Cycles of Change: Lessons from an Academic Medical Center Emergency Department

This article describes the experiences of a quality improvement team that used small cycles of change to improve the emergency department (ED) of an academic medical center. The role of EDs in the provision of healthcare continues to increase in importance. ED bottlenecks contribute to long waits and diminished outcomes for ED patients as well as more system-wide issues, such as inefficiencies in inpatient admission processes. The purpose of this "ED Operational Efficiency Project" was to reduce lengths of stay (LOS) for low-acuity patients. The team used lean management techniques to both improve services and shift the ED culture to prioritize continuous quality improvement. The goal to reduce LOS by 30% was met as the result of several inter=related projects (or small cycles of change). Key lessons include monitoring metrics, communicating with teams and target populations, learning from initial failures, using small wins to increase momentum, and anchoring changes.

Ethnographic analysis on the use of the electronic medical record for clinical handoff

The objective of this study was to understand the social elements of clinical and organizational interactions of the key stakeholders in the specific context of an electronic dashboard used by the emergency department (ED) and inpatient medicine teams at the time of clinical referral and handover. An electronic handover function is utilised at the ED-inpatient interface at this institution and has given clinicians the ability to better communicate, monitor the department and strive to improve patient safety in streamline the delivery of care in the acute phase. This study uses an ethnographic qualitative research design incorporating semistructured interviews, participant observation on the ED floor and fieldwork notes. The setting for this research was in the ED at a tertiary University affiliated hospital. Triangulation was used to combine information obtained from multiple sources and information from fieldwork and interviews refined into useable chunks culminating in a thematic analysis. Thematic analysis yielded five central themes that reflected how the clinical staff utilised this IT system and why it had become embedded in the culture of clinical referral and handover. Efficient time management for improved patient flow was demonstrated, value added communication (at the interpersonal level), the building trust at the ED-inpatient interface, the maintenance of mutual respect across medical cultures and an overall enhancement of the quality of ED communication (in terms of the information available). A robust electronic handover process, resulted in an integrated approach to patient care by removing barriers to admission for medical inpatients, admitted via ED. The value proposition for patients was a more complete information transfer, both within the ED and between departments.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions

Objective

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

Methods

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

Results

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Conclusion

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

Reasons doctors provide futile treatment at the end of life: a qualitative study

OBJECTIVE

Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life.

DESIGN

Semistructured in-depth interviews.

SETTING

Three large tertiary public hospitals in Brisbane, Australia.

PARTICIPANTS

96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling.

RESULTS

Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care.

CONCLUSIONS

Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.