Background: Increasing Emergency Department (ED) stretcher occupancy with admitted patients at our tertiary care hospital has contributed to long Physician Initial Assessment (PIA) times. As of Oct 2019, median PIA was 2.3 hours and 90th percentile PIA was 5.3 hours, with a consequent 71/74 PIA ranking compared to all Ontario EDs. Ambulatory zone (AZ) models are more commonly used in community EDs compared to tertiary level EDs. An interdisciplinary team trialled an AZ model for five days in our ED to improve PIA times. Aim Statement: We sought to decrease the median PIA for patients in our ED during the AZ trial period as compared to days with similar occupancy and volume. Measures & Design: The AZ was reserved for patients who could walk from a chair to stretcher. In this zone, ED rooms with stretchers were for patient assessment only; when waiting for results or receiving treatment, patients were moved into chairs. We removed nursing assignment ratios to increase patient flow. Our outcome measure was the median PIA for all patients in our ED. Our balancing measure was the 90th percentile PIA, which could increase if we negatively impacted patients who require stretchers. The median and 90th percentile PIA during the AZ trial were compared to similar occupancy and volume days without the AZ. Additional measures included ED Length of Stay (LOS) for non-admitted patients, and patients who leave without being seen (LWBS). Clinicians and patients provided qualitative feedback through surveys. Evaluation/Results: The median PIA during the AZ trial was 1.5 hours, compared to 2.1 hours during control days. Our balancing measure, the 90th percentile PIA was 3.7 hours, compared to 5.0 during control days. A run chart revealed both median and 90th percentile PIA during the trial were at their lowest points over the past 18 months. The number of LWBS patients decreased during the trial; EDLOS did not change. The majority of patients, nurses, and physicians felt the trial could be implemented permanently. Discussion/Impact: Although our highly specialized tertiary care hospital faces unique challenges and high occupancy pressures, a community-hospital style AZ model was successful in improving PIA. Shorter PIA times can improve other quality metrics, such as timeliness of analgesia and antibiotics. We are working to optimize the model based on feedback before we cycle another trial. Our findings suggest that other tertiary care EDs should consider similar AZ models.

Background: In 2016 The Fraser Health Authority's Emergency Network established a priority to standardize patient access and flow through their 13 emergency departments (ED). A Model of Care (MOC) was developed after an extensive review of the literature and current practices across BC. Aim Statement: The ED Model of Care (MOC) specifies best practice expectations with respect to emergency patient access and flow. Rather than a ‘top-down’ mandate of expected practices, the MOC provided the opportunity for site-based teams to promote solutions that were ‘locally actioned and regionally enabled’. Measures & Design: ED Quality Improvement (QI) teams were developed at all sites. The ED Network developed a “QI Bootcamp”, a one-day course focused on imparting tools to drive improvements, providing a baseline understanding of how to launch and sustain local QI initiatives. Using Prosci's change approach, an emphasis was placed on using local ingenuity to implement plans, analyze feedback and diagnose gaps. This approach measured utilization of the changes to tangibly link initiatives and change to specific outcomes. As part of this strategy, an online scorecard was created to measure local results against best practice outcomes. The scorecard tracked quantitative access metrics such as ED Length of Stay (EDLOS), Left Without Being Seen rate, and triage time. Measures such as forming a QI team, identifying a QI project and completing a PDSA cycle were included in the scorecard Evaluation/Results: The MOC change management strategy was launched in May of 2018. By December 2018 all 13 EDs had formed a local QI team and identified a project. Twelve sites had completed at least one PDSA cycle and 10 sites had at least 75% of their members attend the QI Bootcamp. The scorecard displayed improvements in flow metrics. Highlights include the average arrival to triage time decreasing by 36% at one site, EDLOS for moderately ill patients decreased from 4.8 to 3.4 hours at another, and a community hospital had low acuity patient EDLOS decrease from 3.52 to 2.37 hours. Discussion/Impact: A standardized approach to patient access and flow in the ED (MOC), combined with the engaging grass roots approach to inspiring local innovation, allied with a concrete change management approach demonstrated significant results for patients accessing and moving through EDs. This pattern that is more likely to sustain itself because the results are felt and locally owned.

Introduction: Emergency department (ED) crowding and increased patient load has been shown to have an impact on physician decision making and patient mortality. As the volumes in Canadian EDs increase, so does the need to effectively prepare new learners for the challenges ahead. This study aims to determine which level of training varying teaching techniques should be employed to educate Emergency Medicine (EM) residents about ED management and flow in the age of competency based medical education. Methods: We designed a survey that contained a previously derived list of ED flow and management teaching strategies. We piloted and edited the survey based on feedback from operations and educational experts. A total of 21 teaching techniques were included in the final survey ranging from didactic teaching sessions to experiential techniques such as residents running the department with supervision. Then, we invited members of the Royal College of Physicians and Surgeons of Canada EM specialty committee, the Canadian Association of Emergency Physicians Education Scholarship Section, and the Canadian EM Simulation Educators Collaborative to participate in our survey. We analysed the results using simple descriptive statistics. Results: A total of 21 EM (38% female, 62% male) educators from 11 programs (78% of Royal College Training sites) responded to the survey, representing 7/10 provinces, with a mean years-in-practice of 15.2 years (SD 9.7). All respondents were involved in resident education; 66% had a current formal educational role, such as Program Director. Results showed a universal trend towards teaching flow and management skills later in residency. Participants endorsed 35.93% of teaching strategies for the “Core of discipline” and 39.65% for the “Transition to practice” stages of training. Didactic and observational techniques were occasionally considered acceptable at earlier training stages, whereas experiential teaching techniques were skewed towards the later stages of residency. Conclusion: EM educators from across Canada believe that most teaching techniques for flow are better suited for the later stages of residency training, with didactic techniques more suitable earlier on. This work will inform faculty development on managerial/leadership skills teaching in the ED.

Introduction: The number of emergency department (ED) visits across Ontario has increased annually over the past two decades leading to overcrowding and longer wait times. ED volume forecasting may provide insight to strategic planners regarding future patient volumes and the effects on health care resources. We investigated the pattern of ED use at the local health integration network (LHIN) level and developed forecasts using historical data. The forecasts were then used to examine the effect on acute care hospital bed requirements and the number of full time equivalent physicians needed. Methods: Aggregated data from the Canadian Institute for Health Information for the period 2003 to 2013 was obtained for each of Ontario’s LHINs. The total number of ED visits per year was first quantified by LHIN and then simple linear regression was used to forecast patient volumes in 2018 and 2023. The rate of hospital admission by LHIN was also calculated. We then used the forecasted volume, admission rate and the total number of acute care hospital beds by LHIN to predict the total number of beds needed by LHIN. Based on the forecasted patient volumes and the hours of coverage model, the total number of full-time equivalent physicians needed was calculated. Results: Over the study period, the number of patients increased from 4 to 37% among LHINs. Admission rates generally decreased from 2003 to 2013. Based on historical trends, all EDs across Ontario are expected to experience increased patient visits in the future but at different rates of growth. Depending on the rate of growth in ED visits, the number of acute care beds needed by LHIN is somewhat variable and affected by the proportion of alternate level of care patients. Given, the forecasted increase in patient volume, the hours of coverage model suggests that approximately 320 additional full-time equivalent ED physicians are needed across the province by 2023. Conclusion: Although all forecasts inherently have a degree of error associated with their estimates, strategic planners require some quantitative prediction of future events to develop initial plans. Through research, these predictions can be focused and refined. The results suggest that many hospitals will experience increased demand for services and will have to do resource allocation planning accordingly to ensure patient demand is met appropriately.

Introduction: The Physician Navigator (PN) is a novel position created to manage patient flow in real-time at a very-high volume emergency department (ED). When paired with an emergency physician, PNs actively track patient wait times, and direct the physician to see and re-assess patients in a particular order to improve measures of emergency department efficiency, and maximize patient flow. Anecdotal evidence has shown that PNs decrease length-of-stay times for non-resuscitative patients in the setting of increased patient volumes, and without additional nursing or physician hours. The objective was to study the operational impact of PN on emergency department patient flow. Methods: A 48-month pre-/post-intervention retrospective chart review at an urban community emergency department from September 2011 to September 2015. The PN program started on March 1, 2013. The main outcome is emergency department length-of-stay (LOS). Secondary outcomes include time to physician-initial-assessment (PIA), left-without-being-seen rates (LWBS), left-against-medical-advice (LAMA), and physician satisfaction rates. Autoregressive integrated moving average models were generated for Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether the impact was sustained over time. Results: Interim results are provided. 399,958 patients attended the ED during the study period. Daily patient volumes increased 11.2% during the post-intervention period. There were no significant increases in the number of physicians shifts/day, and physician hours/day during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.04 hours/PN (p<0.05), and 90th-percentile LOS by 0.14 hours/PN (p<0.05). For secondary outcomes, there was a decrease in overall average PIA by 6.37 minutes/PN (p<0.05), and 90th-percentile PIA by 8.29 minutes/PN (p<0.05). LWBS rates decreased by 40.8% (p<0.05). There were no significant changes in LAMA rates. Conclusion: The implementation of Physician Navigators is associated with significant reductions in LOS, PIA, and LWBS rates for non-resuscitative patients at a very-high volume emergency department.

Introduction: The Thunder Bay Regional Health Sciences Centre (TBRHSC) Emergency Department (ED) has experienced an all patient increase in visits ranging from 1.5 to 6% per year since 2004. As a regional referral centre with no dedicated pediatric ED, TBRHSC is the sole emergency provider. Given the rising visits, we have investigated the pattern of pediatric visits, rates of admission to hospital and for a subset of years the investigations completed. Methods: Pediatric visits from 2004 to 2014 were summarized for the TBRHSC ED. The pattern of visits was examined along with the rate of admission to hospital. We also investigated the trend in acuity over the study period. Laboratory and imaging data are purged 1 year after each visit and were not available prior to 2011 but were summarized for the remainder of the years to identify the rates of all investigations completed. Results: From 2004 to 2014 there was a total increase in visits of 7.5% with the average annual admission rate ranging from 5 to 6.3%. The month to month variability in visits over the study period was high with a minimum of 1292 in August 2004 and a maximum of 2488 in October 2009. Nearly all patients were either CTAS II, III or IV, with level III having the highest occurrence. The mean investigation rate was approximately 16, 0.8, 24, and 2.3% of patients having laboratory, CT, x-ray and ultra-sound completed, respectively. Conclusion: Pediatric patients are an important subset of all patients visiting the ED. They often require special resources and at the TBRHSC use specific treatment spaces. In addition, there is a limited number of pediatric inpatient hospital beds. Managers could use the timing of visits, number of visits and admission rates to examine resource use and the probability of exceeding capacity. This study also provides baseline information on the rates of investigations, especially imaging such as CT which can have long-term radiological consequences.

Introduction: The objective was to study the operational impact of an intervention comprised of simultaneous process improvements to triage, patient inflow, and physician scheduling patterns on emergency department (ED) patient flow. The intervention did not require any increase in ED resources or expenditures. Methods: A 36-month pre-/post-intervention retrospective chart review at an urban community emergency department from January 2010 to December 2012. The ED process improvements started on June 6, 2011 and involved streamlining triage, parallel processing, flexible nurse-patient ratios, flexible exam spaces, and flexible physician scheduling. The main outcomes were ED length-of-stay (LOS). Secondary outcomes included time to physician-initial-assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed on Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether there were changes in the trend between pre-intervention and post-intervention segments. Results: 251,899 patients attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.64 hours (p<0.001), and 90th-percentile LOS by 0.81 hours (p=0.024). When separated by acuity and disposition, there were reductions in LOS for non-admitted CTAS 2 (-0.58 hours, p <0.001), 3 (-0.75 hours, p <0.001), 4 (-0.32 hours, p=0.002), and 5 (-0.28 hours, p=0.008) patients. For secondary outcomes, there was a decrease in overall average PIA by 43.81 minutes (p<0.001), and 90th-percentile PIA by 91.39 minutes (p<0.001). LWBS and LAMA rates decreased by 35.2% (p<0.001) and 61.9% (p<0.001), respectively. Conclusion: A series of process improvements meant to optimize flow in the ED without the addition of resources was associated with clinically significant reductions in LOS, PIA, LWBS and LAMA rates for non-resuscitative patients.

Background: There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital (TWH) created a Neurovascular Unit (NVU) using resources from General Internal Medicine, Neurology, and Neurosurgery for patients with stroke and acute neurovascular conditions. Under resource-constrained conditions, the operational and economic impacts of the Neurovascular Unit were unknown. Methods: Retrospective patient-level data was studied from two years prior and one year post NVU implementation. Descriptive statistical analysis and non-parametric testing were conducted on the acute length of stay (LOS), alternate level of care LOS, total cost per bed-day and per visit, and patient flow within each medical service and hospital wide. Results: The median acute LOS per hospitalization for NVU-eligible patients decreased significantly (p=0.001). For Neurology patients, mean acute LOS decreased from 9.1 days pre-Neurovascular Unit to 7.6 days post and median acute LOS decreased from 6 to 5 days (p=0.002); however, mean alternate level of care LOS per visit more than doubled (from 1.6 to 4.1 days, p=0.001). For the Neurology service, the mean cost per visit decreased by $945, representing a 5% reduction (p=0.042) and the mean cost per bed-day decreased by $233, or 12.5% (p=0.026). Hospital wide, a saving of over C$450 000 was achieved. Conclusions: During the first year of operation, the NVU at TWH achieved decreased acute LOS per visit and lowered the total hospitalization cost per year for NVU-eligible patients. Addressing the issue of increased alternate level of care LOS could result in additional efficiencies.

In a time of increased patient loads and emergency department (ED) exit block, the need for strategies to manage patient flow in the ED has become increasingly important. In March 2002 we contacted all 1282 members of the Canadian Association of Emergency Physicians and asked them to delineate strategies for enhancing ED patient flow and ED productivity without increasing stress levels, reducing care standards or compromising patient safety. Thirty physicians responded. Their suggested flow management strategies, which ranged from clinical decision-making to communication to choreography of time, space and personnel, are summarized here.