And now I would like to introduce our speaker to get us started this morning. Dawn Isaacs is a registered nurse who joined the Moss Adams Healthcare Performance Excellence Team after serving as a hospital nursing leader for more than 10 years, providing clinical expertise and operational guidance to a variety of teams. Dawn's area of expertise is in the emergency department, where she helps organizations improve left without being seen rates, door to doctor times, and overall emergency department boarding hours. We thank you so much for being here with us this morning, Dawn, and we invite you to go ahead and get us started. All right, well, thank you, Lindsay, and thank you, everyone, for joining. I know this is a hot topic lately, just knowing the burdens of the emergency department, so I do love spending time talking about it, and I've given this webinar a few times now. I always tell people that it's really never the same webinar twice because I kind of start, I can talk in circles and I can talk all day. So I do hit some of the high points, if you will, that most emergency departments are struggling with. So, yeah, we'll get started. So, yes, I am a registered nurse. I work as a consultant now for Moss Adams, but I did work in a large hospital system where we saw about 100,000 patients in the ER a year, level two trauma center. I was the nursing director there for years, so I have plenty of experience in battling some of these things that we're seeing today. So we will spend time just really talking through the patient journey from door to dock to discharge. We'll spend time on borders and things like that that are really impacting your emergency department today. So, again, the overview, throughput, that's really the hot topic. Throughput, long length of stay, left without being seen, overcrowding, those are the things we're going to talk about in detail. I'm going to give you some ideas, some solutions on how you might go about taking a closer look at those things in your department and how they all kind of tie together. So front end triage, that's where I'm going to spend some time as well. I do believe that that's where a lot of emergency departments can go wrong, if you will. So we're going to talk about what we can do to make some of those changes as well. Best practices and then also some productivity and benchmarking. There are some new tools out there for that. So you want to make sure with our borders we're doing that accurately today. So the current reality, you know, this slide, I could probably have it go on and on. The current reality is the aging population, exacerbation of acute health care conditions, of course lack of primary care, community resources, those that work in the emergency department know all of these things. We know that COVID really did exacerbate some of the issues that emergency department has today. So now everybody's trying to kind of get back on track, if you will, now that the pandemic, so to speak, is over. Of course, we're still seeing COVID patients and that certainly can still be time consuming when you see those patients due to the PPE and things like that that staff still need to wear. But more or less, we're not having to make any major changes to workflows due to COVID anymore. We're going to talk about fast track or what I call low acuity patients and how you can make sure that we're separating those patients out as they come into the emergency department. And staff shortages and turnover, we're not going to really spend a lot of time on that. I know that that is certainly an issue. So I wanted to make sure that I recognize that it is an issue, but not really going to spend much time on some of those ideas that would be probably for a later session. So this is just the patient journey. I like to just have a visual because when I'm working with a patient or if I'm working with a client, we need to start from the very beginning. And the very beginning is when the patient arrives in the emergency department. And we've all probably been a patient in the emergency department or even if you haven't, you've been with a loved one, a family member. So I think it would be easy to say that all of us have been to an emergency department and you've either had a great experience or you haven't had a great experience. But a lot of times the experience is really encompasses and is related to time. So, you know, when you're thinking, oh, gosh, I think maybe we should go to the emergency department. I wonder how busy it is. How long am I going to be there? That's always like the key driver in your head when you're thinking, oh, gosh, we got to go to the emergency department. How long is it going to take? So we've all been there. When the patient arrives in the emergency department, two things happen. Your quick reg or registration, that means that your name, date of birth, all those things are getting put in the system. And you're getting triaged at the same time. That means a front end nurse, a registered nurse typically is out there seeing the patient and we're getting your chief complaint. Why are you here into the system so that everybody can see there's another patient here and this is why they're here. So that can happen in tandem. It can happen separately and we'll talk a little bit more about that. The main thing in the middle is a medical screening exam or an MSE. That is done by a qualified medical professional, a QMP, typically a provider, a physician, or it could be a nurse practitioner, a PA, could be a sexual assault nurse. Whoever your organization has, you know, made an actual qualified medical professional, your bylaws will state that. So it can be more than a physician, but typically when a patient arrives in the emergency department, they're coming to see a doctor. And the medical screening exam is the key to everything kind of rolling through the emergency department. So patient arriving and asking for care, asking to be examined by a provider is the key in the emergency department. Then, of course, a physician's going to, you know, dictate a treatment plan and a provider disposition. So this is just really high level. This is how it happens. This is what you've seen when you come in. You're registered, triaged, seen by a physician, discharged. But we know along the way there are all kinds of areas of risk. You can leave at any point as a patient. And when you're working in the emergency department, that's one of the things you want to make sure doesn't happen. You don't want your patients to leave once they've arrived. There can be a lot of risk associated to that. There could be potential EMTALA violations. There's a lot of regulatory things that kind of go on in the emergency department. So you want to mitigate the risk along the way through all these steps. And a lot of ways to do that is really to make sure that we're cutting down on some of our time elements. So let's dig into some of those. We know that the consequences of throughput, this is all just intermixed. You know, overcrowding causes patients to leave. If you have too many patients boarding, then you have capacity issues and patients leave. So everything is just kind of a mix that happens. One thing is kind of causing the other thing. So let's talk about overcrowding. What is overcrowding and what is the root cause of it? Well, we talked about the current reality. That's part of the overcrowding is that there's just too many patients right now. Acute exacerbation of illnesses, aging population, those kinds of things. But we also know that overcrowding in an emergency department is specifically because of what we call boarding. Or you may be heard of it as being called holding. We used to call it holding years ago. Now we've really turned it over to the term boarding. And boarding is really defined as when an admission order is placed on a patient in the emergency department, but there's no room for them to go. So your inpatient hospital beds are completely full or they're not staffed. So either one of those things could cause a patient to be held up in the emergency department or boarding. So this can also happen, not just in the emergency department. It can happen in your cath lab. It can happen in your PACU. It can happen in other places where boarding has become kind of a norm, a little bit more of a norm. It happens more in the emergency department than anywhere else. But boarding basically means that the patient has been admitted. They need a bed upstairs, but there's nowhere for them to go. So they're stuck in these ancillary recovery areas or an emergency department. So of course, your length of stay in your inpatient areas, slow discharge process, things like that really can be some of the root cause of the overcrowding in the emergency department. But when I work with folks in the emergency department, we try to like segment that separately. So boarding and inpatient capacity issues are really something that I like to take care of separately. Because it's something that the emergency department staff providers and physicians really can't control. They can't control if there's a bed ready upstairs. They can't control if there's staff up there. So we really need to focus on things that we can control within the emergency department itself. So some of those things are the overall length of stay. So your discharged patients, you know, the majority of your patients in an emergency department are discharged. So depending on what your statistic is, but it could be somewhere around eight out of 10 patients. So again, eight out of 10 patients or 80 out of 100 patients, however many you see in a day, should be discharged. So that means you control that time. So what do you do to like shorten that time up? Because again, time is really the key in an emergency department. It keeps staff safe because patients are turning through. All patients are being seen. They're not leaving and coming back later, sicker or what have you. You're not having any regulatory issues if you're really seeing your patients. So let's talk about your overall length of stay. This is a metric that anybody that runs an emergency department should know. Overall length of stay. Now there's a discharge length of stay and there's an admitted length of stay. And there is very key benchmarks for these numbers. I usually follow everything related to the Emergency Department Benchmarking Association or the EDBA. They're considered the gold standard in the emergency department on any type of benchmarking. So anytime I throw out numbers, I'm going to give you an average of what the ED Benchmarking Alliance is putting out there. Now if you're an emergency department that's a part of the EDBA, that's great. You can do that for a pretty cheap price where you can submit your data to the alliance and then you get access to all of their data. So the data itself, just to talk a little bit about that, is classified out differently based on number of patients that you see in your emergency department annually. And it's usually broke out in 20,000 increments. So there's 40 to 60,000 patients a year, 60 to 80, and then greater than 80,000 patients a year. Then it's also broken out into level one trauma centers and it's broken out into academic medical centers. So usually if we put together a high level benchmarking for you, I'm going to be able to put those numbers in so that we're comparing apples to apples. I'm not comparing a level one trauma center that sees 120,000 patients a year to an ER that sees 50,000 patients a year. So do know that that data is out there so that you can make sure that you're benchmarked appropriately with other like facilities across your state or even the nation. So when I talk about door to doctor time or your first evaluation time or your medical screening exam, those are kind of all the same type of terminology. Again, that's why the patient's there. So they've come in, they've been triaged and they're looking to have that medical screening exam. This should be very, very quick, as quick as you can make it. So again, depending on capacity, your trauma level, things like that. You should be able to see a patient, I like to say in 20 minutes. So a patient should be arrived and seen by a physician within 20 minutes. Again, I can give you specific data points based on where your ER is at. But if you're anywhere like 45 minutes to an hour or whatever it may be, you're way off the mark. That's why patients are leaving your organization. They're waiting too long once they arrive to see somebody and to have things moved along. So the first metric that I should maybe say the second metric that you should look at as a director or whoever as a leader in the emergency department is your overall length of stay and then your first evaluation time. How long does it take from a patient to arrive to be seen by a provider? And arrival time is not triage time. Arrival time is the time the patient steps over the threshold of the door. Because it might be a few minutes before the patient's triaged or in some instances, it could be a really long time before the patient's triaged. So it's arrival, patient stepped over the threshold of the door to the time that the patient has seen the doc. I'll say doctor just to make it easier, but it's really your qualified medical professional, which might be your mid-level nurse practitioner, PA, what have you. So make sure you have goals related to this. What is the metric? And if it's not where it needs to be, you know, set some new goals, have a 10% improvement or what have you, and start putting together some ideas to make that happen. And I'll give you some ideas on that as well. So patient sat and staff satisfaction, they kind of go hand in hand as well. I can tell you as you start to improve your overall length of stay, if that's one of your issues for patients, then you'll just get this incidental improvement in patient satisfaction. You won't even have to focus on it and do things like that. Just to get patients in and out quicker, they will be happier. So again, just focusing on length of stay will make everyone happier. And it just removes those barriers for staff too. So they're just overall happier as well. So left without being seen, that is a publicly reported data element. So is your overall length of stay. Those are two data points that are on the CMS website. I could look up your hospital today. Of course, it's in the rears. It's usually, I think it's nine months to a year behind now. They just updated it the other day. But you can look at it and then know that others can look at it too. So left without being seen, if you're someone that's looking to improve revenue, and of course you want your patients to stay, right? This isn't all about the numbers. Because when I talk about improving the numbers, we're talking about improving the care for your patients in your community. So I don't want to lose sight of the fact that all this is for the patient. But we don't want our patients to leave. And revenue is typically walking out the door when patients leave. And you know, I've had staff say, you know, they're homeless, they weren't going to pay anyway, what have you. And you know, I like to say that that's not necessarily true, because a homeless person isn't going to go to your urgent care because they don't have any money up front. And so, you know, your person that doesn't have any sort of primary care, they're going to stay. They're not going to leave your hospital. So you should know what your publicly reported data element is on this. And you know, the goal is really to have it be less than 1%. And I can tell you with COVID and the EV Benchmarking Alliance, it has really, really escalated over the last few years. Now everyone again is starting to get back on track. But your goal should really be to have it be less than 2%. Less than 1% is better. Now I was at an organization on the East Coast as a consultant and the left without being seen rate was 15%. And they saw about 100,000 patients annually. So you're talking about a lot of patients daily walking out the door that have walked in your door. That is not something again that you want for the risk factors for revenue, those kinds of things. So this is something you want to take a close look at it. And again, what's the root cause? Well, typically the root cause is is too slow. It's linked to stay. So how does it impact your bottom line? Well, if you go to the American College of Emergency Physicians, ASAP, they have a left without being seen calculator. And I have a, I have a, let me skip to this picture. It's actually right here. And I can go back, but I wanted to show this. This is the ASAP calculator. And you can put in your, and this is taking a few assumptions and putting it in here. But if you have your actual data, you can list it there. Your total number of ER visits, how many are admitted for the year? There is a standard on that as well. Most organizations admit about 20% of their patients. So, you know, you can make an assumption. I made an assumption on that and put in 20%. And then, you know, then how many are discharged? Then of course that's subtracted. And then how much revenue is on an admitted patient? You know, 10,000, that's actually probably less than what an admitted patient is, but it's good to keep the numbers low. And then a discharged patient, you can put that in there as well. I put 500. That actually might be a little generous, but again, you can put all this in here. And the big thing is the change in left without being seen. So, say if you saw 40,000 patients a year, but you needed to improve your left without being seen by 2%, that's a $1 million, you can see at the bottom, revenue enhancement. So, left without being seen is something that you really need to focus on. If that's something that's an issue for your organization, again, if you're more than 2%, and again, you heard me say that less than 1% is better. But this would be a focus that I would have your organization take a look at. So, we're going to go back a little bit. Again, that was the ASAP calculator, and you'll be able to get these slides and you'll be able to see that. So, let's talk about the front of the house, the arrival process. So, we're going to talk about how you start improving these things, the length of stay, the left without being seen. Again, they go hand in hand, because if you improve your length of stay and some of your timely elements, your left without being seen will improve. So, your triage, you heard me talk about this. This I'm super passionate about, especially being a nurse. Triage is the key. I like to talk about Chick-fil-A. So when you think about triage, or you think about Chick-fil-A, so you see a hospital and you come in, and typically there's one nurse sitting at triage. And there might even be a lineup. You might be standing in line just to be triaged, because there might be several patients that arrive at the same time. Not uncommon at an ER at all. Well, what does Chick-fil-A, a fast food restaurant, what do they do differently than a lot of other fast food restaurants? Well, they come out. There isn't like one window. There isn't that one bottleneck. They come out. They have multiple people coming out. So that is step number one. If you have a bottleneck at triage, and you often have times where your arrival patterns are several people that come at once, triage should be very, very quick. Your nurse that is working triage, or nurses, you might need more than one if you're a large organization that sees a lot of patients. They need to come out, and they need to make sure that they are really paying attention to the arrivals of the patients that come in the door. Because remember, the start time isn't when the nurse triages you. Your arrival time is when you cross the threshold of the door. So triage should happen pretty quickly within the first few minutes of coming in through the door. Again, think of Chick-fil-A. You have to have a plan. You can't have that one window bottleneck. It has to be somebody else coming out. And I'm not going to tell you who that person is. That's something that from an operations design, you have to figure that out. But I will tell you that somebody has to come out and help. Maybe it's a charge nurse. Maybe it's, you know, you change up nurse assignments, whatever it may be. But that is key number one, is not to have a true bottleneck out at triage. And again, the plan should be to make sure someone else comes out. You have to have someone else come out, because there's just no sense in having a bottleneck out there. The risk is really high out there as well. One of the things I always want to make sure that people keep in mind is when a patient passes the threshold, they come through the door, you have to know that the patient has actually arrived, that someone has arrived. So what if that patient wanted to use the restroom in the waiting room instead of waiting in triage for those few minutes? They go into the restroom and they collapse. And you didn't, as the triage nurse, even pay attention that the person went in there. So once there's a point where the patients are kind of in that overwhelming phase, the nurse is overwhelmed out at triage, you have to have your mitigation plan. You have to have a plan for that and bring someone else out there. So that's not a risk point. There's EMTALA violations that happen out there. And I could go into EMTALA. Most of the time, your director, whoever your operations person in the ER is, is very well versed in that law. And if they're not, they should be. But you want to make sure that the patients are seen. They're not walking in, seeing a line, walking out, going to your competitor, and then complaining. Those are the things that can really bring EMTALA to light. So who can perform triage and how do you validate? I would highly, highly recommend that only a handful of nurses in your department are triage nurses. So this is, this is not a free-for-all. This is not you have a hundred staff in your department and 90 of them can, can do triage. This is you have a hundred department or a hundred RNs in your staff and 10 of them do triage. This is a very specific skill set. I highly recommend that they have education for it. There is education out there for it. The Emergency Nurses Association has a, has a triage tool that you can use. That's another one of my kind of what I call gold standards with the ED Benchmarking Alliance. The ENA is the other society that I follow to stay really up, up and coming up the new information. So make sure that your triage nurses are educated. They're usually experienced, which is wise. And they should probably work short shifts out there, even though most nurses are 12-hour shifts, which is good. When I say short shifts, it means your triage nurse should probably be changed out at least every six hours. So you're going to want to flip them with somebody in the back because you can get overburdened by triage. And you can get what's called triage drift, where the nurse is no longer just paying attention to all the details out front. They get really kind of, you know, that alarm fatigue, if you will. So I always recommend that a triage nurse is switched out every six hours. You could even do it every four hours. And that doesn't mean that you have a different shift assigned to them. It just means that they still work 12s, but they only work the first six up front. And then the nurse in the back, they flip type of thing, just to make sure that your triage stays really accurate. And they're on top of things out there. Again, one of the biggest risk points in your emergency department. And then you validate it. You go back and you have somebody do some audits on your triage nurse to see, you know, did they miss anything? Were they not doing it timely enough? I say that triage should only last two to three minutes. So if your triage nurse is spending more time or your organization has put questions up front in the EMR that a triage nurse needs to ask, but really does not need to ask, they all need to be taken out. So I would highly recommend that you look at your triage questions to make sure that only the necessary ones are in there for an ER visit. You don't need to have all the questions that the organization wants you to put in there. You really just need to keep it very, very streamlined, very focused, and it should only take a few minutes. So use of standard orders or provider and triage. I'm going to skip that and come back to that. That is one solution. It's a complicated solution, but it definitely works. Hallway beds versus waiting room and then door to dock times. We talked a little bit about that. So here I talked a little bit about triage and how important it is to make sure that the triage is done well. And just to talk a minute more about triage, triage we follow typically most organizations follow what's called ESI, emergency severity index, and it's one through five. One being your most critical, usually a resuscitation is in progress. Two being urgent, the patient is sick. Three is the majority of your patients. When you think of an ESI level three, you could think of abdominal pain. We have a lot of abdominal pains that come in. Those are what you would consider an ESI three. And then you have your ESI fours and fives. Those are your low acuity or fast track patients. Those are patients that come in that could go to an urgent care, but chose not to for whatever reason, and that's a battle we're not going to battle. But they might have sore throat, ear pain, dental pain, need a med refill, those kinds of things, an animal bite that they would come into the emergency department for. So that's the ESI one through five. The other triage level is a Canadian triage level. We don't see it in the United States that much anymore, but it is still out there a little bit. But when the nurse, the nurse is the one that picks the level one through five, and then that really dictates where your provider is going to see the next patient. Because remember, it's not a restaurant. It's not first come first serve. Providers see patients based on typically the ESI level. So if you're a resuscitation in progress, then that'll be an ESI one, and a provider typically should see you within the first couple minutes of arrival. And then so on. So if the ones and twos are coming in, and the threes and fours and fives are coming in at the same time, the ones and twos of course are going to be seen faster. So that just gives you a little context about how the triage process works, and why it's important to make sure that you do it timely, quickly upon arrival, and accurately. You don't, you don't want to miss something out there and have your doc, you know, go see a different patient or what have you, and then there is actually a sicker patient that needed to be seen. So that's why it's key to make sure that your nurses are well educated and experienced up there. Triage and quick reg, this is something that you really need to take a look at with patient access. So normally I see the registration process is owned, if you will, by patient access and not the clinical folks in the emergency department, not your nursing director or nurse manager, which is totally fine. But you need to talk about how quick reg is done, or the registration process in general. We don't want reg to be taking up a lot of time out there either. So reg either needs to work with your nurse and do the quick reg and triage together. Quick reg could go first to get the patient in the system and then go to triage. There are a number of different ways, but again, this is something that needs to be looked at to make sure that registration is not slowing your process down on patient arrivals. And there really is only a few key things that need to be put in the system when a patient is registered. So you shouldn't be taking a long time taking a patient's phone number. That is not a part of quick reg. Quick reg is, you know, patient, date of birth, so those things so that you can identify the patient, especially if they've been in your system, to make sure you have the right patient. But the rest of it can be done later. And EMTALA, again, talking a little about EMTALA, you cannot do a full registration on a patient until the medical screening exam is done. So you really can't ask any further questions, especially payer source, until the patient has seen the provider. If they do, if they're asking those questions up front before they've seen the MSC is done, the provider, that is an EMTALA. So that's another piece that patient access has to be very aware of. They might think, oh, I have a couple minutes. I'm just going to finish the full reg up front. There's nobody behind the patient. There's no wait. No way. They cannot do it. The patient has to be seen by the provider before a payer source can be put in the system. So you have to keep those lines clean and make sure that registration knows their part as well. Now, I've seen lots of places where the charge nurse or the triage nurse can go ahead and register the patient. And that's perfectly fine, especially if you're not an ER that sees a high number of patients. And it's not, you know, a couple hundred patients a day. It's, you know, the 40,000 maybe. You might not need both those people out there. So again, just some different ideas to make sure that things are happening timely. So let's talk a little bit about standard orders or provider and triage. These are two different ways to really improve that overall length of stay and make sure that the patient is getting care timely. So standard orders are something that can be put in by a nurse when the patient meets specific criteria. So say a patient arrives, they're put in the system by REG, they're triaged by the nurse, and then perhaps there's another nurse or your triage nurse could drop some standard orders. We call them nursing standard orders. Some examples of that might be if a patient comes in with a sore throat and a cough, and you know it's flu season. Your community has said, yep, it's at this certain percentage in the community. We know it's flu season. And then your organization can approve, usually by a medical executive committee or what have you, the standard order that allows a nurse to perform a flu swab up front without a provider ordering it. So that would be what's considered a standard order. Some of the other standard orders that are really obvious is a patient that comes in with, you know, crushing chest pain. Well, an EKG is a standard order. We know right away that patient is there for chest pain. They've met criteria, and you can get an EKG. So there's a handful of orders that can be approved by an organization's medical committee, however that works in your area, that a nurse can go ahead and put those orders in. So that means that we're not waiting. There's not time in between triage to seeing a provider. The nurse has identified these key things. They've met criteria, and the next step, the lab test, what have you, can be started. So I would highly recommend that. You know, your abdominal pains, it might be a urinalysis, things like that that take a while. If you can get those up front within a few minutes after triage, again, that's going to really, really decrease your length of stay or your back-end time if you can get some of those tests done up front. So those are some ideas for standard orders. Now, I will warn you that these have to be written very well. The Joint Commission gets a little itchy about these. They usually do take a good look at them. Any of your regulatory bodies will take a pretty good look at them just to make sure that your nurses are not practicing outside of their scope and using these specifically as standard orders where the patients have met criteria. So usually, someone that's really well-versed in the ER and the standards, Joint Commission, things like that, should be the one writing these. And then, of course, probably in tandem with your medical director down there. So that's one idea. PIT, we're seeing this more and more. Some people, it works really well in ER. Sometimes it doesn't, and I understand that. But it would be something that I would recommend. So PIT is a provider in triage. So this might be that a provider, a mid-level, what have you, come out to the triage area near the nurse, and they evaluate basically immediately. So the patient arrives, maybe they have abdominal pain, you know, so they're not, it's not an urgent case, but somebody that needs, it's going to need some testing, perhaps lab, ultrasound, things like that while the nurse triages them, puts them, the ESI level in, they're probably an ESI level three, but a provider is right there and can do a quick evaluation and order the ultrasound and order the lab tests. And then the patient could even perhaps go back to the waiting room or what have you, and the lab and the radiology could come out and get the patient, and the patient could start to have these tests completed before they get seen in the back, if you will. So the the providers in the back then, once some of those results start coming back, will be able to see the patient and say, oh yep, you have a kidney stone, or you have, you know, you need to have your gallbladder out, or what have you. But those tests are being performed in that time frame where normally, you know, it's just a lot of lag time. So provider and triage is super important. If you're an organization that sees a lot of patients, it's something that's pretty common these days that you'll see a provider out there. A lot of times it might be a mid-level, which, you know, again, I've seen it work both ways, where sometimes it works well, sometimes it doesn't. But definitely if you put a provider out there, it will, it will decrease the length of stay for patients, because remember, that's why they're there. They're there to see a provider for whatever ailment they might have, and if they're seeing them timely, and tests are being performed right away, then they're not going to be there very long. And then that really improves, again, staff morale, patient satisfaction, it cleans up your productivity, and things like that. So you heard me mention putting patients in hallway, or back in the waiting room, or hallway beds. So this, again, is something I could really go either way on. I am, when I was a nursing director, I did not like to see a lot of patients in the waiting room. A waiting room is a super high-risk area. You heard me talk about a patient that walks in, uses the restroom, collapses, you know, you've seen it in the, in articles, in the news, where patients die in waiting rooms. Of course, we've done a lot since then to make sure that waiting rooms are safe. And you can use your waiting room, I'm not saying not to, but it has to be staffed. Can't have a triage nurse that's seen, I don't know, patients every few minutes, be able to keep an eye on a waiting room with 30 people in it. And that includes family, you know, you have to keep that sorted out too, are they family, are they a patient, or what have you. So if you use your waiting room, and your waiting room's busy, it has to be staffed. That could be with maybe a paramedic, an aide, just there has to be somebody out there reassessing, doing vitals, checking on people, crowd control, things like that. So I would only recommend patients sitting out in the waiting room if there's, if it's safe for, for both the patient and the nurse. We don't want to put the nurse at risk to be monitoring too much where things could go wrong. But hallway beds are something that's super common these days, unfortunately. If I had a choice between putting a patient in hallway beds or the waiting room, it would definitely be hallway beds. When you think of the front of the ER, we always talk about the front of the house, or, and then the back of the house, being triage, being that, that, you know, middle of the hourglass. So the patients are sitting out front in the waiting, then there's triage, and then there's all the rooms in the back. It's safer in the back. Even though it can be chaos, patients that go and sit in the back, maybe they're in a cart in a hallway bed, maybe they're in chairs, there's a lot of people back there. So if something starts to go awry, typically there's someone there that can catch it. They can see that, you know, a patient's color's changed, or, you know, if someone's trying to get out of bed, or what have you, it's just safer back there than leaving patients out in the waiting room, unless your waiting room is staffed. So I would highly recommend hallway beds, even though it's certainly not ideal, and we know that the ERs are very overcrowded these days. In my opinion, hallway beds are still much safer. And then let's talk about low acuity strategy or fast track. Some folks might say, yep, we have fast track, and if that's the case, I would recommend that you know the time of your fast track. Again, there's benchmarking elements that the EDBA has specifically for, again, your number of patients that come in. Fast track, the way to really improve this, again, fast track, I should go back and talk about is your ESI 4s and 5s. Low acuity examples are dog bite, again, ear pain, throat pain, bed refill, work release, those kinds of things. Um, so a nurse up front, your triage nurse, she's the one again, that's he or she is dictating, you know, sick or not sick. That's what triage is. You're either sick or you're not sick. Ones and twos are sick. Fours and fives are not sick. And three is the more of the majority of your patients that sit in the middle, the abdominal pain's not critical, but are going to need a workup. So all you're not sick, you're low acuity. They need to go to a really kind of a separate area. And I don't mean they need to be, you need to do a build and like completely physically rebuild something out, but you have to have the processes separated. You can't have a provider in the back seeing your resuscitated patients and the dog bite at the same time. It just doesn't work because of course your ESI one, your patient in full resuscitation, your, your doc could be in there for easily over an hour if the, if you're critical and then the dog bite patient sits there forever. And then your, you know, those patients are staffed. The nurse can't take any more patients. They're taking up room in the back. So it's just, that's one of your capacity issues. You need to be running a fast track and they're, they're stuck because of the staff that are taking care of both types of patients. So not only providers need to be separated from the fast track and the critical patients, but so do nurses. So I would highly recommend that when you have a fast track, that your nurses and your providers are only seeing fast track, low acuity patients. And then your other nurses and colleagues, providers are seeing your more critical patients because you, again, you can't over mix them. You can't have your nurse too. She's, he or she's always going to drift to taking care of the sicker patient than quickly getting the patients out that are there, you know, for something that's not critical. So if you, if you really want to be good at fast track, fast track patients should be in and out in 60 minutes. So they hardly need any lab tests, things like that, because we know lab and radiology, those kinds of things can slow you down because that's obvious, but usually fours and fives don't need things like that. So again, your triage nurse up front, separating the patients out sick and not sick, your fast track, your low acuity, your fours and fives should go to one area that maybe it's just a subset of room numbers. Again, you don't need to build a physical space because I know that's impossible these days, but should be taken care of by the specific subset of providers and nurses. And that's how you would execute that faster. And again, if you do it really well, 60 minutes should be your, your goal. Now, if your fast track time is like two and a half hours or something really over the top, because you're not running a fast track effectively, your goal should be maybe improved by 10% in the next month and so on. I showed you this again, you can pull that up to look at a revenue enhancement. If you're left without being seen as an issue. We talked about treatment process a little bit. Let's talk about lab and rad for a few minutes. So we know lab and rad, basically, if you're an ESI level three and above, you're going to get lab and radiology. So if you're an operations folks in the ER, you need to be talking to lab and radiology and their leadership too. You should know the turnaround times and you should know if you have an issue with something. If a patient comes in at midnight and they get a CT scan, how long does it take to get your CT result? Is that different than at noon? Does it take eight hours to get a CT result at midnight? And it takes four hours at noon. I can tell you both those times are off the charts. It shouldn't be that long. You should know the benchmark on what the goal should be on your turnaround times for CT, x-ray lab, all of those things so that you know if radiology and lab is one of your ancillary areas that needs work or needs collaboration, things like that to improve some of those turnaround times. Because if they're holding you up, you're going to have a really hard time improving your length of stay if your lab results or things like that are just way too long. So take a look at those as well. Especially if you're an organization that does strokes and things like that, those turnaround times, they all have specific elements that need to be met and you should know what those are and make sure that your teams are meeting those. And then boarding and EV holds. We haven't spent as much time on that because there are lots of things you can do in an emergency department to improve space. Again, if you're cleaning up your fast track and a patient, you know, maybe you get 20 level fours and fives a day and you take an hour of time off of each one of those patients, that's a lot of time you've just cleaned up. So again, that's time you've given back to your providers, your nurses, more space for the next patient to be seen, etc. I'm just taking a look at this to make sure that I've covered most of it. I want to talk about a couple things related to boarding and EV holds without getting too deep into it. So I want to talk about a surge capacity plan. So a surge capacity plan is really, there should be an internal one for an emergency department and an organizational one. And your internal surge capacity plan could simply be the pit method. So maybe it's, I'm just throwing out ideas, maybe during the early morning hours, patients are arriving at a normal pace. But then you have, you know, kind of the busy time of your day where it's like noon and patients start to arrive faster. So maybe at noon you start the pit method, or maybe when all your beds are full, you start the pit method. So those are things that you put in place that when my emergency department reaches X, we have this internal plan. Maybe it's the second triage nurse comes out because we know that we need more help out there, but it is some sort of plan that you have in place internally in your ER alone. Then there's a surge capacity that's more of an organizational one. Well, there is a NEDOCS calculator. It's the National Emergency Department overcrowding score. This is something that you can look up on Google. It is copyrighted and has been around for a while now. Your EMR will probably, I know EPIC and Cerner both, can create this score. Your IT folks can build it. So you can see as the emergency department gets busier, this calculator goes from green, yellow, you know, so on up to black. So basically it talks about how many patients are there, how long it takes to get a bed, the acuity of the patient. So when you get to maybe red or black, you have other areas in the organization that come to help you. So maybe lab sends an extra phlebotomist. Maybe the nursing area, instead of the ER taking the inpatients up to the area, the inpatient nurses now have to come down to get their patient and pull them up to their unit. There's things like that that you can put in place as your NEDOCS score rises. So that might be something that you could take a look at. And that way it's an organizational issue, not just an ER problem, because we know that the ER is kind of the band-aid to all of these things, but the whole organization needs to be committed to helping when the ER is in surge. So you could take a little bit closer to look at that and then see if you have procedures related to it. Let's see, I was just looking at the time. Other things that you could do, you know, perhaps you have providers that are, you know, that are a barrier to some of these things. You could implement a provider scorecard. Maybe your organization has that. You know, when you take a deep dive at your left without being seen, if that's an issue that you have in your ER, you might see that you have a lot of patients that leave on a certain provider shift. And it might be just simply that the provider is not quick enough, not fast enough, and not seeing patients timely enough, so patients leave. So you might want to do a deeper dive and see if it's related to a specific person. It may or may not be, but again, I know for sure if you have Epic, you can get a lot of these types of reports out of the system. Door-to-doc, you want to take a look at that and make sure that docs are being, are seeing patients timely, knowing that there are benchmarks related to that. And then door-to-decision, and what that means is when the patient has arrived, how long does it take the doc that's seeing the patient to make a decision on whether or not that patient needs to be admitted or discharged? Those are, again, timestamps and elements, workflows in your ER that you can control. Again, you hear a lot of the ERs complain about boarding and capacity and things like that. Some of those things are really out of the ER's control, but we want to look at things that what are, what is it that the ER can control and improve on, and then you'll see some of those other things just kind of get cleaned up as well. Length of stay, left without being seen, we talked about a lot of those things. Borders and productivity, I want to spend just a minute on this in case I have some finance folks on the call. So, back in the day, there was really no way to account for all of these borders. Now there is. So, the ENA and the ED Benchmarking Alliance have several methods that are now what they would consider best practices. The four methods are listed here. You can take a look at those. They're, you know, I'm sure you can find them in doing any type of internet search, but it does account for the borders and productivity because if you have 50 borders a day in your ER, you can't just, you know, have productivity based off of hours per patient visit if, if your borders are really sucking up some of your staff. So, there is a way that you can take a look at that and make sure that you're doing it appropriately. Now I have in the, in the second, third bullet here, the buffer method and the modified, modified visit method, those are the two I like the best. The buffer method helps set a target that uses border hours and the modified visit method calculates current productivity. So, I use the buffer method if you're using, if you're trying to set financial goals for the next year. You can look at some of your border hours and things like that and then the modified visit method is the one that makes your productivity more accurate today instead of, you know, looking back in the rears. So, you can take a look at that and then benchmark against others to see if you are kind of where you need to be. I'm going to maybe skip over this. This is just an example of how an organization wasn't using it correctly and it made their productivity look like they were in good shape when actually they were in horrible shape. They were at close to like, I can't remember, nine or more than 12 hours per patient with all the staff that they were sending down there. So, if you're not calculating your borders correctly, you actually might be super overstaffed in your ER. And then a couple things to note and then I'll open it up to Q&A. I would be remiss if I didn't talk about security for at least a minute. If you're an area that, any area really, in an emergency department where you're in a big city, gangs, behavioral health crisis, etc., security should be a very, very competent and visible part of your department. So, usually if I'm in an ER that has any remote patients that come in, like a lot, just if you see a lot of patients in a day, you're seeing a couple hundred, security should be down there. You should have a security guard probably 24-7, if not more than one. So, your staff will talk to you a lot about security if you're someone that's really busy and you don't have an active security department. So, it's a very, very volatile area and it's definitely needed. Clinical decision support. Are your EMR, EHRs, is it helping or hurting? We know that there's lots of pop-ups and things like that, that can really be more of a burden than help. So, do you have teams that are looking at these, making sure that if you have a patient in with sepsis or what have you, that the proper alerts are popping up, not ones that are annoying providers and slowing the process down. And then telehealth. Seeing this more and more specifically related to behavioral health or stroke is probably the two that I've seen the most. You know, maybe in off hours or what have you, if you have a behavioral health patient or a stroke that comes in at night and you want to administer TPA, you can get your neurologist on telehealth, things like that. So, those are some things that I always just want to add in there, even though it's not specific to improving your length of stay operations, etc. So, again, I work for Moss Adams. I'm a consultant. So, I like to come in. I always love to help folks. I kind of talked about some of the things I'd take a look at, work with some different teams. We also do make sure that, I always call this the whale, but one of the key things too is to make sure that you have staffing aligned to the demand. So, basically your patient arrivals, you shouldn't just have X amount of staff working this shift and X amount of staff working this shift just because that's their preferred shift. You should make sure that your staff are coming in at the proper times as your patient arrivals go up and down throughout the day. This is a pretty common arrival pattern for an emergency department. So, that's just another thing that we take a close look at. I think I'm going to end it there. I know that we only have five minutes left for Q&A. So, I want to make sure that if anyone did have any questions or comments, I gave a little bit of time here to just wrap it up. Perfect. Thank you so much, Dawn. I do see one question here in the Q&A before I address that one. If you do have a question for Dawn, go ahead and be typing that into the Q&A option found there at the bottom of your Zoom window, or if you don't see that option, you can, of course, utilize the chat to type in your question as well. Okay. So, this question asks, what happens when the nurse implements the nursing standard orders like a flu swab? If the swab is completed and resulted, the patient then leaves the facility and the patient was not seen by a provider. Would that be considered AMA or leaving without being seen? And is the provider still responsible for signing that flu swab order? Yeah, that's a good question, and it does happen. It happens with anything, even like an EKG. A patient thinks they're dying, they get an EKG, and then they leave. So, yes. Well, I should start by saying that the provider does still have to sign off on the order. Typically, what I've seen is that the medical director who has agreed to the standing orders, you know, whoever it may be, is the one who signs these standard orders who don't get seen by a provider, but I would mark that patient as against medical advice because an order has been dropped because the patient has met criteria. And so, there are, we're really calling it left without treatment complete now as the ED benchmarking uses, LW, wait, left without, LWTC, and AMA then goes into that metric with you're left without being seen. So, left before treatment complete is a whole other metric, but then AMA goes into that. So, we will see that at times where the AMA is actually really high in an organization, but that's not publicly reported. So, I'm not sure. Hopefully, I answered that, but you do see it. You can still bill the patient because they've been at least the quick reg for that test, whatever it may be, because that's another thing I know that sometimes the finance department gets nervous that you're going to drop standard orders, and then you're not going to get reimbursed for them. But if you follow the process to make sure a provider signs off on a mark a patient appropriately, you can still bill. Okay. Thank you so much for that. And if you do have a follow-up question, don't hesitate to let us know. Don, is your contact information included here in the slides? Yes, I believe it is. Yep. Perfect. Yep. Yeah. And please feel free to reach out if you, if anybody has any specific questions that I can answer or just wanted to talk through something, I'm happy to do that. Just know that really, again, we always talk about numbers and metrics, but know that it's really about the patient and really the staff as well. If you improve some of these things in your emergency department, then the overall staff engagement starts to climb as well. Although we know change is hard, they always see the changes as positive in time. Perfect. And Sean, I'm typing a response here to you in the chat. I see your hand is raised. So if I can help with anything, just send me a chat message here and I'm happy to help any way that I can. I did go ahead and post some information there for you all in the chat, just as a quick reminder that you will receive an email tomorrow morning. Just note that it will come from education, no reply at zoom.us. And so because it comes from that zoom email address, very often it does seem to get caught in your spam quarantine, possibly junk folders. So if you don't see that in your inbox in the morning, I would encourage you to go ahead and check those additional folders. Then if it's still not there and you just like to go back and access the recording of today's presentation, you can just use that same zoom link that you are using to join us for today's live session to also access that recording. And then just remember that the link to the recording will be available for 60 days. And then we do have an additional security measure in place so that we are protecting Dawn's intellectual property here. So when you click on that zoom link, it will prompt you to enter your information and then that will send an email to us to approve your recording access request. We do approve those very quickly, typically within just a few moments that we ask that you give us one business day to grant that approval. And then again you will have full access to the recording for 60 days from today's date. And then also included in that email will be a link to the slides that Dawn presented for us today. I did go ahead and provide that link there for you in the chat, so you'll have that as a resource now as well. And as she mentioned, her contact information is included there in those slides and I know she would welcome any additional questions that you have for her. So please don't hesitate to reach out. And then if we can be a further assistance or possibly maybe pass a question along to Dawn and her team, you can always reach us at education at gha.org and we'll be happy to get that over to her as well. Okay, I don't see any other pending questions at this time. So thank you all for joining us today and thank you so much Dawn for your time and information that you shared with us. We hope to have you all back with us for future sessions and I hope you have a wonderful afternoon. Thank you so much. Thank you. Bye-bye. Bye-bye.

Dawn Isaacs

healthcare consultant

emergency department operations

triage efficiency

patient throughput

left without being seen rates

nursing standard orders

COVID-19 impact

surge capacity plans