Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

LWBS and Door-to-Order Time

11/12/2015 12:30:16 PM | 3 comments

By Robert Schambach, RN; Pamela Stuart, MD; Melissa Lynch, MD; Nancy Farah, PA-C
Across the country, teams staffing crowded EDs are longing for more space. But the experience of St. Louise Regional Hospital in Gilroy, Calif., proves that the quality of an ED's care need not be limited by its size. The following is adapted from a poster presented at CEP America's 2015 conference.


At the St. Louise Regional Hospital ED, our team cares for 29,000 patients a year in very tight quarters. Our department has eight licensed beds and a waiting room capacity of 12. The only other rooms available are dedicated to triage and a small treatment area.
Despite these limitations, very few patients presenting to St. Louise were leaving without treatment. Then in mid-2014, volumes began growing much faster than expected. Beds were filling on most days. LWBS rates jumped from less than 2 percent to over 4.
ED Medical Director Pamela Stuart, MD, and Director of Emergency Services Robert Schambach, RN, recognized that the situation was potentially costly for the hospital. Nor did it represent optimal care for patients. To address the problem, we convened a working group of CEP America providers, ED clerks, ED nurses and hospital administrators.


By reviewing the available data, our team identified time-to-provider (TTP) as the number one reason patients were leaving without care.
Industry regulators define TTP as the length of time a patient waits before receiving a medical screening exam (MSE) from a qualified medical professional (QMP). From the patient's point of view, this is the encounter that really gets their care moving forward.
Placing a dedicated provider in triage (PIT) is a common best practice to improve TTP. But due to space and staffing constraints, this really wasn't an option for us. Nor was it feasible to place a registered nurse (RN) or allied health provider in the cramped waiting room to greet patients and immediately start the triage process.
Improving throughput within our limited physical space required thinking outside the box. Ultimately, our group identified two strategies to improve TTP and reduce LWBS rates:
  1. Add an additional triage RN during high volume hours.
  2. Change the culture of the department so that no patient is returned to the waiting room after triage without receiving an MSE and appropriate orders.
Number two was an unusual step. Traditionally, once an ED patient is triaged, they return to the waiting room until a bed opens up. This works fine so long as there are an adequate number of beds relative to patient volume. But when beds are scarce, this approach can delay an MSE and care by hours.
By adhering to this traditional model, we were placing absolute limits on our throughput and capacity. In addition, recent studies demonstrate that many ED patients do not require horizontal treatment. We needed a new, more flexible process that would expand our "virtual" capacity.
With this in mind, we began exploring an alternative concept to TTP, which we defined as "door to meaningful MSE with all appropriate orders." (This was an idea that our department had considered under its previous leadership but never implemented.) We reasoned that efficiency and capacity would improve if patients had a full MSE and all reasonably foreseeable orders completed during their initial provider encounter.
To facilitate this, our group set some new expectations. First, all patients would be triaged within ten minutes of entering the department. Second, no patient would return to the lobby after triage without seeing a qualified medical provider (QMP) for an MSE with all appropriate studies and medications ordered.
Whenever possible, the QMP would see the patient in the triage room. If this weren't feasible, the patient would be placed in a hall chair to await their MSE.
The proposed process naturally raised concerns about patient privacy. To address this, we created a new exam area off of the hallway. This was equipped with a gurney and could be curtained off as needed.
The most difficult part of implementing the new process was culture change. We were asking nurses and providers to step up the pace and make big changes to their workflow. We also needed lab and radiology personnel to begin pulling patients from the waiting room.
Through a series of meetings with stakeholders, we explained the "whys" behind the new process and sought to address concerns. Some rationales we found effective:
  • Patients come to the ED specifically to see a provider. Your prompt appearance means a lot to them.
  • Nurses can begin gathering data and enter preliminary orders, but the provider is the one who really starts care moving forward. And timely care is essential for patient satisfaction and safety.
  • Every minute that orders are delayed is unrecoverable within the ED operational cycle.
In addition, we needed to communicate the new process to patients. Those who had visited us (or any ED) recently would no doubt wonder why they were waiting in the hallway to see a doctor. To this end, we created some scripting to explain what we were doing, what to expect and the potential benefits.


Following implementation of the new process, LWBS decreased dramatically to less than 0.6 percent.

During the same period, "Door to MSE with all appropriate orders" fell to less than 30 minutes.

*June 2014 to October 2014 data is estimated, as we didn't track "door to QMP MSE with all appropriate orders" at that time.


The new process was successful in reducing ED walkouts, and we have continued to use and refine it. LWBS rates and "Door to MSE/Orders" times continue to improve as providers and staff become more familiar with the system and buy into the new culture.
Implementation of this process taught us a lot about patient flow through our department. As the pace picked up, we were able to identify some bottlenecks we hadn't been aware of. Minor staffing adjustments helped our providers keep up with the increased flow of patients through triage.
Our executive leadership has been very pleased with our results so far. While they don't have exact numbers yet, they believe this process has the potential to increase hospital revenue and decrease risk.
It's worth noting that this process isn't necessarily ideal. Given unlimited space and staffing, we'd certainly do things differently. But we do feel proud that we've been able to innovate with the resources we have. While it takes a little extra effort on our part, we're succeeding in meeting the needs of our patients and the community. And that, of course, is what really matters at the end of the day.

David Carter
This team has done some amazing work behind the scenes as well as in front of patients.
11/16/2015 9:45:04 AM

Cyndy Flores
Wow! Great work!!
11/15/2015 4:41:26 PM

Rick Newell
Great work St. Louise team. What you all are able to accomplish in the severely space challenged physical plant that you do is absolutely amazing!
11/13/2015 7:46:11 AM