The patient population in Emergency Departments (EDs) has been steadily increasing and this trend will only rise in the years to come. The U.S. Centers for Disease Control and Prevention reports that ED visits rose 9.9% to 136 million over the calendar year in 2009 from 2008. Furthermore, factors such as population growth, the physician shortage, and hospital closures should exacerbate this patient growth in the future. As a result, there is an immediate need to increase efficiency in the ED. Quick Emergency Disposition (QED) is a program to improve ED patient throughput. It is a simple concept that has been leading to turn around times plummeting at our pilot sites. QED could also be applicable outside the ED in the Acute Care Continuum and play a role in the general movement towards efficiency in hospital integration.
QED’s first component focuses on immediate written communication needed for the next disposition. It is a process where the provider immediately documents the information needed for the next decision point so that the team can unite around the goal of moving the patient efficiently through the ED. The upshot is that the ED staff works with higher cohesion with the series of decision points that result from having a preliminary plan in writing.
In the chaotic atmosphere of the ED, even a small amount of ambiguity and miscommunication from the beginning can reverberate loudly through the sequence of actions that arise during the patient care life cycle. We have found that the simple action by the provider of documenting the patient disposition as soon as possible has led to significant throughput improvements. An argument for the effectiveness of the principle behind QED is evident in the time management writings by productivity consultant David Allen. In Getting Things Done, Allen writes about the importance of recording tasks externally. According to Allen, the benefits of this can range from the mental advantages of seeing results in writing to the workflow that can result from this.
The biggest challenges I have seen to implementing this QED principle are the culture changes and process changes that must be made. The culture change begins at the provider level in terms of identifying what information is essential for the next decision point and developing the habit of disseminating that information. In addition, nurses and staff must learn that this communication is important, and must come to incorporate it into team dynamics. As this program was implemented at my hospital through using a special notes section of the EMR for disposition, I noticed that the staff learned to respond to information immediately while it was still fresh. As an indication of the culture change, I noticed that the nurses became more actively involved in QED, at times anticipating the flow of events and asking me if I had not written disposition yet, “What’s your plan?”
While the initial goal of the QED written communication was merely to clarify the action plan for the team, the resulting improvements in metrics indicates that having a disposition in writing has a significant impact on team speed. For example, after QED was implemented at my hospital throughput time decreased by 32 minutes for admitted patients and 9 minutes for discharged patients. The drivers behind these improvements appear to be systematic communication within the team around decision points and a culture shift towards anticipating the need for the documentation of disposition and subsequent immediate action. As QED continues to help EDs improve important patient care metrics, there will be increased opportunities to build on this momentum.
Technology innovation will be a crucial factor in the future and QED should fit in seamlessly with these increased efficiencies. As EMR develops into robust systems that can automate parts of a treatment process, EMR vendors will integrate best practice systems such as QED into their product. For example, they can include QED prompts for providers entering initial dispositions. Technological support like this could cascade into other departments that work closely with the ED such as radiology and hospitalists. As health reform and bundled payments drive the need for collaboration between departments, something as simple as writing down disposition could become a force to achieve this goal.