Lutheran achieves best left-without-being-seen rate in hospital’s history
In 2022, as many as 7% of people who walked into Lutheran Medical Center’s Emergency Department left without being seen. Sky Arce, ED director, and Sarah Malacaria, clinical nurse manager, saw this as a big opportunity for improvement.
Fast forward to February of this year, the hospital attained a left-without-being seen rate of only 0.51% — nearly four times better than the national average. That’s the lowest rate in Lutheran’s history! It’s also the best rate in the Peaks Region in February.
In a related outcome, Lutheran’s hall bed numbers also plummeted — an important improvement to both patient experience and clinician and caregiver safety.
Q: How did the department achieve such a dramatic turnaround in such a relatively short period of time?
A: Research, process analysis, teamwork and a willingness to adapt. The team adopted a new nimble workflow that’s constantly flexing in response to live conditions in the ED.
“The entire team worked together to create a new front-end process, which we call Flex Care,” said Scott Miner, MD, medical director in the Emergency Department. “In this process we are able to initiate and often complete patient care without having to use a single designated room for each patient. By doing this, we increase the department’s capacity for patient care while at the same time reducing wait times for patients and family members.”
Lutheran’s Emergency Department team
The new flex care area takes a space that had previously served as a waiting room and instead uses it to treat lower-acuity patients. A physician, tech, registered nurse and licensed professional nurse staff the flex area.
Think of it this way: The old model is like a highway on which many different vehicles must merge into a single lane and fast cars get stuck behind slower traffic. Having all patients wait to be treated in one emergency area can create a bottleneck as lower-acuity patients wait at the end of the queue behind more urgent (and often more time-consuming) cases. As additional higher-acuity patients arrive, they merge in front of lower-acuity patients, who get pushed further back in the queue and wait even longer.
In the new model, patients with lower acuity are diverted to the flex area to be treated quickly and go on their way — freeing up space in the main ED and shortening wait times, which in turn reduces the number of people who leave without being seen and improves patient experience.
Or this way: “A lot of hospitals refer to it as a split flow process. What it does is keep vertical patients vertical and horizontal patients horizontal,” Malacaria said of the new set-up.
After launching the new concept, the team tracked data and met weekly to make it as efficient as possible — refining the hours of operation, staffing levels and days of the week of the new flex area.
Recognizing the complexity and wide swings that emergency departments experience, they also implemented an ED capacity workflow algorithm to help the department adapt to changing conditions. The workflow identifies triggers that require action: 1) If there are more than four patients in the waiting room, 2) if a patient has been waiting more than 40 minutes, or 3) if more than four patients’ length of stay has exceeded four hours, the charge nurse will initiate rapid cycling. This involves pulling patients from the lobby into a discharge room and starting care and orders there.
The workflow algorithm reminds caregivers to regularly assess four major variables that can impact patient flow: provider capacity, nursing capacity, ED bed capacity and inpatient bed capacity. For each limiting factor, it offers recommended tactics to reduce the bottleneck.
“The ED capacity workflow is like a guideline for what the issue of the day is that needs to be addressed and what's causing said backup, because each issue requires a different response,” Malacaria said.
Both Malacaria and Arce emphasized the importance of feedback from staff in shaping the new process.
“We were the drivers initiating the process, but we used their ideas to remold and make it what it needed to be,” Malacaria said. “Input and feedback from clinicians and caregivers on projects like this are really important and really help drive that change.”
“And they’re the ones doing it,” Arce said. “All of this success is because of them. I really want to recognize the whole ED team and Lutheran bedside clinicians.”
Lutheran clinicians and caregivers who also played a critical role include Amanda Adams, ED clinical coordinator; Meredith Carey, PA-C; Jill McCormick, manager of Continuous Improvement; and all Lutheran ED charge nurses, clinical nurses, techs and clinicians, as well as the house supervisors.
Congratulations to the Lutheran ED team on their outstanding work improving multiple important patient experience metrics.