Overcrowding Issues in Emergency Department
Overcrowding in emergency departments (ED) continues to be one of the major issues happening within the public healthcare systems and for patients and medical professionals worldwide. It occurs due to the massive number of people waiting to be admitted or seen (input), long delays in the patient ED treatment process (throughput), and/or obstructions to patients leaving the ED after completing their treatment (output) (Morley et al., 2018). In general, there are many causes of ED overcrowding such as hospital staff shortage, inefficient healthcare processes, limited hospital bed capacity, various patient acuity levels, etc. (Al-Owad et al., 2020; Yarmohammadian et al., 2017). Without effective solutions, severe implications will occur such as Access Block and Ambulance Ramping – phenomena that are impacting many EDs across the world.
Access Block – As defined by the Australasian College for Emergency Medicine (ACEM), access block is the state where patients could not gain access to inpatient beds in the ED for a prolonged period due to the fully occupied inpatient beds, overwhelming demands of medical services, and long patient waitlist (as cited in Hammond et al., 2012; Stanton et al., 2014; FitzGerald & Ashby, 2010).
Ambulance Ramping – A situation whereby ambulances transporting patients are forced to queue outside the hospital building for a long period of time before being able to hand over patients into the ED because of unavailable inpatient beds (Clay-Williams & Cutler, 2022; Stanton et al., 2014; Hammond et al., 2012).
Australia, for instance, is currently facing both issues and has been for decades. According to Clay-Williams and Cutler (2022) in The Conversation, approximately 25,000 people visit hospitals’ EDs across the country every day and many of them have reported prolonged waiting times to get admitted into the ED. Despite the effort of increasing the capacity for ambulances and staff to work harder and longer during the peak COVID-19 phase, massive burnout among the staff occurred in long term, resulting in the resignation of around 20,000 Australian nurses in 2021 (Clay-Williams & Cutler, 2022; Livingstone, 2021). Evidently, the pandemic has only made an underfunded health system worsen and droving out essential workers. Now, combining access block, ambulance ramping, staff shortages, surging Covid-19 and flu cases, and Covid-19 backlogs, the situation calls that patients will fall victim to having to wait for hours to days just to get admitted into the ED wards, receive treatment and get discharged (Visontay, 2022; Davey, 2022; Clay-Williams & Cutler, 2022).
Overcrowding in EDs is a very concerning matter as it can cause adverse effects, especially to patients. For example, delay of treatment and pain relief, increased mortality and morbidity, prolonged hospital stay and ambulance turnaround times, low patient satisfaction, and poor experiences for ED patients and staff (Ngo, 2018; Morley et al., 2018, Hammond et al., 2012). It has been found that ED overcrowding can only be solved in the long term when the ED system efficiencies are optimized and enhanced for smoother throughput flow and fast track system (Clay-Williams & Cutler, 2022; FitzGerald & Ashby, 2010). According to The National Emergency Medicine Programme, in order for patients to receive timely medical assessment in the ED with more efficient processes, all EDs are encouraged to carry out a 6-Hour rule for ED attendees so that 95% of the patients can be admitted or discharged within six hours. Ultimately, this approach will assist in reducing delays yet still maintaining service and operational qualities (Daly et al., 2021).
However, achieving this great feat does require a thorough evaluation and analysis of all the processes and procedures done within the system (e.g., from patient arrival and registration until the discharge process) so that the proposed approach can be employed effectively and ensure the highest service quality and smoother patient flow (Daly et al., 2021); thus, requiring an effective strategy that can guide to a fruitful outcome.
Therefore, to help maintain the EDs’ effort in this process and quality improvement, reduce access block and ambulance ramping issues applying Lean Six Sigma (LSS) in this endeavor is one of the most effective strategies to implement.
Lean Six Sigma in Healthcare/Emergency Department
Lean Six Sigma Methodology has shown positive impacts on healthcare service or ED. Lean Methodology is useful in reducing waste and improving the quality and capacity of enterprises of health services, as well as generating value for the customer, society, and economy (Souza et al., 2021). On the other hand, Six Sigma methodology provides suitable tools for healthcare to improve the performance of a service or product while minimizing the variation in process defects up to 3.4 defects per million to achieve customer satisfaction (Mandahawi et al., 2017).
Since the early 2000s, LSS has been applied in multiple healthcare services to achieve quality and operational excellence, as well as enhanced process efficiency. Due to financial and essential resource constraints, healthcare providers around the world seek efficiencies that could still deliver quality services. For years, LSS has proven to be effective to assist in process improvement in many clinical and administrative processes including clinic management and appointment, medication management, and operating room (OR) efficiency and organization. Moreover, LSS achievements also include improving ED’s waiting time and patient flow; thus, reducing issues of access block and ambulance ramping (Daly et al., 2021).
Case Studies on The Application of Lean/Six Sigma/Lean Six Sigma to Resolve Emergency Department Overcrowding Issues
There are studies that apply Lean, Six Sigma DMAIC methodology, and Lean Six Sigma (LSS) management tools that indicate improvement in healthcare and ED performances after implementation. The integrated use of both methodologies for the analysis of processes allows the improvement of the overall performance. Similar contributions are expected to expand the current body of research for the ED and increase the utilization of these hybrid approaches (Souza et al., 2021).
Al-Owad et al.’s (2020) study investigated the patient flow and waiting time problems in Aseer Central Hospital’s (ACH) ED in Abha City, Saudi Arabia based on an integrated Voice of Customer (VOC) and Voice of Process (VOP) perspectives to establish a new Lean framework for ED operation process. Surveys, Lean tools (e.g., process mapping, A3 problem-solving sheets), and root cause analysis were used to determine non-value-added tasks and the reasons for the long wait time problem in the ED. Results show main factors for the long wait time include poor layout of ED, limited bed capacity, unavailability of essential staff, and lack of understanding among patients about the nature of emergency services and procedures. Here, the authors recommended utilizing Lean tools with the integration of the VOC and VOP perspectives as well as value stream mapping to address these issues and improve the quality of ED operations.
Improta et al. (2018) demonstrated the success of an emergency department at Hospital National Company AORN A. Cardarelli of Naples in improving patient throughput times, the efficiency of services, and reducing waste (waiting times) through the application of Lean methodology assessment (i.e., Value Stream Mapping and 5S).
Johannessen and Alexandersen (2018) applied Lean principles by utilizing Value Stream Map (VSM) and targeted improvement combined with a focus on planning and increased front personnel involvement to detect bottlenecks and sources of waste, and ultimately address waiting times and long wait list issues at 12 different outpatient clinics from four hospitals across a range of medical specialties. Results have shown a significant improvement in the admission and discharge processes. All clinics were able to reduce their waiting time from 162 ± 69 days (74-312 days) to 52 ± 10 days (range 41-74 days) within six months after the intervention. In addition, the waiting list of new patients decreased from 15,874 (range 369–2980) to 8922 (range 296–1650), and the number of delayed returning patients was reduced from 18,700 (310–3324) to 5993 (40–1337).
Kane et al. (2015) implemented Lean Thinking to support a specific local system of a healthcare unit, leading to the creation of the Stanford Operating System (SOS). Through the Kaizen method, the study achieved significant gains such as patient satisfaction, reduction in waiting time, and standardized activities. It shows that with Lean Thinking, it was possible to obtain reductions in the average time of care from emergency to hospitalization and patient discharge.
Arafeh et al. (2018) described the holistic approach that combines Discrete Event Simulation (DES) and stakeholder analysis under the umbrella of Six Sigma’s DMAIC framework to examine and address the issue of patient discharge time at King Hussein Cancer Center (KHCC) in Amman, Jordan. Results have found that the project has succeeded in reducing the patient discharge time by 54% from 216 minutes. This was achieved through the utilization of simplified and standardized processes, improved communications, and system-wide management as well as tools like Project Charter, Supplier-Input-Process-Output-Customer (SIPOC) diagram, Fishbone diagram, and 5 Whys.
Hussein et al. (2017) conducted a case study on the integration of Six Sigma methodology with discrete event simulation (DES) in the effort to reduce overcrowding issues in the ED of a private tertiary hospital in Cairo with more focus on the influence of the utilization and change of medical equipment technology on patients’ waiting time and satisfaction. The DMAIC approach is implemented to analyze and diagnose the problem and causes, as well as control the process improvement plans. Results have shown that this Six Sigma and DES integration approach is effective in reducing ED crowdedness, increasing patient throughput, reducing patient length of stay (LOS), and enhancing the overall ED operational performance.
Mandahawi et al. (2017) conducted a study that involves the development of a Discrete-Event Simulation (DES) model to redesign the already existing emergency department (ED) in a Jordanian hospital. Additionally, a new simulation model was developed with the validation from a triaged management system derived from the Manchester triage system. This whole simulation study was carried out as a part of Six Sigma project through Design for Six Sigma (DFSS) or DMADV methodology to establish the proposed triage process and demonstrate new operational methods to help enhance and improve ED operations. Ultimately, the proposed model succeeded in reducing patient waiting time (WT) by 61% and length of stay (LOS) by 34%. Moreover, it was found that the six sigma level for WT improved from 0.66 to 5.18 and from 0.58 to 3.09 for LOS.
Daly et al. (2021) conducted a study that involved redesigning an emergency department (ED) data management system to enhance and improve the availability and accessibility to data to facilitate patient flow. LSS methodology, specifically through the voice of the customer (VOC), Gemba, and 5S techniques, was applied to implement a pre/post-intervention design that can determine areas for improvement in the ED data management processes and to notify solutions for improved ED process of patient flow. The study was able to reduce the time taken to gain access to ED patient flow data from a mean of 9 min per patient pre-intervention to immediate post-intervention. Hence, it gave the ED team a better and faster decision-making process in relation to patient assessment and treatment, as well as information on improvements in patient flow. Through LSS methodology implementation, the ED succeeded in improving the availability of current information on ED patient flow in a shorter time frame and allows the staff and management team to detect any activities impacting patient flow for faster response.
Godley and Jenkins (2019) involved a quality improvement (QI) project by using LSS’s DMAIC approach at an outpatient vascular procedure department of a community hospital in the Southeastern United States. Despite not being an emergency department, this hospital’s department has shown similar issues in long patient waiting times and received quite a low score in patient satisfaction. Yet, with the application of LSS approach, results have shown a statistically significant decrease in wait times and a large increase in patient satisfaction in terms of registration, test/treatment, and likelihood to recommend. Hence, proving the effectiveness of LSS deployment in healthcare.
Furterer’s (2018) case study on applying LSS’s DMAIC methodology at a hospital’s emergency department shows significant results in which the ED was able to reduce the process flow of patient’s length of stay (LOS) by 30% in only three months and lessen the percentage of patients leaving without receiving treatment from 6.5% to .3%. Additionally, patient satisfaction increased from 24% to 89.9%, thus leading the ED to obtain the top 1% level of hospitals nationally.
Gijo and Antony (2013) demonstrated the application of LSS’s DMAIC methodology at an outpatient department (OPD) of a super specialty hospital attached to a manufacturing company in India to reduce patient waiting time. In this initiative, non-value-added steps in the process were identified, and actions were initiated. Also, a cause-and-effect diagram was prepared for high patient waiting time and causes were validated. Kruskal–Wallis test, Box Cox transformation, Control charts, and normality test are among the statistical tools utilized within the LSS methodology to identify the high patient waiting time causes and sustain the improvements. As a result of this project, clinicians and the hospital management have better ways to identify the weak areas in the process for improvement and the OPD succeeded in reducing the waiting time from 57 min to 24.5 min and the standard deviation was reduced to 9.27 from 31.15 min.
The Benefits of Lean/Six Sigma/Lean Six Sigma in Healthcare/Emergency Department
The use of Lean, Six Sigma, or Lean Six Sigma in healthcare or EDs has been proven to produce beneficial results especially to prevent ED overcrowding, access block, and ambulance ramping. Overall, these main benefits include
- Reduction of waiting time, cost, length of stay (LOS)
- Improved and smoother patient flow and procedure times
- Increased patient satisfaction
- Enhanced operational efficiencies, productivity, standardization, quality, and safety
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