Kingston Health Sciences Centre (KHSC) has recently made significant improvements in reducing their emergency department (ED) length of stay. To learn how they achieved this success, Health Quality Ontario had a chance to catch up with Carol McIntosh, Director of Ambulatory Clinics and Emergency Care and Mike McDonald, Executive Vice President of Patient Care and Community Partnerships at KHSC.
Reducing ED length of stay is often a big challenge for hospitals. What led to your recent significant improvement?
On April 1, 2017, Kingston General Hospital and Hotel Dieu Hospital joined together to create Kingston Health Sciences Centre. Shortly after, a re-organization occurred that brought together the emergency, medicine and psychiatry departments under one portfolio.
Prior to this re-organization, these departments operated independently, which made it challenging to address flow challenges and corporate access from a system perspective.We recognized the interdependencies between medicine, psychiatry and ED length of stay, and now we think of ourselves as one team dedicated to improving patient flow together.
Members of the KHSC team from left to right: Danny Quann NP, Laura Lynch RN, Heather Jenkins PT and Home First team lead, Caroline Knapp-Mulcaster, ED social worker
Can you describe the strategies you use to improve patient flow and reduce ED length of stay?
There are three strategies that have made the biggest impact on improving patient flow and ED length of stay:
1. Creation of a new patient intake and flow coordinator position:
- Funding through “Pay for Results” from the South East Local Health Integration Network has allowed for the creation of a new Patient Intake and Flow Coordinator position. This position reports to the Access and Flow Director and has helped optimize bed utilization and timely transfer of patients from the ED to admitted beds.
- The Coordinator role has made a significant impact. This role has a bird’s eye view of overall hospital patient access and flow. The Coordinator works with departments across the organization and with community partners to make recommendations about the placement of patients from the ED, diverting patients from the ED through direct admission and surge and overcapacity protocols.
2. Creation of an Admit Transfer Unit (ATU):
- Our ATU is a repurposed space that is in close physical proximity to the ED. This space is a transitional care unit for all inpatients who have been admitted to the hospital and are waiting for an inpatient bed. The ATU frees up ED stretchers to enhance the ED’s capacity to manage the inflow of patients.
3. Development of a surge protocol:
- During the winter season, we often experience a seasonal increase of patients that may require admission to the hospital for the flu, respiratory symptoms or exacerbations of chronic diseases. We revised the surge protocol to optimize bed utilization and assist in the flow and transfer of patients during these peak seasons. The Ministry of Health and Long-Term Care also provided additional funding to open extra surge beds during the flu season.
- All departments across the hospital review the corporate surge protocol and are accountable for implementing it in their specific area. The Patient Intake and Flow Coordinator also supports this process and works with the various departments to assist with any barriers.
Do you have other strategies in place?
Yes. There are several other strategies in place that not only focus directly in ED, but create capacity within the organization to ensure that patients are cared for in the most appropriate care environment.This also includes ensuring that patients transition back into the community when their care needs no longer require acute care in the hospital.
Home First Initiative:
- Our Home First Initiative is focused on the philosophy that everyone admitted to the hospital will be discharged home (wherever “home” is).Home First identifies patients who may need additional supports and services to return to the community.
- The Patient Flow Coordinators and care teams work with patients at high risk for discharge delay as soon as possible to develop a plan and coordinate these services. This plan can include supports to prevent admission or for patients who no longer require acute care expedite discharge. Services could be related to social issues, housing, home care, nursing services, and so on.
Admission avoidance clinics:
- Nurse Practitioner led clinics have been initiated through ‘Pay for Results’ funding. The goal is to create an environment that supports timely access to patient assessment and follow-up outside of an ED environment. These types of clinics have proven to be successful and we’re expanding.
- A new clinic that operates within the Urgent Care Centre at the Hotel Dieu Hospital site gives patients with multiple chronic conditions access to a nurse practitioner, reducing repeat visits to the ED.
- We have a rapid access clinic for patients who are discharged but can’t access primary care. The nurse practitioner sees a low volume of patients, but with high intensity to connect to primacy care.
- Our Medical Surgical Assessment and Procedure Clinic create rapid access for physicians and surgeons to assess and treat patients who would have otherwise come to the ED. The clinic is open daily and into the evening and avoids non-emergent patients going to the ED.
- To ensure appropriate cross referral for opioid overdose prevention and other mental health and addictions issues, we work with The Street Health Centre, a local harm reduction health centre open 365 days a year that provides accessible, responsive health services to communities that are marginalized from mainstream health care services.
- We also work with Kingston Homeless Services if we identify that a patient is homeless. We coordinate support before discharge to help prevent ED re-admission.
- We are currently delivering a pilot program supported by the Ministry of Health and Long Term Care and the South East LHIN to provide short-term transitional care where patients currently designated ALC or patients who no longer require acute care and are likely to be designated ALC. KHSC partnered with an external home and community care provider to deliver an innovative program in a 10 bed unit located at a retirement home. Patients receive comprehensive assessments, supportive care and restorative therapies designed to meet their care needs and enhance their health outcomes so that they can return to their pre-hospital living arrangement. This program ensures that inpatient beds are most available for acutely ill patients in our region.
What advice do you have for other hospitals looking to reduce ED length of stay?
There is no one silver bullet. There are many good ideas to try, but figuring out what works for your hospital is the difficult part. Significant improvements started to occur for us when patient flow became a hospital-wide team effort and not just the responsibility of the ED department. The pay for performance funding we’ve been able to secure has also been very helpful.
What are your next steps?
This work is never done! We’ve had a significant increase in patients with mental health and addictions issues especially among young adults. We’re now working with the community mental health associations and internal psychiatry departments on holistic solutions. We need to stay adaptable and flexible to respond to these types of changes.
Do you work to improve ED length of stay at your organization? Add your comments below or connect with Mike McDonald at KHSC.