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Table 5 What Hospitals Did to Reduce ED Length of Stay

From: New Zealand’s emergency department target – did it reduce ED length of stay, and if so, how and when?

  New Resources (staff and beds) Improving Patient Flow Better Information and Communication Leadership and Social Marketing
Hospital 1 (H1)
Early Implementation July 2009-Dec 2010 Prior to target QI project (2008):
Staffing added ED nursing, flow coordinator trial (2008).
Post target added/implemented:
Staffing: ED, hospital, SSU - Added medical staff SSU and hospital (2010).
Beds: ED, hospital, SSU - Reconfigurations of SSU adding ED observation beds and of medical/surgical wards to add medical (2010).
Added bed to acute surgical unit (2010).
Prior to target QI project implemented 2008:
ED Processes - ED fast track, care pathways for certain conditions.
Post target implemented:
ED processes - 3-2-1 model, changes in triage processes (2010), rapid assessment and direct SSU referral model (2010), ED discharge planning (i.e. discharge model including allied health), orderlies in ED (2010).
Hospital and SSU processes - Discharge planning (i.e. hospital ward discharge, discharge lounge), reconfiguration of bed and clinical specialty models in SSU and hospital wards, daily bed management meetings (2010).
ED patient flow and reporting -
IT screens upgraded for LOS (2010).
Prior to target:
ED leadership of QI project.
Post target:
CEO leadership - New CEO focused on ED target & “front of house” (2010).
Later Implementation Jan 2011-Dec 2012 Staffing: ED, hospital, SSU
Added ED, SSU nursing and medical staff, implemented aged care/hospital liaison role (2011–12).
Hospital processes:
Added acute medical clinic for GP referral (2011). Additional acute operating theatre for flow (2012).
ED patient flow and reporting -
Visible real time data in ED, hospital and SSU for clinicians/managers, target breach reports (2011).
Bed information - Hospital/ED bed information improvements (2011).
Leadership - Separate hospital groups encouraged to include ED target focus (2011). Whole of hospital target leadership group (2012).
Hospital 2 (H2) New resources (staff and beds) Improving Patient Flow Better Information and Communication Leadership and Social Marketing
Early Implementation July 2009-Dec 2010 Prior to target QI project (2008): Staffing: added ED nursing and flow manager, added medical staff for new observation unit (2008).
Beds: New acute observation unit (2008).
Post target added/implemented:
Staffing: ED, hospital, SSU - Added nursing staff ED, hospital, SSU, afternoon medical coordinator role. Added medical staff added SSU/ED, and orderlies (2009–10).
Beds: ED, hospital, SSU - Increase and reconfiguration hospital medical, surgical ward beds (2009) and specialty SSU beds (2010).
Prior to target: QI project whole of hospital project including 6 h ED target (2008).
Post target implemented:
ED processes - 3-2-1 model, changes in triage processes, care pathways for certain conditions, rapid assessment and direct SSU referral model, ED discharge planning (i.e. discharge model including allied health), orderlies in ED (2009–10).
Hospital and SSU processes - Ward and specialty SSU reconfiguration to increase beds and SSU hours, discharge planning (i.e. hospital ward nurse facilitated discharge at weekends, surgery discharge lounge), bed management meetings, cohorting patients for improved bed availability, afternoon medical coordinator, staff scheduling, changes (2009–10).
Prior to target: ED patient flow (2008):
IT LOS screens upgraded (2008)
Post target implemented:
ED patient flow and reporting - Visible real time data in ED, hospital, SSU for clinicians/managers, target breach reports (2009–10).
Bed information - Hospital/ED bed information improvements (2009–10).
Communication devices - Cell phones, voice activated devices for medical, nursing, orderly staff (2010).
Leadership - Whole of hospital target leadership, clinical/management champions, and governance groups.
Culture - Ready for target, strong QI and “can do” culture.
Social marketing - Social marketing strategy group implemented and activity about target within whole hospital.
Later Implementation Jan 2011-Dec 2012   Patient flow and staff management – New hospital operations new unit management (2011).   
Hospital 3 (H3) New Resources (staff and beds) Improving Patient Flow Better Information and Communication Leadership and Social Marketing
Early Implementation
July 2009-Dec 2010
Staffing: ED, hospital - Added ED nursing, ED orderlies, and hospital medical staff (2009). ED flow nurse, bed management coordinator and data analyst role for ED target project (2010). ED processes - ED flow nurse and orderlies in ED (2009).
ED Patient flow process engineering project with ED 3–2-1 model, flow coordinator, bed management coordination in ED and hospital (2010).
ED patient flow and reporting - Visible real time LOS data in ED, hospital, SSU for clinicians/managers. Results posted on ED/ hospital noticeboards (2010).
Bed information - Hospital/ED bed information improvements (2010).
Leadership - Initially ED target implementation led by ED managers & clinicians.
Later Implementation
Jan 2011-Dec 2012
Staffing: ED, hospital, SSU - Added nursing, medical staff for ED, hospital SSU (2011).
Beds: ED hospital, SSU - New ED with additional beds (2011). Reconfiguration and additional medical ward beds (2011).
Additional beds in children’s and medical SSUs (2012).
ED patient flow process engineering project (cont.) (2011)
ED processes - Changes in triage processes, flow coordination strategies. ED frequent attenders strategy and low acuity redirect. ED and hospital staff scheduling changes (2011).
Hospital, SSU processes - Ward and specialty SSU reconfiguration to increase beds (2011), extended SSUs hours (2012).
Rapid assessment and direct SSU referral model. New Integrated Operations Centre (2011).
Communication devices - Cell phones, voice activated devices for medical, nursing, orderly staff (2010–11). Leadership - Whole of hospital leadership group introduced (2011) but faltered, revised leadership group (2012).
Social marketing - Social marketing activity re target within whole hospital (2011).
Hospital 4 (H4) New Resources (staff and beds) Improving Patient Flow Better Information and Communication Leadership and Social Marketing
Early Implementation July 2009-Dec 2010 Staffing: ED, hospital, SSU
QI improvement quality coach (2009)
ED target coordinator (2010).
Added ED, SSU nursing, medical staff, orderlies (2010).
ED processes - 3-2-1 model, changes in triage processes, ED nurse triage assessment, discharge planning (i.e. discharge safety checklist, ED lab requests prioritized), ED and hospital staff scheduling changes, orderlies in ED (2010).
Hospital processes – Discharge planning (i.e, hospital laboratory system reorganized, hospital ward discharge lab requests prioritized, discharge planning safety checklist), weekend hospital clinics implemented (2010).
ED patient flow and reporting - IT LOS screens upgraded (2009).
Visible real time LOS data in ED, hospital, SSU for clinicians/managers, daily breach reports (2010).
Leadership - ED target lead and monthly meetings with ED management (2010).
Later Implementation
Jan 2011-Dec 2012
Staffing: ED, hospital, SSU - Added nursing, medical staff for ED, hospital, SSU (2011)
Beds: ED hospital, SSU - New ED with additional beds (2011).
SSU ward redeveloped & increased in beds, mixed specialty model (2012)
ED processes - Patient flow project (2011)
Rapid assessment and direct SSU referral model, discharge planning (i.e. discharge planning model including allied health), ED orderlies (2011).
Hospital and SSU processes – Discharge planning (i.e. hospital ward discharge lounge development) (2011). SSU review for patients with uncertain needs (2012).
  Leadership - New hospital operations group (2011).
Social marketing - Social marketing activity about target within whole hospital (2011).
  1. Abbreviations used in Table: ED Emergency Department, LOS Length of Stay, QI Quality Improvement, SSU Short-Stay Unit, GP General Practice