Using START to Reduce ED-2: A Quality Improvement Initiative

Abstract

Purpose: Long emergency department (ED) length of stay (LOS) is associated with increased mortality, delay in care, longer inpatient (IP) stays, readmission risk, poor patient satisfaction, and opportunity for error. Within the ED LOS is a quality indicator measuring the time a provider determines a patient will be admitted to the time the patient leaves the ED for an IP unit, called ED-2. Prolonged ED-2 indicates impaired ED output. Despite previous interventions, the ED-2 at a rural Midwest hospital was about 63.5 minutes; the goal set forth by the Centers for Medicare and Medicaid is 35 minutes or less.

Sample: All patients over the age of 18 years presenting to the ED over a 3-month period were eligible.

Method: A literature review identified admission prediction and proactive IP bed allocation as evidence-supported interventions to reduce ED-2. The Sydney Triage to Admission Risk Tool (START) was selected to aid nurses in predicting patient admissions at the time of triage. Staff were educated on START and proactive bed allocation. When a patient scored 17 or greater using START, ED staff contacted the IP bed manager to begin the bed assignment process. The ED-2 was compared 3 months pre-post implementation. Additionally, staff perceptions and experiences surrounding the change were evaluated.

Findings: A 1-minute reduction in ED-2 postintervention was observed, however, the difference was not statistically significant. Survey results indicated perceived value in the intervention, but there were notable barriers impacting its success.   

Conclusions: The lack of postintervention ED-2 reduction, accuracy of START, and staff perceptions differed from the findings of previous studies, however, staff indicated a desire to continue the process change with modifications.