Time from initial physician contact to disposition decision is a critical timeframe for emergency department (ED) flow. Patient flow can be best described as
- Input: Door to doctor (evaluation)
- Throughput: Doctor to disposition decision
- Output: Disposition decision to (actual) disposition
The “physician-to-disposition decision” throughput interval represents the middle (throughput) segment of the patient visit, during which patients receive their medical assessments and screening. During this segment patients are monitored, treated, diagnosed, and get their most important question answered: “Do I get to go home or will I be admitted?”
The input (time of arrival to seeing physician) and output (time from disposition decision to departure) are two intervals of a patient visit during which the registration and nursing staff play a greater role in the flow. During the physician-to-disposition decision interval, physicians assume the more critical role. The physician-to-disposition decision stage both begins and ends with the physician. Although nurse-initiated orders and triage protocols may be started to expedite care during this throughput interval, the physician ultimately manages throughput. He or she starts the evaluation, workup, and treatment, and makes a disposition once all necessary diagnostic test results, consultations, and treatments have been completed (Figure 35-1).
Input-throughput-output model of patient flow.
There are many steps and variables that impact the physician-to-disposition decision interval. Figure 35-1 includes lab, radiology, and consultations. It is important to note that the lab process is not one single process. There may be many lab tests ordered for any given patient and it is not always possible to order and obtain all the needed tests at one time. Similarly, “radiology” includes plain radiographs, CTs, MRIs, ultrasounds, and use of nuclear medicine. All EDs have different physical setups, systems, and processes. Each ED may require multiple steps between physician evaluation and test ordering, and with each step, the potential for delay is increased. Thus, reengineering the physician-to-disposition decision stage is complex and not to be taken lightly.
When EDs attempt to reduce and improve physician-to-decision times, the speed and efficiency of physicians is commonly blamed for prolonged throughput time. This focus leads to a common conclusion that the way to improve throughput is to simply hire faster doctors, improve their productivity, and push them to work faster. While physician productivity is significant to flow, looking at this aspect alone can be problematic as it takes a unidimensional view to a complex process. There are multiple elements that impact throughput. However, studying the behaviors and actions of productive physicians reveals strategies that can help the slower physicians to be more prepared and organized, and therefore more efficient. Ordering labs and planning for discharges early in the visit, as well as the use of scribes, are process examples that can help improve and enhance provider productivity and throughput.